How we can improve maternal healthcare -- before, during and after pregnancy | Elizabeth Howell

翻译人员: Jingdan Niu 校对人员: Tianji (Homer) Li

It was chaos as I got off the elevator.

当我从电梯里出来的时候 眼前一片混乱。

I was coming back on duty as a resident physician

作为一名住院医师，

to cover the labor and delivery unit.

我正从值班的妇产科部门回来。

And all I could see was a swarm of doctors and nurses

我所能看见的是待产室里 一大群医生和护士

hovering over a patient in the labor room.

徘徊在一名病人周围。

They were all desperately trying to save a woman's life.

他们正绝望地尝试 挽救一名产妇的生命。

The patient was in shock.

病人已经休克了。

She had delivered a healthy baby boy a few hours before I arrived.

她在我到达的几小时之前 生了一名健康的男宝宝。

Suddenly, she collapsed, became unresponsive,

突然之间，她昏倒了，毫无反应，

and had profuse uterine bleeding.

并且开始血崩。

By the time I got to the room,

当我到达房间，

there were multiple doctors and nurses, and the patient was lifeless.

里面有各种医生和护士， 而病人生命迹象微弱。

The resuscitation team tried to bring her back to life,

复苏组尝试使她恢复意识，

but despite everyone's best efforts,

但是尽管每一个人都尽力了，

she died.

她还是走了。

What I remember most about that day was the father's piercing cry.

我对那一天记忆最深刻的 是那位父亲撕心裂肺的哭声。

It went through my heart and the heart of everyone on that floor.

那哭声刺激了我的心， 以及那层楼所有人的心。

This was supposed to be the happiest day of his life,

那一天本应该是他 生命中最快乐的一天，

but instead it turned out to be the worst day.

但是最后却变成了最糟糕的一天。

I wish I could say this tragedy was an isolated incident,

我希望我可以说 这场悲剧是一个个案，

but sadly, that's not the case.

但遗憾的是，并不是这样的。

Every year in the United States,

在美国，每一年

somewhere between 700 and 900 women die

有700至900名妇女

from a pregnancy-related cause.

死于与妊娠相关的原因。

The shocking part of this story

这个故事令人震惊的部分在于

is that our maternal mortality rate is actually higher

我们的产妇死亡率实际上

than all other high-income countries,

高于其他高收入国家，

and our rates are far worse for women of color.

并且这个概率在有色人种 的女性身上更加糟高。

Our rate of maternal mortality actually increased over the last decade,

在过去一个世纪我们的 产妇死亡率实际上增加了，

while other countries reduced their rates.

与此同时其他国家降低了。

And the biggest paradox of all?

这里最大的悖论是什么？

We spend more on health care than any other country in the world.

我们在医疗保健上有着 比其他所有国家都要高的花费。

Well, around the same time in residency that this new mother lost her life,

当然，几乎与在住院时 那位新母亲失去生命的同时，

I became a mother myself.

我成为了一名母亲。

And even with all of my background and training in the field,

尽管我有着这个领域 所有的背景和培训，

I was taken aback by how little attention was paid

我仍然对无法保证一个高质量的

to delivering high-quality maternal health care.

孕期保健而震惊。

And I thought about what that meant, not just for myself

我思考着这意味着什么， 不仅仅是对于我，

but for so many other women.

而是对于许许多多的妇女们。

Maybe it's because my dad was a civil rights attorney

也许因为我的父亲 是一名民权律师，

and my parents were socially conscious

并且我的父母非常具有社会意识，

and demanded that we stand up for what we believe in.

并且要求我们要坚持自己的信仰。

Or the fact that my parents were born in Jamaica,

或者是因为事实上我的 父母出生在牙买加，

came to the United States

移民到了美国，

and were able to realize the American Dream.

并且能够实现他们的美国梦。

Or maybe it was my residency training,

又或者是我的住院医师培训，

where I saw firsthand

使我直接地看到了

how poorly so many low-income women of color were treated

医疗系统是多么恶劣的对待

by our healthcare system.

