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

譯者: Harper Chang 審譯者: SF Huang

It was chaos as I got off the elevator.

當我踏出電梯，院裡正是一片混亂

I was coming back on duty as a resident physician

身為住院醫師的我回院值班

to cover the labor and delivery unit.

去增援分娩生產部門

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

我看到產房裡一大群的醫生和護士

hovering over a patient in the labor room.

圍在一個產婦身邊

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

拼命地搶救她的生命

The patient was in shock.

她已經休克了

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

在我抵達的前幾個小時 她剛產下一名健康的男嬰

Suddenly, she collapsed, became unresponsive,

突然，她虛脫休克，沒有反應

and had profuse uterine bleeding.

並伴有嚴重的血崩（子宮出血）

By the time I got to the room,

我進入產房時

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

裡面聚集了不同的醫護人員

但她已沒有了生命跡象

The resuscitation team tried to bring her back to life,

醫療團隊嘗試搶救她的生命

but despite everyone's best efforts,

但儘管每個人都盡了最大的努力

she died.

她還是走了

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

我仍記得那個父親悲傷欲絕的哭聲

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

穿透了我和那層樓所有人的心

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

那本該是他人生中最快樂的一天

but instead it turned out to be the worst day.

但卻變成了最痛苦的一天

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

我多希望這個悲劇只是個單一事件

but sadly, that's not the case.

但很遺憾，它並不是

Every year in the United States,

在美國，每一年

somewhere between 700 and 900 women die

有 700 至 900 位女性 死於妊娠相關的疾病

from a pregnancy-related cause.

The shocking part of this story

最令人震驚的是

is that our maternal mortality rate is actually higher

我們的孕產婦死亡率

遠高於其他高收入國家

than all other high-income countries,

and our rates are far worse for women of color.

且非白人女性更為嚴重

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

在過去十年中 我們孕產婦死亡率攀升

while other countries reduced their rates.

然而其他國家都在下降

And the biggest paradox of all?

這其中最大的悖論是什麼？

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

我們花在衛生保健上的費用 高於世界上任何一個國家

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

大約是我當住院醫師遇到 那位母親往生的那段時間

I became a mother myself.

我自己也成為母親

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

即便擁有這個領域的背景和知識

I was taken aback by how little attention was paid

我對鮮少人會關注提供孕產婦 高品質的保健而感到吃驚

to delivering high-quality maternal health care.

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

我思考著這意味著什麼呢

不僅為我，更為千千萬萬的女性

but for so many other women.

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

或許是因為我的父親是位民權律師

and my parents were socially conscious

我的父母很有社會意識

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

也要求我們要堅守自己的信念

Or the fact that my parents were born in Jamaica,

或是因為出生在牙買加的他們

came to the United States

移居美國

and were able to realize the American Dream.

並得以實現美國夢

Or maybe it was my residency training,

又或我在接受住院醫師培訓時

where I saw firsthand

親眼目睹

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

低收入的非白人婦女 在我們的醫療體系下

by our healthcare system.

如何被惡劣地對待

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

不論如何，我有責任站出來

not just for myself,

不僅為我自己

but for all women,

更為所有的女性

and especially those marginalized by our healthcare system.

尤其是那些被醫療體系邊緣化的人

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

於是我決定致力於改善孕產婦保健

So what's killing mothers?

所以，造成母親們死亡的原因為何？

Cardiovascular disease, hemorrhage,

心血管疾病、失血

high blood pressure causing seizures and strokes,

高血壓引發的癲癇及中風

blood clots and infection

血栓和感染

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

這些是美國孕產婦死亡的 部分主要原因

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

然而孕產婦死亡還只是冰山的一角

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

每一例的死亡都代表著 有超過 100 位的女性

遭受與妊娠和分娩相關的嚴重併發症

related to pregnancy and childbirth,

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

每年有超過 60,000 名女性 會碰到其中的一項

These complications, called severe maternal morbidity,

這些併發症稱為孕產婦重大疾病罹患率

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

在美國呈現上升趨勢 而且它們會改變人的一生

It's estimated that somewhere between 1.5 and two percent

據估計，在美國 每 400 萬次分娩中

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

1.5% 至 2% 會出現這些病症

are associated with one of these events.

