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In today’s AMA Update, Sandra Fryhofer, MD, and Nicole Plenty, MD, discuss the new CDC data showing a 40% increase in maternal deaths in the U.S. and what physicians and patients can do to improve maternal health outcomes. AMA Chief Experience Officer Todd Unger hosts.
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- Sandra Fryhofer, MD, chair, AMA Board of Trustees
- Nicole Plenty, MD, division director, Wellstar Maternal-Fetal Medicine
Unger: Hello and welcome to our AMA Update video and podcast series. Earlier this month, we recognized Black Maternal Health Week. And today, we're continuing this important conversation and spotlighting one of the most worrisome trends in health care—the increasing maternal mortality rates in the U.S.
I'm joined by Dr. Sandra Fryhofer, the AMA board chair and a board-certified internal medicine specialist, to get her perspective and hear about the AMA's work in this critical area. Later, I'll be speaking with Dr. Nicole Plenty, a double-board certified OB-GYN physician and maternal-fetal medicine specialist who works daily to decrease maternal mortality and morbidity.
I'm Todd Unger, AMA's chief experience officer in Chicago. We'll begin with Dr. Fryhofer. Welcome back.
Dr. Fryhofer: Hello, Todd and thanks for having me.
Unger: Dr. Fryhofer, the CDC just released new data about maternal mortality in the U.S. Let's start by having you tell us a little bit more about the latest update.
Dr. Fryhofer: Well, Todd, this trend is very disturbing. The number of maternal deaths in the United States increased by 40% from 2020 to 2021. CDC released these new numbers just last month in March. In 2021, 1,205 maternal deaths were reported, up from 861 maternal deaths in 2020.
These more than 1,200 maternal deaths translate to a maternal mortality rate of 32.9 deaths per 100,000 live births for 2021, up from 20.1 in 2019 and a maternal mortality rate of 23.8 in 2020.
Unger: Dr. Fryhofer, to dig a little bit deeper into those numbers, were there any differences in mortality rates among historically minoritized and marginalized communities?
Dr. Fryhofer: Yes and those trends are even more worrisome. Maternal death rates for Black women were more than two and a half times those for white women. For 2021, the maternal mortality rate for Black women was 69.9 deaths per 100,000 live births, which is 2.6 times the mortality rate for white women.
For white women, the maternal mortality rate was 26.6 deaths. For Hispanic women, the maternal death rate was 28 maternal deaths per 100,000 live births.
The study also found maternal death rates increased with maternal age. The maternal mortality rate for older moms, those age 40 and older, was more than 6.8 times higher than for younger women, those under 25. However, increases in maternal death rates for each of the age groups was also significant.
Unger: Do you think that these numbers were affected by the COVID pandemic?
Dr. Fryhofer: Well, that's a great question. And certainly, COVID did have a negative effect. We know pregnant or recently pregnant people are more likely to get sicker from COVID as compared to those who are not pregnant. We also know that getting a COVID vaccine can help protect pregnant people from getting really sick.
CDC data also show Black women have lower COVID vaccination coverage during pregnancy as compared to pregnant women from other racial and ethnic groups. WHO's global look at the effect of COVID on maternal mortality recognizes more deaths being due to being pregnant and getting COVID, as well as more deaths due to pregnancy complications, either not prevented or not properly managed due to disruption in health care services during the pandemic.
These numbers reveal the ever-widening gap in care that disproportionately affects Black women and reflects inequities and access to quality health care. But understand, we have a crisis in care for pregnant women in the United States. Certainly, the pandemic impeded progress, but this problem predated COVID. The pandemic further exposed longstanding inequities in care, including maternal care.
Unger: And that's a theme that really pops up over and over and over again, your point here that this is a trend that predated COVID and has gotten worse. Clearly, then, we haven't been heading in the right direction for years. Maternal mortality rates in the U.S. are now the highest since 1965. That is shocking. How do we get here?