许多有色人种的妇女的。

For whatever the reason, I felt a responsibility to stand up,

不论是因为哪一个原因， 我感觉到我有责任站出来，

not just for myself,

不仅仅为我自己，

but for all women,

而且为了所有的女性，

and especially those marginalized by our healthcare system.

尤其是那些被我们 医疗系统所边缘化的。

And I decided to focus my career on improving maternal health care.

所以我决定将我职业的重点 放在改善孕产期医疗。

So what's killing mothers?

那么是什么杀害了母亲们？

Cardiovascular disease, hemorrhage,

心血管疾病，大出血，

high blood pressure causing seizures and strokes,

高血压引发癫痫和中风，

blood clots and infection

血栓和感染

are some of the major causes of maternal mortality in this country.

则是我们国家孕产期 死亡的部分主要原因。

But a maternal death is only the tip of the iceberg.

但是孕产期死亡仅仅是冰山的一角。

For every death, over a hundred women suffer a severe complication

每一类死亡，超过 100名女性都遭受了

related to pregnancy and childbirth,

严重的与怀孕和分娩 相关的并发症，

resulting in over 60,000 women every year having one of these events.

导致了每年有超过6万名 女性有其中的一个症状。

These complications, called severe maternal morbidity,

这些并发症，被称为 严重的产妇发病率，

are on the rise in the United States, and they're life-altering.

在美国呈现上升的趋势， 并且这些并发症会改变人的一生。

It's estimated that somewhere between 1.5 and two percent

据统计，我们国家每年

of the four million deliveries that occur every year in this country

的四百万次分娩中，

are associated with one of these events.

有1.5%到2%都与这些症状相关。

That is five or six women every hour having a blood clot, a seizure, a stroke,

也就是每小时有五到六名女性 患上了血栓，癫痫，中风，

receiving a blood transfusion,

接受一次输血，

having end-organ damage such as kidney failure,

患上终末器官损害比如肾衰竭，

or some other tragic event.

或者其它突发症状。

Now, the part of this story that's frankly unforgivable

现在，这个情况明显 不能原谅的部分在于

is the fact that 60 percent of these deaths and severe complications

60%的死亡和并发症

are thought to be preventable.

被认为是可以避免的。

When I say 60 percent are preventable,

当我说60%是可以避免的，

I mean there are concrete steps and standard procedures

我的意思是有一些具体步骤

that we could implement

和标准程序我们可以实行，

that could prevent these bad outcomes from occurring

以避免这些糟糕的结果出现，

and save women's lives.

并且挽救这些女性的生命。

And it doesn't require fancy new technology.

而且这并不需要高级的新技术。

We just have to apply what we know

我们只是需要将 我们知道的付诸于行动

and ensure equal standards between hospitals.

并且确保医院之间的同等标准。

For example, if a pregnant woman in labor has really high blood pressure

比如说，当一名正在分娩的孕妇 有着非常高的血压

and we treat her with the right antihypertensive medication

如果我们及时给她正确的

in a timely fashion,

抗高血压药物，

we can prevent stroke.

我们就可以避免中风。

If we accurately track blood loss during delivery,

如果我们可以准确的观测到 分娩中的血液流失，

we can detect a hemorrhage sooner and save a woman's life.

我们就会及时察觉到出血 并挽救孕妇的生命。

We could actually lower the rates of these catastrophic events tomorrow,

那么明天我们就可以从根本上 降低这些灾难性事件发生的概率，

but it requires that we value the quality of care

但是这需要我们重视

we deliver to pregnant women

孕妇在孕前、孕中和产后

before, during and after pregnancy.

治疗的质量。

If we raise quality of care universally to what is supposed to be the standard,

如果我们将治疗的质量普遍 提升到我们认为的“标准”，

we could bring the rates of these deaths and severe complications way down.

就可以将死亡率和 并发症发生率大大降低。

Well, there is some good news.

当然了，也有一些好的消息。

There are some success stories.

有一些成功的案例。

There are some places that have actually adopted these standards,

有一些地区已经落实了这些标准，

并且出现了实质性的改变。

and it's really making a difference.

