There's a lot to celebrate today: It's the third International Day for Maternal Health and Rights, a day the Center for Health and Gender Equity created two years ago to promote quality maternity care. The WHO reports that between 1990 and 2015, global maternal mortality dropped by 44% — but that means that every day, 830 women still die from complications of pregnancy and birth. That's one death every two minutes.
As obstetrician, gynecologist, and Merck for Mothers executive director Dr. Priya Agrawal attests, the United States contributes a shockingly high number of deaths to that figure.
"There's a complacency issue," she tells Refinery29. "People are not aware that this is happening here... It's the U.S., of course this isn't happening here, it's an issue over there."
Maternal mortality, however, is an issue here, and a serious one: 700 to 800 American women die during pregnancy or soon after birth each year, and the U.S. maternal mortality rate has more than doubled in the past few decades. In fact, the U.S. is the only developed country in the world in which the maternal mortality rate is climbing. This dismal fact is one of the reasons why Merck for Mothers — a 10-year, $500-million-dollar maternal health initiative launched in 2011 — is focusing on improving outcomes for mothers in the U.S. as well as India, Senegal, Zambia, and Uganda, with Dr. Agrawal at the helm.
We spoke with the global women's health expert at last week's Women in the World Summit about why maternal health cannot be forgotten or ignored.
What sparked your passion for maternal health?
"I am one of three girls. My mom hails from the state with the highest maternal mortality in India, but she had all of us in the U.K., and she nearly died in pregnancy with my sister. And I remember at that point really thinking, Oh wow, what would my life be like in a South Asian patriarchal extended family if my mum wasn't there? She was my sponsor. So that's when I think I became aware of the void mothers leave. And then the corny thing: My purpose is making this world a better place for girls and women. I love Sheryl Sandberg's Lean In, but there's no leaning in if you're not alive. So let's start with the basics; let's make sure you survive childbirth, and that you're there for the rest of the community." Over the past decade and a half, you've conducted research and implemented healthcare innovations in around 45 countries. How has the maternal healthcare landscape changed in this time?
"Maternal health did not have the attention or funding when I first started, so I actually started in cervical cancer, which has similar numbers of deaths — and that's really because no one was really talking about maternal health. I have to give a lot of credit to Women Deliver and the leaders behind that, because they really got the advocacy going. "[Because maternal mortality has decreased,] people...[say,] 'Oh well, road traffic accidents are affecting more, and cardiovascular disease,' and you're like, 'Yes, but you're not actually totally measuring the impact well.' You lose a mom, you [also] lose the baby, the other children don't go to school, the father often has to stay home, the community doesn't have a worker — so that's why healthy women [mean] healthy communities, healthy nations." The statistics on maternal mortality in the U.S. are both shocking and little-known. What's going on?
"I think in the U.S., there isn't much awareness... Second, I have to say, do we even value women in this society? We don't even count the maternal deaths in this country. If you're not counting them, they don't matter — you measure what matters. "Then, beyond that, it's a huge issue of chronic diseases, so one in five pregnant women [in the U.S.] will be diabetic, obesity's on the rise, hypertension...so people are just getting into pregnancy sicker. And the last thing that actually shocked me, as well as the not counting maternal deaths...is there's no standard way of dealing with obstetric emergencies [in this country]. There's no code blue. If you have a heart attack, a man has a heart attack, the hospital knows exactly what to do. The ambulances talk about the Golden Minute, you go in, everyone's like, Okay, there's a protocol. "You bleed after childbirth, you have high blood pressure, you have a pulmonary embolism — the three biggest causes of mothers dying in this country, [there's no protocol for that]. If I'm on call, the nurses are like, 'Oh, Dr. Agrawal would like this done, but another doctor's on call, I think they want that done'... So [first we need to] count the deaths, learn what happens so it doesn't happen again. Second...let's have some standardized care like we do for more male diseases. And third, we've got to fix the system where community and facility health come together for the chronic diseases." We're also seeing huge disparities in maternal health outcomes for white women and women of color. How can we explain these and what can we do about them?
"In [Merck For Mothers'] lifetime of three years of programming in New York City, it used to be an African-American woman had seven times the risk of dying than a white woman. It's now 12 times...but we don't actually know why. There's a lot of theories. What Merck for Mothers is now proposing is to do more to uncover the why, so you'll see a lot of announcements in the next six months where we're actually digging deeper with a lot of our partners. Is it happening in the hospital? Is it something that's happening in the community? We do know that education, income, the usual things that people think are related are not the causes. If you look at the statistics, a rich, educated black woman still has four times the risk of dying than a rich, educated white woman, and some of the new data that's going to come out is going to show that a rich, educated black woman still has a much higher risk of dying than a poor, uneducated white woman. "We're finding [that having] a checklist, so moms know what danger signs to look out for, is literally saving lives. I'm getting stories in my inbox of, 'Well I had this checklist, I went home, and I felt that shortness of breath, so I went into the hospital.' "[Internationally,] we're really supporting the private entrepreneurs on the ground...90% of India goes to seek health care from the private sector. We need to strengthen [that]. So my hope is that by the time Merck for Mothers has ended, maternal health isn't something we'd need to continue worrying about. We won't have Merck for Mothers, because there won't be a need." So in the U.S., you're focusing on standardizing care, and internationally, you're focusing on bolstering the private sector. What are the commonalities in how you're tackling maternal mortality around the world?