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

也就是每小時有 5 到 6 位女性

會出現血栓、癲癇、中風

receiving a blood transfusion,

接受輸血

having end-organ damage such as kidney failure,

終端器官損傷，如：腎衰竭

or some other tragic event.

或是其他悲劇

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

這件事情最無法原諒的部分是

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

這當中有 60% 的 死亡和嚴重併發症

are thought to be preventable.

是可以預防的

When I say 60 percent are preventable,

60% 可以「預防」

I mean there are concrete steps and standard procedures

是指有可實施的具體措施和標準流程

that we could implement

that could prevent these bad outcomes from occurring

來預防憾事的發生

and save women's lives.

並拯救這些女性的生命

And it doesn't require fancy new technology.

而這並不需要昂貴的新技術

We just have to apply what we know

只需要運用我們已知的知識

and ensure equal standards between hospitals.

並確保醫院間的標準要一致

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

例如，如果一位產婦 在分娩過程中出現了高血壓

and we treat her with the right antihypertensive medication

我們能及時給她正確的抗高血壓藥

in a timely fashion,

we can prevent stroke.

我們就能防止中風

If we accurately track blood loss during delivery,

如果我們準確記錄 分娩時的失血情況

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

我們就能更快地發現大出血 從而拯救產婦的生命

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

未來我們確實可以降低 這些悲慘事件的發生率

but it requires that we value the quality of care

但前提是我們需重視

對孕產婦產前、產中 和產後的醫療照護品質

we deliver to pregnant women

before, during and after pregnancy.

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

如果我們將整體醫療照護品質 提高到應有的標準

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

我們就可大大降低 死亡和嚴重併發症的機率

Well, there is some good news.

好消息是

There are some success stories.

已經有了一些成功的案例

There are some places that have actually adopted these standards,

一些地區落實了這些標準

並取得了顯著的成效

and it's really making a difference.

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

幾年前，美國婦產科醫師學會

joined forces with other healthcare organizations,

聯合了其他醫療機構 像我一樣的研究員和社區組織

researchers like myself and community organizations.

They wanted to implement standard care practices

他們希望在全國的醫院 和醫療體系中

in hospitals and health systems throughout the country.

執行標準化的醫療照護

And the vehicle they're using is a program called

他們的方法是成立一個叫做：

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

孕產婦健康創新聯盟 即 AIM 計畫

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

旨在透過高品質和安全的新措施

through quality and safety initiatives across the country.

來降低孕產婦死亡率 和孕產婦重大疾病罹患率

The group has developed a number of safety bundles

這個組織針對最可預防的 孕產婦死亡病因

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

構建了一系列的「醫療工具包」

The AIM program currently has the potential to reach

AIM 目前應能涵蓋全美 超過 50% 的分娩所需

over 50 percent of US births.

So what's in a safety bundle?

醫療工具包裡有什麼呢？

Evidence-based practices, protocols, procedures,

實證醫療、醫療計畫、程序步驟

medications, equipment

用藥指導、醫療器材

and other items targeting these conditions.

以及其他相關的醫療用品

Let's take the example of a hemorrhage bundle.

以大出血工具包為例

For a hemorrhage, you need a cart

遇到大出血時 需要有一台治療推車

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

裡面裝有醫護人員急救所需的醫材：

an IV line, an oxygen mask, medications,

靜脈注射管線、氧氣面罩、藥物

checklists, other equipment.

檢查表及其他醫療器材

Then you need something to measure blood loss:

接著你需要測量失血量的用品：

sponges and pads.

海綿塊和棉墊

And instead of just eyeballing it,

醫護人員不僅目測失血量

the doctors and nurses collect these sponges and pads

還把這些海綿塊和棉墊收集起來稱重

and either weigh them

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

或用更先進的技術來準確評估失血量

The hemorrhage bundle also includes crises protocols for massive transfusions

大出血工具包還包括

大量輸血的急救方案 以及定期的培訓與演練

and regular trainings and drills.