A few years ago, the American College of Obstetricians and Gynecologists

几年前，美国妇产科学院

joined forces with other healthcare organizations,

联合了其他医疗机构，

researchers like myself and community organizations.

研究员们，比如我，和社区组织。

They wanted to implement standard care practices

他们希望在整个国家 的医院和医疗系统里

in hospitals and health systems throughout the country.

实施标准治疗工作。

And the vehicle they're using is a program called

他们采用的方法则是一个

the Alliance for Innovation in Maternal Health, the AIM program.

叫做孕妇保健的联盟创新计划， 即AIM计划。

Their goal is to lower maternal mortality and severe maternal morbidity rates

他们的目标是通过 质量和安全新举措

through quality and safety initiatives across the country.

在全国范围内降低孕妇死亡率 和严重产妇并发症发病率。

The group has developed a number of safety bundles

这个组织已经开发了一些安全方案，

that target some of the most preventable causes of a maternal death.

针对一些最可预防的孕产妇死亡原因。

The AIM program currently has the potential to reach

AIM计划现在有覆盖

over 50 percent of US births.

超过美国百分之五十 出生人数的可能性。

So what's in a safety bundle?

那么什么是安全方案？

Evidence-based practices, protocols, procedures,

将这些情境作为目标所需要的 循证实践，习惯做法，步骤，

medications, equipment

用药，设备，

and other items targeting these conditions.

和其他物品。

Let's take the example of a hemorrhage bundle.

以出血的安全方案为例。

For a hemorrhage, you need a cart

在病人出血时， 你需要一个手推车，

that has everything a doctor or nurse might need in an emergency:

准备好医生或者护士 可能在急救中会用到的所有东西：

an IV line, an oxygen mask, medications,

静脉注射管线，氧气罩，药物，

checklists, other equipment.

清单，其它仪器。

Then you need something to measure blood loss:

然后你需要测量血液流失的仪器：

sponges and pads.

海绵和衬垫。

And instead of just eyeballing it,

医生和护士收集 这些海绵和衬垫，

the doctors and nurses collect these sponges and pads

称出重量，或者是 用新技术来准确的评估

and either weigh them

到底流失了多少血，

or use newer technology to accurately assess how much blood has been lost.

而不是一直盯着它们。

The hemorrhage bundle also includes crises protocols for massive transfusions

出血安全方案也包括需要 大量输血时的危险期医疗方案

and regular trainings and drills.

和常规培训和教学。

Now, California has been a leader in the use of these types of bundles,

现在，加州已经成为应用 这种安全方案的领导者，

and that's why California saw a 21 percent reduction

这也是为什么加州实施 这种安全方案的第一年，

in near death from hemorrhage

医院里因出血而

among hospitals that implemented this bundle in the first year.

濒临死亡的人数就降低了21%。

Yet the use of these bundles across the country is spotty or missing.

但是这些方案在全国范围内的 应用是参差不齐或者不完整的。

Just like the fact that the use of evidence-based practices

比如说，即便使用循证实践

and the emphasis on safety

和对安全的重视，

differs from one hospital to the next,

每一个医院都是不同的，

quality of care differs.

治疗的质量也不尽相同。

And quality of care differs greatly for women of color in the United States.

而且对有色人种的女性， 治疗的质量则区别更大。

Black women who deliver in this country

在这个国家，黑人女性分娩时

are three to four times more likely to suffer a pregnancy-related death

可能遭受的与妊娠有关的死亡

than are white women.

是白人女性的三到四倍。

This statistic is true for all black women who deliver in this country,

这个统计对于所有在这个国家 分娩的黑人女性是真实有效的，

whether they were born in the United States

不管他们是出生在美国，

or born in another country.

或是出生在其它国家。

Many want to think that income differences drive these disparities,

很多人愿意相信是因为 收入差异导致了这些不同，

but it goes beyond class.

但是这超出了阶级的范畴。

A black woman with a college education

一个有着大学学历的黑人女性

is nearly twice as likely to die as compared to a white woman

死亡的可能性是一个 不到高中学历的

with less than a high school education.

