The phrase “maternal deaths” tends to conjure up images of awful complications of delivery: uncontrollable bleeding after birth or the Cesarean section that goes terribly wrong. But these heartbreaking catastrophes account for the minority of maternal deaths.
Two-thirds of them happen either before birth or more than a week after delivery. In most cases, the woman is home when whatever will kill her — uncontrolled high blood pressure, heart failure, blood clots, suicide, drug overdose — initially strikes.
Obstetricians and others have worked hard to prevent in-hospital tragedies, but these efforts can’t prevent the majority of maternal deaths. Some publications I’ve read recently make me think we need to turn our attention to what happens outside the hospital — in the community and in the home — and also learn how we can better leverage digital technology to prevent these deaths.
Both within and beyond the health care system, women of color are more likely to die or experience complications just before, during, or soon after giving birth. In a report in the journal Obstetrics and Gynecology last month, Dr. Rebekah Gee and colleagues analyzed maternal deaths in Louisiana over a six-year period. During that time, black women represented 37% of births but 70% of maternal deaths. The researchers also found that while 9% of deaths among white women were preventable, an overwhelming 59% of deaths among black women were preventable.
Another study showed that within any hospital in New York City, black women were more likely to experience serious maternal complications than white women, regardless of their insurance status.
To frame these findings positively, I could conclude that the American health care system is unable to adequately address the unique clinical needs of minority patients. To frame it less charitably, I’d conclude that the American health care system is inherently racist. Since either explanation is endemic, institutionalized, and unlikely to change soon, we’re going to have to be creative to find ways to prevent maternal deaths.
Among the leading causes of these deaths —high blood pressure, bleeding, infection, heart failure, blood clots, pre-eclampsia, and mental health conditions — only bleeding is obvious in its presentation. High blood pressure can be silent or written off as a headache; the symptoms of blood clots ignored; depression chalked up to “the baby blues.”
Think about it: this epidemic strikes women at home, is subject to systemic racism, and isn’t obvious in its typical presentation.
Our challenge is to create largely from scratch a surveillance system — what exists today is inadequate — for the first signs of conditions that kill women and to encourage families and the primary care health system to recognize the signs of trouble and raise warning flags. We must deploy tools that can be used at home and in the community to identify women at risk or those in the early stages of a medical crisis and get them seen quickly by the proper physician or midwife.
This epidemic presents digital health companies like the one I work for with opportunities to be part of the solution. Health apps could become integral parts of the surveillance system. Most women use one or more pregnancy apps on their phones or tablets, so I encourage these app makers to include postpartum blood pressure checks and provide guidance for abnormal readings. Apps and non-digital sources of information can develop content targeted to women of color, conduct depression screening, provide referrals for patients who are at risk, and be sources of information for women and their families that distinguishes “normal” from early signs that something’s very wrong.
Apps won’t replace clinicians or wise and vigilant family members at preventing maternal deaths. But we must come up with new ways of identifying women who are in the early stage of a life-threatening condition and get them the care they need. The current approach — focused within the health care system — isn’t working.
You can be part of the solution, too, by offering your thoughts below on how we can collectively solve this public health crisis.
Adam Wolfberg, M.D., an obstetrician, is the chief medical officer for Ovia Health. He blogs at www.adamwolfberg.com.