Dr. Fryhofer: Well, sadly, this is true. We are here and CDC says Black women are three times more likely to die from a pregnancy-related cause than white women. Multiple factors contribute to these inequities, including variations and quality of and access to health care, underlying chronic conditions, as well as structural racism and implicit bias. Social determinants of health prevent many people from historically minoritized and marginalized communities from having fair opportunities for economic physical and emotional health.
AMA has also identified other factors which contribute to poor maternal outcomes. These include lack of insurance or inadequate insurance coverage prior to, during and after pregnancy. Also, lack of interprofessional teams trained in best practices, as well as closure of maternity units in many rural and urban communities—this is also an additional factor that leads to poor maternal outcomes.
Unger: Absolutely. Dr. Fryhofer, while OB-GYNs are well versed on this issue, it's not on any one specialty, of course, to fix these problems that are very systemic. Why do all physicians need to get educated on this particular issue and be part of the solution?
Dr. Fryhofer: Well, certainly OB-GYNs are on the front line of caring for pregnant people, but this is everyone's problem. Maternal mortality affects everyone in our society.
Unger: The AMA has been and continues to be an outspoken advocate on this issue at the federal and state levels. Late last year, the data mapping to Save Mom's Lives Act was signed into law with the AMA support. Dr. Fryhofer, how does this law help address the issues of maternal mortality that we've talked about today?
Dr. Fryhofer: This law identifies where maternal mortality rates coincide with lack of broadband services and aims to help ensure these regions have access to telehealth services that pregnant women need for better care and which could be life-saving. AMA supports ensuring new mothers have access to and coverage of telehealth services and broadband and internet-connected devices so barriers to access to postpartum care are reduced.
Unger: In addition to our support of that particular legislation, the AMA has also been urging policymakers to take other concrete actions. Tell us a little bit more about what the AMA is calling for and how it can help reduce deaths.
Dr. Fryhofer: Well, AMA has advocated for expanding access to medical and mental health care and social services for postpartum women. The American Rescue Plan Act signed into law on March 11, 2021, makes available an additional pathway that now allows states to extend Medicaid coverage for pregnant women from 60 days to one-year postpartum. This pathway is a state plan amendment, and is also referred to as a SPA, and became effective in April of 2022.
AMA's advocacy efforts also include urging policymakers to increase support for maternal mortality review committees with equitable standardized data collection methods. We also continue to work towards developing a health care workforce that's diverse in background and experience.
We also advocate for standards to ensure respectful, safe and quality care before, during and after delivery. To quote our AMA CEO and new grandfather, Dr. Jim Madara, "Pregnancy, childbirth and the postpartum period will always carry some degree of risk. But we, as a nation, must do all we can to minimize that risk and help ensure that mothers and their babies thrive throughout pregnancy and for the rest of their lives."
Unger: That's a great quote. Thank you very much, Dr. Fryhofer, for joining us today and sharing more information about the AMA's advocacy efforts on this important issue.
Now we're going to turn to Dr. Nicole Plenty for her perspective and experience treating pregnant people and her personal efforts to make pregnancy safer. Dr. Plenty, welcome back.
Dr. Plenty: Thanks for having me, Todd.
Unger: Well, Dr. Fryhofer shared some of the biggest factors behind the increase in maternal deaths, which the CDC defines as happening during pregnancy or within that 12 months after. In your work with patients, what do you see as driving poor maternal health outcomes?
Dr. Plenty: Well, I think that there's a lot of factors that drive maternal health outcomes. As a high-risk specialist, of course, I'm dealing with patients that have underlying co-morbidities. And so I see that a lot of times patients are not controlled when they come into the pregnancy. So people are not getting as much prenatal care or preconception care early on or before pregnancy.
And if people would get care before they get pregnant to make sure their hypertension is controlled or their diabetes is controlled, then that would help offset the risk of having complications later on in pregnancy. So, a lack of preconception care is a big driving factor.