白人女性的两倍。

And she is two to three times more likely to suffer a severe pregnancy complication

并且她有两到三倍的 可能在分娩的时候

with her delivery.

经历严重的妊娠并发症。

Now, I was always taught to think that education was our salvation,

现在，我总是被教导着认为 教育是我们的救世主，

but in this case, it's simply not true.

但是在这种情况下， 这根本不是真的。

This black-white disparity

根据疾病控制中心所说，

is the largest disparity

黑人-白人的差异

among all population perinatal health measures,

在所有人口围产期健康措施中，

according to the CDC.

是最大的。

And these disparities are even more pronounced

而这些差异在一些城市中

in some of our cities.

则更加显著。

For example, in New York City,

比如，在纽约，

a black woman is eight to 12 times more likely to die

黑人妇女因为妊娠 相关原因死亡的概率

from a pregnancy-related cause than is a white woman.

是白人妇女的12倍。

Now, I think many of you are probably familiar with

我想你们大部分人都可能很熟悉

the heart-wrenching story of Dr. Shalon Irving,

谢纶·欧文博士那令人 撕心裂肺的故事，

a CDC epidemiologist who died following childbirth.

她是一名疾病防治中心 的流行病学家，死于后来的分娩。

Her story was reported in ProPublica and NPR

不到一年前她的故事

a little less than a year ago.

被ProPublica和NPR报道。

Recently, I was at a conference

最近，我在一个会议上

and I had the privilege of hearing her mother speak.

有幸听到了她母亲的演讲。

She brought the entire audience to tears.

整个观众席都被她的 演讲感动到热泪盈眶。

Shalon was a brilliant epidemiologist,

谢纶是一名杰出的流行病学家，

committed to studying racial and ethnic disparities in health.

立志于研究种族和人种 在医疗方面的差异。

She was 36 years old, this was her first baby,

她才36岁，那是她的第一个孩子，

and she was African-American.

她是一名非裔美国人。

Now, Shalon did have a complicated pregnancy,

Shalon得了妊娠并发症，

but she delivered a healthy baby girl and was discharged from the hospital.

但是她分娩了一名健康 的女孩，然后出院了。

Three weeks later, she died from complications of high blood pressure.

三周之后，她死于高血压并发症。

Shalon was seen four or five times by healthcare professionals

谢纶在那三周里

in those three weeks.

与医疗专家见了四五次。

She was not listened to,

她的话被当作了耳旁风，

and the severity of her condition was not recognized.

她情况的严重性也没有被认可。

Now, Shalon's story is just one of many stories

谢纶的故事只是在美国的

about racial and ethnic disparities in health and health care

众多关于健康和医疗的

in the United States,

种族和人种差异故事的其中一个，

and there's a growing recognition that the social determinants of health,

并且越来越多人认可健康的 社会决定因素，

such as racism, poverty, education, segregated housing,

比如种族，贫穷，教育，隔离住房，

contribute to these disparities.

都是导致这些差异的因素。

But Shalon's story highlights an additional underlying cause:

但是谢纶的故事 使另外一个潜在的因素凸显出来：

quality of care.

治疗的质量。

Lack of standards in postpartum care.

缺乏产后治疗的标准。

Shalon was seen multiple times by clinicians in those three weeks,

谢纶在那三周里见了 好几次临床医生，

and she still died.

但是她仍然去世了。

Quality of care in the setting of childbirth

在美国，妊娠死亡和严重并发症中，

is an underlying cause of racial and ethnic disparities

分娩环境中的治疗质量

in maternal mortality and severe maternal morbidity

是导致种族和人种差异的

in the United States,

一个潜在因素，

and it's something we can address now.

并且这是我们现在 就可以处理的问题。

Research by our team and others

我们团队的研究员和其他人

has documented that, for a variety of reasons,

已经书面记录了这些状况， 因为不同的原因，

black women tend to deliver in a specific set of hospitals,

黑人女性倾向于在一些 特定的医院进行分娩，

and those hospitals often have worse outcomes for both black and white women,

而不考虑病人的风险因素，

regardless of patient risk factors.

