By: Bill Frist, M.D.
This piece is coauthored by Saketh R. Guntupalli, MD, FACOG, FACS. Dr. Guntupalli is assistant professor of gynecologic oncology at University of Colorado School of Medicine, Denver.
This past year, the United States received the dubious distinction of being one of only 7 countries in the world, including Somalia and Afghanistan, which have seen an increase in maternal mortality.
While countries with far fewer resources such as India and Brazil have made great strides to decrease the number of women who die each year as a result of pregnancy, our nation has more than doubled its rate of maternal mortality in the last twenty-five years (28 maternal deaths per 100,000 births in 2013, up from 12 in 1990). Since 2005, it has increased more than 20%. According to the World Health Organization (WHO), as many as half of these maternal deaths are preventable. This begs the question: How can we lead the world in cutting-edge health innovation and medical discoveries, yet fall behind in this telling public health metric?
The reasons for the increase are complex.
The first is tied to our nation’s leading public health problem: obesity. While traditional causes of maternal mortality such as hemorrhage and eclampsia have remained relatively flat, obesity-related illnesses such as hypertension, diabetes, and heart disease have increased the risk associated with pregnancy, and led to labor complications, higher-risk surgical procedures, and in-utero fetal death. As our nation’s obesity rate has skyrocketed, so has our maternal death rate. And underserved, low-income, and inner-city communities—which tend to have higher obesity rates—have been hardest hit. The death rate for African-American women in pregnancy is nearly four times that of white women—even after correcting for differences in other medical conditions.
We must modify our approach to recognize the health of the woman prior to conception is just as important, if not more important, than health during pregnancy. Women who are uninsured and haven’t benefitted from primary care services are three to four times more likely to die of pregnancy-related complications than those who have insurance coverage. While Medicaid provides emergency coverage for uninsured pregnant women, this can take time to go into effect in some states, and often doesn’t last long after birth. Many deaths occur in the post-delivery period after the expiration of emergency Medicaid benefits. While the WHO defines maternal mortality as the death of a woman during pregnancy or within 42 days of birth, miscarriage or termination of pregnancy, studies have found mortality is still “significantly elevated” in the three months following pregnancy. Because many post-partum deaths result from diseases such as hypertension and other chronic medical conditions, the loss of coverage can substantially increase the risk for death. In addition to further expanding coverage for our nation’s uninsured, women should receive emergency coverage for a longer post-partum period to decrease rates of maternal mortality and better offer their children the care that they deserve.
Another growing issue that must be better addressed prior to pregnancy is the rising rate of opioid abuse, which has increased tremendously among all demographic groups in the last decade. Pregnant women are no exception, seeing a 127% increase in opioid use from 1998 to 2011, which translates into significant risk for maternal death. This also increases the risk for neonatal abstinence syndrome (NAS) or withdrawal of the newborn from narcotics, which can cause long term cognitive and developmental delays in children. Connecting these women to support services in the community through a coordinated care approach—which is increasingly covered under value-based models of reimbursement—can help them detox and get off opiates for the duration of their pregnancy.
Lastly, federal and state funding for maternal health must be a priority, and policies must be enacted to ensure our expecting mothers get the best possible care. This year, Texas achieved the sad distinction of being one of the most dangerous places in the industrialized world for a woman to have a baby. Like many public health challenges, the causes are multifactorial. The state’s decision not to expand Medicaid, significant cuts in funding to women’s health clinics, and shortage of substance abuse treatment resources and mental health coverage likely all played a role.
Other nations have put in place frameworks to improve care for high-risk pregnancies. Since 1990, the global maternal mortality rate fell by almost half while ours doubled. A 2010 study published in The Lancet, which looked at international maternal mortality data over three decades, found over 180,000 fewer maternal deaths annually in 2008 compared to 1980. This significant progress is attributed to varying factors including higher income (translating into better nutrition and healthcare), better education access for women, increase in health providers, and access to antiretrovirals in areas with high rates of HIV/AIDS. Improved family planning and healthy timing and spacing of pregnancies also played a role, something Nashville-based humanitarian organization Hope Through Healing Hands has helped advocate with support from the Bill and Melinda Gates Foundation.
In Europe, countries such as Denmark, the U.K. and the Netherlands have adopted national hospital guidelines for high-risk pregnancies—an area where the U.S. lags behind. While national bodies such as the American Congress of Obstetricians and Gynecologists publish guidelines for managing many disorders in pregnancy, hospitals are not required to adopt them. Therefore we have “patchwork” in the U.S. of inconsistent management particularly for high-risk pregnancies. National standards for hospitals should be adopted to ensure that women around the country with similar problems receive a baseline of care that is validated by experts. Additionally, a national database of maternal deaths should be implemented to best observe trends and adopt needed changes.