Secondly, people don't have access to care. So patients that see me are driving from hours and hours away sometimes to get their ultrasounds or to get their consult. And you can see if somebody has heart disease and we need to control their blood pressures, it can be a little limiting if you have to drive two hours for your follow-up appointment. So that leads to noncompliance just because we don't have enough high-risk specialists or OB-GYNs in the community to take care of patients that have these high-risk conditions.
And then, of course, now with the way medicine is, people are rewarded for volume. And because of that, a lot of OB-GYNs, and even MFMs, are stretched somewhat thin. Like, we're seeing patients in the clinic, but we may have to run out and go do a delivery. So that limits the time that we are spending with patients.
And unfortunately, if you have other providers that may not know that patients history that come in and try to cover physicians while they're out doing other things, which are important, obviously, but not taking care of that patient during their actual clinic visit, it can lead the patient to not feel comfortable talking to that other provider. Or the other provider may not be aware of the barriers that patient is going through.
And then, of course, bias. Bias has a big part in maternal morbidity and mortality. And a lot of it is unconscious, right. I think that most doctors go into medicine because we want to help people. We want to make sure they get safely through the pregnancy.
But because of things that we've heard or even maybe the experiences we've had with certain cultures or certain groups, it could lead us to believe that people are complaining too much or if they're complaining of pain but they're texting on their phone. So we then assume that they're not in as much pain as they really are in.
So sometimes these biases can lead us to either over-treating patients or under-treating patients. But there's just a lot of factors that lead to this increase that we're seeing.
Unger: Well, let's just talk a little bit more in detail about this particular aspect which really is rooted in systemic racism. How do you advise patients, particularly Black patients, how to advocate for themselves, especially in those circumstances you just describe where they may be seeing someone they're not familiar with, not comfortable, just to ensure they're getting the care that they deserve?
Dr. Plenty: So, what I usually tell people is, one, make sure you feel comfortable with the provider that you choose. So if you are someone that has never been pregnant before, go and look at the provider's videos, look at their feedback, get suggestions from other friends and family that you're close to to see who do they like.
If this is your second pregnancy and you didn't have a good experience with your first provider, it doesn't mean you have to go back to the same provider. You can choose another provider.
And as a provider, we don't like to think of us being an option that people shop for. But we are options. We are doing a service for patients. And so if a patient does not feel comfortable with their provider, they should get a new provider and get that new provider early.
I also tend to talk to my colleagues very bluntly because I get consulted sometimes because patients are labeled as difficult, right? If this patient has preeclampsia, which is when you have high blood pressure and vascular damage, and I'm recommending a delivery and they're being difficult. So can you go and talk to this person and tell them they need to be delivered.
And so sometimes the way you deliver things really does impact patients and the way they trust you. So trying to empathize with patients and saying, hey, why is it that you don't want to be delivered? Like, let me explain to you what the risks are of not being delivered.
Sometimes just people taking the time to see what their barriers are makes a big difference in patients and how they trust the provider. So I always talk to my colleagues and say, "Did you explain to them what was going on, because some of this you don't need a high-risk provider to come in and do. So did you take the time to explain?"
And nine times out of 10, they're busy, right? And that's because of the environment we live in. That is obviously punishing people that take more time with their patients, unfortunately, and rewarding people that have high volume but that may not take the time to show empathy to their patients.
And that lack of empathy to a lot of Black and Brown women looks like this person doesn't care about me. And that may not be racist to the provider. But to a woman that comes in already knowing that the odds are against her making it through this pregnancy, it looks like this person doesn't care about the health of me or my baby. So we do need to, as providers, slow down and stop what we're doing to make sure that patient feels the empathy from us.
Unger: One of the other obstacles that you brought up is this issue around access. One of the solutions that the AMA advocates for here, of course, is greater use of telehealth. Talk to us a little bit about how you've been using telehealth with your patients before, during and after their pregnancy to help improve outcomes.