这些医院的黑人和白人女性 都时常有更严重的预后不良。

This is true overall in the United States,

这样的情况在全美国比比皆是，

where about three quarters of all black women

在美国大约四分之三的黑人女性

deliver in a specific set of hospitals,

在一些特定医院进行分娩，

while less than one-fifth of white women deliver in those same hospitals.

而同时只有不到五分之一的 白人女性在同样的医院分娩。

In New York City, a woman's risk of having a life-threatening complication

在纽约，一名妇女在一家医院里 进行分娩时患上威胁生命

during delivery

的并发症的风险

can be six times higher in one hospital than another.

可能是另外一家医院的六倍。

Not surprisingly, black women are more likely to deliver

也难怪，黑人女性在医院 分娩时遇到不良结果

in hospitals with worse outcomes.

的可能性更大一些。

In fact, differences in delivery hospital

事实上，不同分娩医院的区别

explain nearly one-half of the black-white disparity.

解释了接近一半 黑人-白人差异的原因。

While we must address social determinants of health

如果我们要在这个国家 真正实现公平的医疗保健，

if we're ever going to truly have equitable health care in this country,

我们就必须解决健康 的社会决定因素，

many of these are deep-seated and they will take some time to resolve.

而这些因素大部分都是根深蒂固的， 解决它们需要一些时间。

In the meantime, we can tackle quality of care.

同时，我们可以处理 治疗质量的问题。

Providing high-quality care across the care continuum

在整个连续的治疗中 提供高质量的治疗

means providing access to safe and reliable contraception

意味着在妇女的整个生殖周期

throughout women's reproductive lives.

提供安全而有保障的避孕。

Before pregnancy, it means providing preconception care,

在孕前，这意味着提供孕前保健，

so we can manage chronic illness and optimize health.

这样我们就可以控制慢性病 并且维持最佳健康状态。

During pregnancy, it includes high-quality prenatal and delivery care

在孕中，它包括了高质量的 产前和分娩治疗，

so we can produce healthy moms and babies.

让我们可以有健康的 妈妈们和宝宝。

And finally, after pregnancy, it includes postpartum and inter-pregnancy care

最后，在产后，它包括了 产后和怀孕间的治疗，

so we can set moms up to have a healthy next baby

让我们能够帮妈妈们康复， 为生育下一个健康的宝宝，

and a healthy life.

和拥有一个健康的生活做准备。

And it can literally spell the difference between life and death,

它可以从字面上来分辨 生命和死亡的区别，

as it did in the case of Maria,

就像玛丽亚的案例中一样，

who checked into the hospital after having an elevated blood pressure

玛丽亚在孕前检查时，

during a prenatal visit.

发现有高血压之后去了医院检查。

Maria was 40, and this was her second pregnancy.

她40岁了，这是她第二次怀孕。

During Maria's first pregnancy that had happened two years earlier,

玛丽亚在两年前第一次怀孕时，

she also didn't feel so well in the last few weeks of her pregnancy,

她在怀孕的最后几周 感觉并不是很好，

and she had a few elevated blood pressures,

她有一点高血压，

but nobody seemed to pay attention.

但是并没有人注意到。

They just said, "Maria, don't worry, you'll be fine.

大家只是说， “玛丽亚，别担心，你没事的。

This is your first pregnancy. You're a little nervous."

“这是你第一次怀孕 所以你有一点紧张。”

But it did not end well for Maria last time.

但是情况并没有变好。

She seized during labor.

她在分娩时癫痫发作。

Well, this time her team really listened.

不过这一次她的团队听进去了。

They asked smart and probing questions.

他们询问了一些巧妙的探索性问题。

Her doctor counseled her about the signs and symptoms of preeclampsia

她的医生和她讨论了 关于子痫前期的迹象和征兆，

and explained that if she was not feeling well,

并且向她解释如果她感到不适，

she needed to come in and be seen.

她需要去医院检查。

And this time Maria came in,

然后这一次玛丽亚去了，

and her doctor immediately sent her to the hospital.

她的医生立刻将她送去了医院。

At the hospital, her doctor ordered urgent lab tests.