For the small but increasing number of pregnant women today experiencing deadly complications, it reminds us that pregnancy is not without risks and should be managed under the care of a trained provider. Setting the above standards, in addition to establishing a new approach to women’s health that focuses on the social determinants prior to pregnancy, will be vital to reducing maternal mortality. The U.S. should be the safest place in the world to have a child, but we have work to do to make that goal a reality.
Oct 12 2016
By Kimberly JohnsonOnce I stepped off of the plane and into the gate entrance leading into the airport, I was greeted with the warm, muggy air. Once our group had made it through customs, gathered our luggage, and headed outside to meet our bus drivers the fiery heat hit us like a brick wall. Even though the heat will take some getting use to, I am overjoyed to finally be in Cambodia.
Oct 12 2016
By Kimberly JohnsonI will be traveling with a group from Belmont University; this group includes professionals and students of pharmacy, physical therapy, and nursing. We will be traveling to many locations in Cambodia (Phnom Penh, Battambang, & Siem Reap). We will be taking part in nurse education and patient care in the hospital, clinic, and home visit settings.
By: Jennifer GrantI’d gone to Haiti with Hope Through Healing Hands, a Nashville-based global health organization founded after the earthquake in 2010. Because of my global health reporting and interest in the welfare of mothers and children at home and abroad, I was invited on a “learning tour” of health initiatives there.
CARE Partners with Hope Through Healing Hands on Learning Tour to Haiti to See U.S. Investments in Women’s Health
Oct 01 2016
Sep 30 2016
(Christianity Today, Sept 2016)
Melinda Gates is known for her work as the co-chair of the Bill and Melinda Gates Foundation, and she is passionate about making the world a better place through intentional philanthropic investment. So far, it’s paying off. In the last 25 years, thanks in part to the work of the foundation, extreme poverty and childhood deaths have been cut in half. Maternal deaths have been nearly cut in half. Although there’s work yet to be done, Gates is convinced that if we deliver to developing countries the simple tools we take for granted in the West, we can see those numbers halve again at a much faster rate.
“There is a passage in Luke, that you do not put a light under a bushel basket,” said Gates in her CT interview last year. “You put it up for everybody to see. We at the foundation are trying to shine light on the world, on the world’s problems and inequities, so that other people will feel this calling too.”
Driven by her Christian faith, Gates is using her influence to speak out for people who often don’t have a voice, especially women. During the recent Willow Creek Leadership Summit, I sat down with Gates to talk about her work with the foundation, both globally and domestically, and why she thinks women are such a good investment.
Why does the foundation primarily focus on women? What makes women a good investment?
We know that for every marginal dollar a woman gets in her hands, she’s twice as likely [as a man] to pile it back into her family. So if she gets more income that actually stays in her hands, she spends it on the family. Men tend to spend it on other things. When a woman is empowered, she transforms everything around her because she is often the center of the family. So how do we break down some of the barriers that exist around women?
Sometimes in India [the barrier is] the mother-in-law. Sometimes in a patriarchal society, it’s the husband. In some societies, it’s a religious leader. For instance, there are societies around the world where a woman can’t breastfeed until the religious leader tells her to. Her child isn’t getting colostrum and may actually be starving for a couple of days before she can breastfeed. Sometimes they give the child goat’s milk or a substitute made with dirty water, and that has huge implications for the child’s life and development.
So breaking down the barriers around women and giving them the information they need for themselves and for their kids is transformative—it’s what we’ve got to do. That’s why I’m so intent on making sure that we collect more data about women so we can understand what we need to program for them. We just put $80 million behind an initiative specifically to gather data about women.
What’s one area where you want to collect more data?
Maternal death is a great example. Reporting has to be done by country, but even inside the country, it’s got to be done by district and by region. Then you can actually start to see: Maybe most of the maternal death is taking place in one region. Why is that? Well, maybe they don’t have the right health facility or the right outreach or the right tools. They might have the health facility and the right outreach, but if they don’t have a blood pressure cuff to take a woman’s blood pressure, she’s in trouble. So you have to have enough data to be able to take apart the problem and know where to intervene.
Effective philanthropy is incredibly important to the foundation. How do you gauge effectiveness?
We do the work because of the heart tug, but we also want to know we get results. If you put down money, you want to get the “best buy” you can to make the most difference in the world. That's just common sense. So we actually set up data systems to measure things like: Where is the most malaria? How many malaria bed nets are getting out, and are they getting where we think they ought to go, and are they actually getting used? Where there are good data systems, we use them. Where there are just okay data systems, we try and make them more robust. And where there are none, we actually had to go out and build them.