Dr. Plenty: Well, telehealth has exploded during the pandemic. And as an MFM provider that does a lot of consultation—meaning, I'll do an ultrasound of the patient's baby—but a lot of the care that I give is talking to the patients to figure out what's really going on with you or your baby and talking to them about how their care will change and providing guidance to the general OB-GYNs so they know what to do and when to deliver them.
So a lot of my consultations were done virtually before the pandemic. And after once the pandemic happened, then almost all of them were virtual.
Now I'm back in person. And so, I only do preconception consultations virtually. And that's because if you're coming in for your ultrasound, then I can do your consult right after your ultrasound because you're already there.
But for preconception visits, I don't have to do a physical exam. I'm literally going through your history and saying, "These are the labs that you need to have done. You can go to the lab, get them done. The lab then sends me the results. I can review them and then call you and then give you further guidance."
So the virtual world is great for maternal-fetal medicine specialists because we can do a lot of that preconception care without the patient having to come in. And during the—I call it the wards of COVID, it was crucial for us to try to keep people away from the clinic. We don't want pregnant patients coming in and being exposed to COVID-19.
And pregnancy in itself is a high-risk condition for moms passing away due to COVID. So we literally try to keep them out of our clinics and out of the hospital as much as possible. And luckily, they still have access to that convenience and don't have to drive three and four hours for those follow-up consult visits even now.
So our diabetics, we can see them once a month. Between that, they can email us their glucose logs. We can talk to them on the phone and tell them how to adjust their own insulin without them having to come in.
So it's been good in terms of access. It's been great in terms of not having to over-bill patients. Because if we can just send you a reply email, that's less money the patient has to spend because we don't have to bill them for a visit. So for us, it's been great. So that's the bittersweet of the pandemic.
Unger: Well, speaking of digital tools, you have your own podcast where you educate patients about every aspect of pregnancy. What inspired you to create the podcast?
Dr. Plenty: Well, I started the podcast during the pandemic. And that was because I relocated from Indianapolis. And a lot of those patients weren't comfortable with their providers. And I was the basic sole high-risk provider at the institution that I was working for.
And so, the OBs were texting me and saying, can you just talk to this person? Like, I don't know how you would bill for this, but can you talk to this person? And I started getting the same questions over and over. And so, I said, you know what, I should probably put this information out there.
And so initially, I started a YouTube channel to give people information about those bread-and-butter high-risk topics. And a friend of mine who worked for Radio 1 at the time said, hey, we want you to join our podcast network and put this information out on a more regular basis.
So then I started Pregnancy Pearls with Dr. Plenty. And people will contact me on social media, they'll ask me questions. And I basically stockpile those questions and talk about that topic for the upcoming week, depending on the questions that I have.
And so, for me, it's a way to get information out to patients for free. It's a way for me to answer questions via social media if they have quick questions. It's also a way for me to keep in touch with people that I've met across the country.
And now the thousands of listeners that I have, it's a way for me to interact with them and give them more information and make sure that that information is ACOG guideline, or the American College of Physician guidelines, so that they're not googling.
Google is very good for different things. It's good for shopping. It's great for trying to find maybe a new house to look up Zillow and things like that. But it's really not good for medical advice. And chat groups and Facebook groups aren't good for that either because people will share their own personal opinions about what's going on with them, which may not necessarily be applicable for everyone else.
So I wanted to make sure that patients got that information. And after I almost, honestly, died, Todd, with my own child and had an extremely high-risk pregnancy, I realized that people that I have access to don't necessarily have access to that, right? I can handpick my own OB-GYNs who's my best friend, who handpicked my hematologist and cardiologist and pulmonologist. Yes, Todd, I had a very high-risk pregnancy.
But I knew everyone taking care of me, and I could text them at home and I could ask them if I should come in. Patients don't have that. And through the podcast and social media, I'm able to be a little bit of that for people that listen.