在医院，医生立刻安排了 紧急的实验测试。

They hooked her up to multiple different monitors

为她连上了不同的监控器，

and paid special attention to her blood pressure,

并且认真观察她的血压，

the fetal heart rate tracing

胎儿心率，

and gave her IV medication to prevent a seizure.

并且给她注射静脉 药物来防止痉挛。

And when Maria's blood pressure got so high it put her at risk for a stroke,

当玛丽亚的血压高到 令她有中风的风险时，

her doctors and nurses jumped into action.

她的医生和护士立刻行动。

They repeated her blood pressure in 15 minutes

他们将她的血压重复了15分钟，

and declared a hypertensive emergency.

然后宣布了高血压急症。

They gave her the right IV medication according to the latest correct protocol.

他们根据最近的正确规程 给了她合适的静脉注射药物。

They worked smoothly together as a coordinated team

他们作为一个合作的团队， 工作进展的很顺利，

and successfully lowered her blood pressure.

并且成功降低了她的血压。

As a result, what could have been a tragedy became a success story.

结果就是，一个潜在的悲剧 变成了一个成功的故事。

Maria's dangerous symptoms were controlled,

玛丽亚危险的征兆被控制住了，

and she delivered a healthy baby girl.

并且生下了一个健康的女婴。

And before Maria was discharged from the hospital,

然后在玛丽亚出院之前，

her doctor counseled her again about the signs and symptoms of preeclampsia,

她的医生又和她讨论了 子痫前期的迹象和征兆，

the importance of having her blood pressure checked,

特别是产后第一周

especially in this first week postpartum

检查血压的重要性，

and gave her education about postpartum health and what to expect.

并且给了她关于产后健康和 可能出现的情况的说明。

And in the weeks and months that followed,

然后在接下来的几个月里，

naturally, Maria had follow-up visits with her pediatrician

很自然地，玛丽亚和她的儿科医生 进行了几次术后随访

to check in on her baby's health.

来检查宝宝的健康。

But just as important,

但是一样重要的是，

she had follow-up visits with her ob-gyn

她也在妇产科进行了术后随访

to check in on her health, her blood pressure,

来检查她本人的健康和血压，

and her cares and concerns as a new mother.

以及作为一名新手妈妈的 谨慎和忧虑。

This is what high-quality care across the care continuum looks like,

这就是贯穿整个过程的连续性 高质量治疗的样子，

and this is how it can look.

这就是它应有的效果。

If every pregnant woman in every community

如果每一个社区里的每一名孕妇

received this kind of high-quality care

都可以接受这种高质量的治疗，

and delivered at facilities that utilized standard care practices,

并且在使用标准治疗 实践的机构里分娩，

our maternal mortality and severe maternal morbidity rates would plummet.

我们的产妇死亡率和严重的产妇 发病率将会骤然下跌。

Our international ranking would no longer be an embarrassment.

我们的国际排名再也 不会让人觉得尴尬。

But the truth is, we've had decades of unacceptably high rates

但是事实是，我们 已经有了几十年的

of maternal death and life-threatening complications during delivery

高产妇死亡率和在分娩时 威胁生命的并发症高发率，

and decades of devastating consequences for moms, babies and families,

以及几十年来母亲、婴儿 和家庭的毁灭性后果，

and we have not been moved to action.

我们并没有任何实质性行动。

The recent media attention on our poor performance on maternal mortality

最近媒体对我们在 产妇死亡率上表现不佳的关注

has helped the public to understand:

已经帮助公众来了解：

high-quality maternal health care is within reach.

高质量的产妇医疗是伸手可及的。

The question is:

问题则是：

Are we as a society ready to value pregnant women from every community?

我们的社会是否准备好 从每一个社区开始重视孕妇？

For my part, I'm doing everything I can to ensure that when we do,

对我来说，我做了一切来 确保当我们开始做了，

we have the tools and evidence base ready

我们已经准备好了 技术和证据基础

to move forward.

继续前进。

Thank you.

谢谢大家。

(Applause)

（鼓掌）