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

加州在醫療工具包的 應用上已然成為急先鋒

and that's why California saw a 21 percent reduction

這就是為什麼採用了 醫療工具包的加州醫院

in near death from hemorrhage

在第一年裡因出血死亡的 產婦人數減少了 21%

among hospitals that implemented this bundle in the first year.

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

然而國內醫療工具包的應用 卻存在著良莠不齊或不完整的現象

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

比如實證醫療和對安全的注重

and the emphasis on safety

differs from one hospital to the next,

因各醫院而異

quality of care differs.

醫療照護品質也有所差異

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

在美國，非白人女性的 醫療差別待遇最為嚴重

Black women who deliver in this country

在國內黑人女性死於妊娠相關疾病的 機率是白人女性的 3 至 4 倍

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

than are white women.

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

這個統計數據顯示的是 所有在美國妊娠的黑人女性

whether they were born in the United States

無論她們是否在美國出生

or born in another country.

Many want to think that income differences drive these disparities,

很多人將差異歸咎於收入差距

but it goes beyond class.

但這超越了社會階級

A black woman with a college education

一個受過大學教育的 黑人女性的死亡率

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

比一個學歷不到高中的 白人女性高 2 倍

with less than a high school education.

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

且她在生產時出現重大產科併發症的 機率比白人女性高 2 至 3 倍

with her delivery.

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

人們總說「教育可以改變人生」

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

但在這個例子裡，卻行不通

This black-white disparity

據美國疾病管制與預防中心統計

is the largest disparity

在產前、產後所有人口的 健康基準差距中

among all population perinatal health measures,

according to the CDC.

黑人與白人間的差距最大

And these disparities are even more pronounced

這些差異在一些城市中更為明顯

in some of our cities.

For example, in New York City,

如：在紐約

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

黑人女性死於妊娠相關疾病的機率

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

是白人女性的 8 至 12 倍

Now, I think many of you are probably familiar with

我想大家都聽說過 沙隆 · 歐文醫生令人痛心的故事

the heart-wrenching story of Dr. Shalon Irving,

a CDC epidemiologist who died following childbirth.

她是在產後離世的美國疾病管制 與預防中心的流行病學家

Her story was reported in ProPublica and NPR

不到一年前

她的故事被 ProPublica 和全國公共廣播電台報導

a little less than a year ago.

Recently, I was at a conference

最近，我在一個會議上

and I had the privilege of hearing her mother speak.

很榮幸地聽到了她母親的演說

She brought the entire audience to tears.

所有聽衆都為她流下熱淚

Shalon was a brilliant epidemiologist,

沙隆曾是一位出色的流行病學家

committed to studying racial and ethnic disparities in health.

她致力於研究不同種族、民族 所受到的醫療差別待遇

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

36 歲時，她產下了 人生中第一個孩子

and she was African-American.

她是非裔美國人

Now, Shalon did have a complicated pregnancy,

沙隆經歷了艱難的妊娠過程

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

最終產下了一名健康女嬰並出院了

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

三週後，她死於高血壓併發症

Shalon was seen four or five times by healthcare professionals

在這三週裡

她由專業的醫療人員看診了四、五次

in those three weeks.

She was not listened to,

但沒有人傾聽她的主訴

and the severity of her condition was not recognized.

也沒人辨識出她的嚴重病症

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

沙隆的故事只是衆多

about racial and ethnic disparities in health and health care

美國不同種族的 醫療差別照護的故事之一

in the United States,

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

越來越多人瞭解到 醫療保健的社會決定因素

such as racism, poverty, education, segregated housing,

例如種族歧視、貧窮 教育、隔離的住宅區

contribute to these disparities.

導致了醫療差異的擴大

But Shalon's story highlights an additional underlying cause:

但沙隆的故事突顯了另一潛在因素：

quality of care.

醫療照護的品質

Lack of standards in postpartum care.

產後醫療照護缺乏標準程序

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

在那三週中，沙隆多次去醫師那看診

and she still died.