Unger: Well, just talk to us a little bit more about what you just mentioned. I mean, the theme of this particular update is around maternal morbidity. You yourself have had, as you said, a very high-risk pregnancy. You have the privilege of knowing those that are treating you.
What advice do you have coming out of this particular situation for you? Is there something that you learned that you want to pass on to patients or other physicians out there?
Dr. Plenty: So the main thing that I learned is that people need to open their mouths. And it doesn't matter if you're a provider. It doesn't matter if you are the layperson that works at Walmart. If you have questions, you should ask them. Don't assume that your providers know.
And initially, even as a provider, I was like, well, they already know to do these things, right. And once I got pregnant, at 10 weeks, I end up having a really big blood clot in my leg, called a deep vein thrombosis, and had three blood clots that navigated to my lungs, called a pulmonary emboli.
And I assumed—I called my OB-GYN and said, "Hey, listen, I think I have a DVT. I need you to order a lower extremity doppler and I need you to start Lovenox on me, right."
And she said, are you sure? I said, yeah, I'm pretty sure. And I did my surgery that morning, which was very dangerous to do, but I did. I had a case for a patient and I did it. And then I went to the triage area where they ordered the things that I requested.
And even in that, the internal medicine doctor that came and said, well, we're going to start you on either Eliquis or—I can't remember the other—Arixtra was the other one. And I said, well, you can't do those in pregnancy. And she was, like, well, yeah we can.
And that's when I realized, OK, not everybody understands what is safe in pregnancy and what's not. And if I don't open my mouth, I may inadvertently be started, although temporarily, but I would be started on something that wasn't necessarily deemed safe in pregnancy. So even as a provider, I had to advocate for myself and say, that's not safe.
I mean, that was the main reason for starting the podcast to let people know these are the questions you need to ask your providers. You need to ask them, is there safety that's proven of this drug? I realize that everybody may not have the knowledge to know that this is not safe in pregnancy. So I need to put this out there.
So I learned that open your mouth and advocate for yourself. I also learned that if you don't feel well, tell somebody. And some doctors will be like, well, that's just normal pregnancy.
Be adamant when you say you don't feel well. Like, patients know their bodies better than we know their bodies. And so, we as providers have to trust what our patients tell us that they're not feeling well. And if somebody tells me they don't feel comfortable going home, and I'm consulted, and the OBs like, well, she don't have reason to stay, I'm going to say I'm going to keep her for an additional day just to monitor her.
And sometimes nothing happens, right? It just reassures the patient that we're watching them. But sometimes something does happen. So we need to listen to and trust the patients.
So I always tell patients advocate for yourself. If somebody says it's pregnancy, it may be a pregnancy symptom. But we need to prove to you that this is a normal pregnancy symptom once we rule out other issues that this could be.
And Todd, I know I'm speaking from a high-risk standpoint because obviously, I see the bad stuff that can happen. And so when I see patients, I'm always thinking, OK, let me rule this out. It's not this because of these things.
But I also explain to the patient, have a very low suspicion for any of these things because of this. And most of the time when I explain to the patient, they're accepting of that. But patients have to be able to understand that.
So, I always tell people, advocate, advocate, advocate for yourself. And if you need a second opinion, that's not insulting to a provider. Just say, you know what, I really just don't feel good, I would like a second opinion.
That's not harmful, that doesn't hurt the provider. We will make sure you get the second opinion that you need to feel comfortable with the decisions that we are suggesting.
Unger: Dr. Plenty, thank you so much for joining us and really for sharing your experience, both as a patient and a physician, on what is an enormous challenge in health care right now.
That concludes our special AMA Update on the rise of maternal morbidity in the U.S. and how we can address this growing crisis. We'll be back soon with another AMA Update. You can find all our videos and podcasts at ama-assn.org/podcasts.
Thanks so much for joining us. Please take care.
Dr. Plenty: Thanks, Todd.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.