"A safe delivery [after] a happy pregnancy is a universal wish, expectation, and right. How do you make sure everyone has the same expectation? Women here expect that everything's going to be fine and actually that's causing a problem when they leave the hospital, because they don't think anything could possibly go wrong. In India and Africa, they have an expectation that they could die. "One of the things we're launching [is a platform] to get women to know and then be able to weight the quality of care. So, then, other women are like, I'm not going there...because [they won't] give me quality care. [Ed. note: Merck for Mothers' website describes this project as a 'free mobile platform that uses interactive voice response technology to reach low-income women with limited literacy, [allowing] women [in India] to rate the care they receive and hold private providers accountable for delivering high quality services.'] "Demand better care. It's the same here. If I was pregnant here, maybe I will be, I would like to ask the hospital, 'Do you have standardized protocols? No? Maybe I'm not interested, because maybe you don't have safety at the top of your mind'... Our thing is: Empower women, get the right products and technologies to the people, and empower the people that are on the ground, fighting the fight."
"I am one of three girls. My mom hails from the state with the highest maternal mortality in India, but she had all of us in the U.K., and she nearly died in pregnancy with my sister. And I remember at that point really thinking, Oh wow, what would my life be like in a South Asian patriarchal extended family if my mum wasn't there? She was my sponsor. So that's when I think I became aware of the void mothers leave. And then the corny thing: My purpose is making this world a better place for girls and women. I love Sheryl Sandberg's Lean In, but there's no leaning in if you're not alive. So let's start with the basics; let's make sure you survive childbirth, and that you're there for the rest of the community." Over the past decade and a half, you've conducted research and implemented healthcare innovations in around 45 countries. How has the maternal healthcare landscape changed in this time?
"Maternal health did not have the attention or funding when I first started, so I actually started in cervical cancer, which has similar numbers of deaths — and that's really because no one was really talking about maternal health. I have to give a lot of credit to Women Deliver and the leaders behind that, because they really got the advocacy going. "[Because maternal mortality has decreased,] people...[say,] 'Oh well, road traffic accidents are affecting more, and cardiovascular disease,' and you're like, 'Yes, but you're not actually totally measuring the impact well.' You lose a mom, you [also] lose the baby, the other children don't go to school, the father often has to stay home, the community doesn't have a worker — so that's why healthy women [mean] healthy communities, healthy nations." The statistics on maternal mortality in the U.S. are both shocking and little-known. What's going on?
"I think in the U.S., there isn't much awareness... Second, I have to say, do we even value women in this society? We don't even count the maternal deaths in this country. If you're not counting them, they don't matter — you measure what matters. "Then, beyond that, it's a huge issue of chronic diseases, so one in five pregnant women [in the U.S.] will be diabetic, obesity's on the rise, hypertension...so people are just getting into pregnancy sicker. And the last thing that actually shocked me, as well as the not counting maternal deaths...is there's no standard way of dealing with obstetric emergencies [in this country]. There's no code blue. If you have a heart attack, a man has a heart attack, the hospital knows exactly what to do. The ambulances talk about the Golden Minute, you go in, everyone's like, Okay, there's a protocol. "You bleed after childbirth, you have high blood pressure, you have a pulmonary embolism — the three biggest causes of mothers dying in this country, [there's no protocol for that]. If I'm on call, the nurses are like, 'Oh, Dr. Agrawal would like this done, but another doctor's on call, I think they want that done'... So [first we need to] count the deaths, learn what happens so it doesn't happen again. Second...let's have some standardized care like we do for more male diseases. And third, we've got to fix the system where community and facility health come together for the chronic diseases." We're also seeing huge disparities in maternal health outcomes for white women and women of color. How can we explain these and what can we do about them?
"In [Merck For Mothers'] lifetime of three years of programming in New York City, it used to be an African-American woman had seven times the risk of dying than a white woman. It's now 12 times...but we don't actually know why. There's a lot of theories. What Merck for Mothers is now proposing is to do more to uncover the why, so you'll see a lot of announcements in the next six months where we're actually digging deeper with a lot of our partners. Is it happening in the hospital? Is it something that's happening in the community? We do know that education, income, the usual things that people think are related are not the causes. If you look at the statistics, a rich, educated black woman still has four times the risk of dying than a rich, educated white woman, and some of the new data that's going to come out is going to show that a rich, educated black woman still has a much higher risk of dying than a poor, uneducated white woman. "We're finding [that having] a checklist, so moms know what danger signs to look out for, is literally saving lives. I'm getting stories in my inbox of, 'Well I had this checklist, I went home, and I felt that shortness of breath, so I went into the hospital.' "[Internationally,] we're really supporting the private entrepreneurs on the ground...90% of India goes to seek health care from the private sector. We need to strengthen [that]. So my hope is that by the time Merck for Mothers has ended, maternal health isn't something we'd need to continue worrying about. We won't have Merck for Mothers, because there won't be a need." So in the U.S., you're focusing on standardizing care, and internationally, you're focusing on bolstering the private sector. What are the commonalities in how you're tackling maternal mortality around the world?
"A safe delivery [after] a happy pregnancy is a universal wish, expectation, and right. How do you make sure everyone has the same expectation? Women here expect that everything's going to be fine and actually that's causing a problem when they leave the hospital, because they don't think anything could possibly go wrong. In India and Africa, they have an expectation that they could die. "One of the things we're launching [is a platform] to get women to know and then be able to weight the quality of care. So, then, other women are like, I'm not going there...because [they won't] give me quality care. [Ed. note: Merck for Mothers' website describes this project as a 'free mobile platform that uses interactive voice response technology to reach low-income women with limited literacy, [allowing] women [in India] to rate the care they receive and hold private providers accountable for delivering high quality services.'] "Demand better care. It's the same here. If I was pregnant here, maybe I will be, I would like to ask the hospital, 'Do you have standardized protocols? No? Maybe I'm not interested, because maybe you don't have safety at the top of your mind'... Our thing is: Empower women, get the right products and technologies to the people, and empower the people that are on the ground, fighting the fight."