We’re finding that women will let you into their homes and talk very readily about their lives. Sometimes there are access issues, like the husband will turn you away. But the woman will come out right after and say, “Come back at such and such time,” or, “Meet me at the market at such and such time,” which means she has something she wants to tell the interviewer. We end up learning a lot, not just about what we care about, but what they care about. So we are really starting to hear about what women’s lives are like around the world.
In the past, we didn't spend the money to ask women about their lives and collect the data. But there’s huge value in it. We start to learn where we make mistakes. Here’s a great example: We are involved in trying to get a drought-resistant seed out to farmers—more than half of farmers in the developing world are women. We assumed that if we got the old seed system up and running, we would get the seed equally in the hands of men and women. It turns out if you make that old seed system robust, you predominantly reach the men, not the women. So we had to ask the question: If we’re trying to reach the women, how do we get the seed to them?
How has your global work with the foundation affected your work in the United States?
As I’ve come back home from these trips, I’ve thought, “Women are not that empowered in [this] country I’d just been in.” But I’ve also had to ask myself, “How empowered are women in the United States?” We’ve gone a certain distance, but we still have a long way to go.
In terms of education, women are on the rise. We’re seeing more girls educated and doing well in college. All of these statistics are actually quite good. But only 17 percent of computer science graduates are women. That’s a huge problem, particularly when you think about the fact that there isn’t a business in the United States that doesn’t need some piece of technology. Somebody’s got to run it or program it or create the new business app. These are some of the best jobs in society, and if women aren’t qualified to take them, that’s a problem.
Another [problem] is women in leadership roles. Until we see lots of female CEOs of Fortune 500 companies, lots of women in Congress—not something around 20 percent—and lots of women in state legislatures, we’re just not going to get there. Girls have to be able to look up and say, “Oh, I don’t want to be like those five, but I could be like those two.” It’s really important for them to have those role models in society.
I was just meeting with a group of state legislators in Oregon where they actually do have a majority of female congressional leaders at the state level. They’re making different choices and looking at things like equal pay and family leave. The priorities are different, because women live different lives than men. There are tons of enlightened men who are great at this, but they have to help lift women up. Until we get women up to those equal levels, we just won’t get an equal society.
Earlier this year, the foundation changed its policy on parental leave. The new policy allows mothers and fathers to take a year of paid leave after having or adopting a child. Is that one of the things you’re using your voice for?
Yes, and this is something I’ve become very passionate about.
This policy is an investment in women, because poor parental leave policy can be a barrier for women in the workforce.
Huge. We need to balance work and family life. I knew I was going to speak out about this issue [globally], and I thought, “I can’t go out and say it’s the right thing for the world if we aren’t modeling it inside our own foundation.” We did it to “walk the talk” of what we believe in. We’re a purpose-driven foundation, living out the values that Bill and I have. I hope my son and my daughters someday are in companies that allow family leave, so we need to model this. We need to use our voice in the world to say, This is what’s right.
If you look at the really great parental leave policies in Europe, there’s a lot of good data about what makes them work. We know they need to be gender-neutral, and we know that if you can have the father take it, not just the mother, it has different positive outcomes for kids long-term. If Mom takes more time off, she’s better off, and the kids are going to be better off [because of] better feeding early on. For instance, breastfeeding rates go up if women have more time off, and we know that’s the gold standard for kids. If Dad takes time off, there are different benefits. Men spend more time caregiving if they start early, and that helps with the balance of roles in the household. Plus, kids are better off cognitively and emotionally.
A few states have started offering paid parental leave: California, Massachusetts, New Jersey, and Rhode Island. There was a lot of pushback originally in California, particularly from the Chamber of Commerce and small businesses. After they had their policy implemented well over a year, though, they started to see that there wasn’t a huge effect on business. They are able to make it work.
In just the first few months of our policy being in place [at the foundation], I’m seeing lots of people take it. It’s not any easier on us if a woman takes off or a man takes off. It’s hard in both cases, but you adjust. You train up the newer employees or the more junior person earlier than you may have otherwise, which benefits the company and that person, too. It forces managers to spend more time [training], and that’s not a bad thing. Then when the person comes back from leave, you have two trained employees.
Looking forward, what’s your vision for the Gates Foundation?
The foundation is the embodiment of our values. So we’re putting our hearts, our minds, and our money behind that every single day, and we think of it as a huge responsibility. We want to do it incredibly thoughtfully and incredibly well, because it’s a gift to be in the situation we’re in.