What are the primary causes of maternal death?
The leading causes of death differ across states. In Colorado, the No. 1 maternal health-related killer is unintentional or intentional overdose or other suicide, particularly in the postpartum period. About 35% of people who die, intentionally or unintentionally, have an opioid in their system. That just shows how the opioid crisis is impacting the perinatal population. To add to the challenges, oftentimes the substance-use disorder coincides with a perinatal mood disorder. So depression and anxiety also are a big part of the puzzle.
Recently released Centers for Disease Control and Prevention data for 2019 and 2020 revealed a surge in maternal-related deaths fueled largely by high rates within the Hispanic and Black population. What are your reactions to that report?
I’m not surprised. We know that we have a crisis within our healthcare and hospital systems that is really fueled by racism and bias, and that includes obstetrics.
Black women had the overall highest maternal mortality rate, at 55.3 deaths for every 100,000 live births. That rate was nearly three times higher than the 19.1 deaths per 100,000 births among white women. What can you tell us about that substantial gap?
I think it’s the underlying racism and the care that we render. Whether it’s bringing bias to the care that we provide, not recognizing things in a timely manner, not listening to patients, it’s the challenges that exist within the systems. And when you dive into that data even more, someone who is Black and educated and in a higher social demographic class is still more likely to die than a white person.
Among women with a college education or higher, Black women have an over five times higher pregnancy-related mortality rate compared to white women (Kaiser Family Foundation).
How would you describe the effects of postpartum depression on women you’ve seen?
There’s profound sadness, loss of interest in doing things, exhaustion, anxiety, fear. It’s feeling like they are failing or not living up to what they should do. I’ve heard people who have depression and a component of anxiety express feeling almost paralyzed, unable to get out of bed, unable to move, unable to care for themselves or child.
“There’s profound sadness, loss of interest in doing things, exhaustion, anxiety, fear.”
I think what comes with that is just this enormous guilt. ‘I’m supposed to be happy. Society tells me I should be happy. I have this amazing human being in my life that I’m supporting.’ And it’s just this guilt. I’ve had people talk about how they’ve thought about suicide, how it would just be easier if they would go away.
What do you do when you confront the issue with your patients?
I’ve had patients who have been admitted for psychiatric care. I’ve had other people who we’ve followed and cared for really closely in collaboration with some of the services at CU Anschutz on both the inpatient side and the ambulatory side as well.
Economics play a role in a woman’s overall health; one survey found Black women were more often than white women to continue to work at the cost of their own health. Do you see that?
I’ve seen people who, based on their life situation, need to go back to work too soon. So instead of someone who has a three-month leave that’s paid through their employer’s benefits package, those who don’t have that have to return to work at six weeks postpartum because they need to pay their bills or feed their other children. I’ve seen people go back even earlier, which is a shame.
What are some solutions?
Diversifying the workforce. That’s something we hear often, especially from Black pregnant people, is they want a healthcare provider who looks like them. (Diversity, inclusiveness and cultural responsiveness are prime tenets of the CU Nursing Nurse Midwifery program, which has established a scholarship to support diverse students joining the profession).
Screening. At CU Anschutz, within our OB/GYN department, we have streamlined screening for postpartum depression at certain time points during pregnancy and postpartum.
Prior to the pandemic, before healthcare moved to telehealth, I implemented a postpartum two-week mood check by telehealth. Access to care can be tough, especially when you have a baby. You have to pack up, leave your house, get to the clinic – all when you have to care for your new baby, and you’re tired. So this gave us an extra touch point with patients from the comfort of their homes that includes a provider and screening. Typically, patients are just seen at six weeks postpartum.
Continuous care. For example, at CU, if someone does have a positive screen or there are concerns for a diagnosis of postpartum depression and/or anxiety, we have a fantastic program called PROMISE, a group of providers and nurses who see patients in the clinic and include psychology, psychiatry, obstetrics, case management and social work. They care for patients who have a perinatal mood disorder diagnosis, and they follow them for one year postpartum.
The midwifery philosophy of care addresses some of these problematic gaps. Could broadened midwifery help with the maternal-death crisis?
Midwifery care has been targeted as an answer at both the state and the national level as a potential intervention. For us at CU Nursing, midwifery is about providing people options, high quality, evidence-based care, and the ability to access a care provider that seems like the right fit for them. And for me as the director of midwifery, my role is to get midwifery into communities that do not have midwives, so people can have access to the care they desire.
Are we making any progress targeting maternal deaths in the state?
The Colorado Perinatal Care Quality Collaborative (CPCQC) works with communities and families across the state to improves lives of mothers and their babies. It has three quality improvement initiatives targeting: maternal mental health; maternal substance use disorder; and substance exposed newborns. I’m on the CPCQC board, and we collaborate with hospitals to initiate these programs. The UCHealth University of Colorado Hospital, for example, is involved in all three projects.
CPCQC helps with data collection, initiating interventions and providing education for staff and providers. It’s a really robust way for continued quality improvement at the system or hospital level. And if we have all these hospitals participating in the evidence-based approach for caring for maternal mental health or maternal substance use disorder, we’re going to improve outcomes in the state. CPCQC works very closely with the health department. So, yes, we’re making progress, but we still have a lot of work to do.