A 28-year old woman arrived to the ER wheezing and short of breath. She had asthma and came in requesting a refill of her inhaler.
But when I examined her, I found out that something else much more serious was going on. The patient’s blood pressure was very high. Her legs and arms were swollen. Her lungs were filled with fluid. She told me that she had given birth a month before. During her pregnancy, she started having wheezing and trouble breathing, which she attributed to her asthma. Actually, she had untreated high blood pressure that progressed and worsened to life-threatening heart failure.
This scenario was tragically typical. As an emergency medicine physician working in ERs in Boston and Washington, D.C., I saw devastating cases like these far too often.
About 700 women in the U.S. die every year from complications of pregnancy, according to the CDC. And more than 50,000 women face severe health consequences in pregnancy. All of this is to say that women giving birth in the U.S. today are actually more likely than their own mothers to die in childbirth. In fact, more people in the U.S. are dying from pregnancy-related complications than in any other developed country, according to an investigation by NPR and ProPublica in 2017.
The public health crisis of maternal mortality is particularly acute for black women, who have three-to-four times the likelihood of dying in pregnancy and childbirth than white women. To some extent, this can be attributed to inequities in access to care, yet we know that these racial disparities persist even when controlling for all other factors. Structural racism in health care is a key contributor, as the research shows that health care providers are less likely to take the pain of black patients seriously. A recent study from the CDC found that three-in-five pregnancy-related deaths can be prevented, compounding the tragedy.
As a mother of a two-year-old, expecting my second child in March, I know that the period spanning pregnancy to parenting an infant is one of the most rewarding yet vulnerable times in a person’s life. In medicine, we refer to pregnancy as a physiological stress test. A pregnant woman’s blood supply increases by nearly 50 percent; hormone levels fluctuate; and because of the growing uterus and increasing demands of the body, lung volumes reduce by five percent, while oxygen consumption increases. The levels of clotting factors in the blood increase in preparation for active labor, which is in itself a marathon that often lasts many hours.
The postpartum period is another time of incredible vulnerability. During this period, new mothers face a wave of new challenges that can accumulate and often compound mental health conditions like postpartum depression. After giving birth, they become full-time caregivers to a newborn, while learning breastfeeding, barely sleeping, and often navigating the return to work. In a country that lacks federal paid parental leave, many new mothers are back to work within weeks of giving birth, which can result in health consequences like maternal stress and anxiety. Medicaid coverage for new mothers, many of whom are people of color, ends at 60 days after delivery, and many people lose health insurance during this time of medical need. Through these challenges, parents often prioritize the care of their infants and push their own health aside; it is estimated that as many as 40 percent of women do not attend a postpartum visit.
In recent months, there has been increased attention to maternal deaths during childbirth. These are important calls to action, but we must also pay attention to the research that shows that the majority of maternal deaths occur outside of the labor and delivery period itself. Approximately two-thirds of maternal deaths occur before or even months after delivery, according to the CDC. These deaths are largely attributed to undertreated chronic illnesses such as heart disease, high blood pressure, and mental illness.
In order to improve maternal health, we have to focus on improving all women’s health and access to care—not just during labor and delivery, but before and after pregnancy, and throughout our lives.
It is imperative that we address the barriers to access and the systemic racism that we know is contributing to our astronomically high maternal mortality rates. The onus must be on the health care system to make necessary changes. But we can’t wait for systemic change to occur if we need medical care now. Here are a few crucial steps you can take to advocate for yourself and obtain the best care you can:
You can stay on top of your wellness visits. Regardless of whether or not you have given birth or plan to in the future, you can do your best to take care of your health now. Women are often caregivers for our loved ones, but we must care for ourselves to care for others. The best time to keep yourself healthy is before you get sick.
So instead of waiting for something to be up, go ahead and schedule a well-woman visit with your doctor. Your doctor can screen you for common conditions like high blood pressure and diabetes, which are associated with complications during pregnancy including heart disease, preeclampsia and eclampsia (pregnancy-related disorders of high blood pressure), placental abruption (when the placenta separates from the wall of the uterus), and gestational diabetes.
You should also get tested regularly for STIs. If left untreated, STIs can lead to pelvic inflammatory disease and ectopic pregnancy (a pregnancy that grows outside of the uterus), the most common cause of death among women during the first trimester.
Make sure that you are up-to-date with preventive testing such as Pap tests and breast screenings. Even if you’re not pregnant, diagnosing and treating medical conditions now can prevent complications during a future pregnancy.
You can choose contraception if you’re not looking to get pregnant. Birth control can help you plan and time your pregnancy, which can help some women get pregnant at a time that is best for them and their bodies. Experts estimate that without access to contraceptives, many more mothers would die globally from pregnancy-related complications. Another study found that increasing contraceptive use in developing countries has cut the number of maternal deaths by more than 40 percent over the past two decades.
Birth control can also be beneficial for many patients in ways that don’t directly relate with becoming pregnant. It can help with symptoms of other conditions, like polycystic ovarian syndrome (PCOS) and endometriosis.
You can ask for help. This is true for all women, regardless of whether or not they’re pregnant or plan to be pregnant. But pregnancy and the postpartum period can be particularly vulnerable times for mothers, especially those experiencing a mental health condition or substance abuse or addiction.
It can be really hard to know where to turn when you need help, but one place to start would be your primary care doctor or a local health clinic. Remember that your mental health is just as important as your physical health. Tell your doctor if you have feelings of depression, anxiety, and trouble coping. If you find yourself relying on substances such as alcohol or opioids to deal with the stresses of life, you may have a medical condition that treatment can help.
If you’re pregnant or have recently given birth and you’re experiencing any worrying symptoms, do not hesitate to seek medical attention. For urgent concerns, go to the ER to get care.
The patient whom I mentioned earlier was in the Intensive Care Unit for a week. Though she will now always have a heart condition, she is able to live her life and care for her young daughter. Her outcome could have been vastly different had she not received care in time—and it could still have been different if her high blood pressure was treated much earlier.
Ending maternal mortality won’t be easy, but as mothers, future mothers, spouses, and friends, let’s start with what we can do right now. After all, to have healthy women, children, and families in the future, we must start with healthy women today.
Leana S. Wen, M.D. M.Sc. FAAEM is an emergency physician and Visiting Professor at the George Washington University Milken School of Public Health. Follow on Twitter: @DrLeanaWen.
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