但她還是死了

Quality of care in the setting of childbirth

分娩時的醫療照護品質

is an underlying cause of racial and ethnic disparities

在美國是造成不同種族間

in maternal mortality and severe maternal morbidity

孕產婦死亡率和重大疾病罹患率

in the United States,

差異的潛在因素

and it's something we can address now.

而我們可以從現在開始改變它

Research by our team and others

我們和其他的研究團隊已證明

has documented that, for a variety of reasons,

由於各種原因

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

黑人女性往往會在某些特定醫院分娩

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

排除病人自身的風險因素

這些醫院的黑人和白人女性 經常面臨更高的孕期風險

regardless of patient risk factors.

This is true overall in the United States,

這種現象存在於整個美國

where about three quarters of all black women

約 75% 的黑人女性 會在這些特定醫院分娩

deliver in a specific set of hospitals,

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

但少於 20% 的白人女性 會選擇這些醫院

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

在紐約

女性在分娩時，發生 具生命危險併發症的機率

during delivery

在不同醫院間有高達 6 倍的差距

can be six times higher in one hospital than another.

Not surprisingly, black women are more likely to deliver

所以，黑人女性在醫院分娩時 面臨更高的風險就不足為奇了

in hospitals with worse outcomes.

In fact, differences in delivery hospital

事實上，產科醫院間的差異

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

解釋了近半數黑人與白人女性間 差異的原因

While we must address social determinants of health

如果我們想要在美國 擁有真正公平的醫療照護

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

就必須設法解決這些社會決定因素

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

其中很多因素根深蒂固 需要投入時間去解決

In the meantime, we can tackle quality of care.

同時我們可以處理醫療品質的問題

Providing high-quality care across the care continuum

在整個醫療照護期中 提供高品質的醫護服務

means providing access to safe and reliable contraception

意味著為生育期的女性

throughout women's reproductive lives.

提供安全而可靠的避孕方法

Before pregnancy, it means providing preconception care,

在孕前，提供孕前保健

so we can manage chronic illness and optimize health.

從而管理慢性病並優化健康狀態

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

在孕中，提供高品質的產前和分娩保健

so we can produce healthy moms and babies.

從而保障母子的健康

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

在孕後，提供產後 和兩次孕間期的保健

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

可讓媽媽為下一個健康的寶寶

and a healthy life.

和健康的生活做好準備

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

這個方法運用在瑪麗亞身上時

as it did in the case of Maria,

確實造成了天大的差異

who checked into the hospital after having an elevated blood pressure

她在產檢後發現血壓增高而住院

during a prenatal visit.

Maria was 40, and this was her second pregnancy.

瑪麗亞 40 歲 這是她的第二次懷孕

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

兩年前她第一次懷孕時

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

她同樣在產前最後幾週 感到身體不適

and she had a few elevated blood pressures,

並出現了幾次血壓偏高現象

but nobody seemed to pay attention.

但醫護人員不以為意

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

他們只是告訴她：「別擔心，會好的

這是第一次懷孕 你只是有點緊張罷了」

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

But it did not end well for Maria last time.

但瑪麗亞的狀況並沒有改善

She seized during labor.

她在分娩時癲癇發作

Well, this time her team really listened.

不過這一次，醫療團隊 認真傾聽了她的主訴

They asked smart and probing questions.

他們的問診精準而詳細

Her doctor counseled her about the signs and symptoms of preeclampsia

她的醫生告知了她 子癇前症的徵兆和症狀

and explained that if she was not feeling well,

並告訴她，如果感到身體不適

she needed to come in and be seen.

她需要回診做檢查

And this time Maria came in,

這一次瑪麗亞回診後

and her doctor immediately sent her to the hospital.

她的醫生立即將她送往醫院

At the hospital, her doctor ordered urgent lab tests.

在醫院，醫生囑咐了立即的檢測

They hooked her up to multiple different monitors

他們將她接上各種監視器

and paid special attention to her blood pressure,

並特別關注她的血壓

the fetal heart rate tracing

監測胎兒心率

and gave her IV medication to prevent a seizure.

給予靜脈注射用藥來防止癲癇發作

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

當瑪麗亞的血壓過高 有引發中風的危險時

her doctors and nurses jumped into action.

醫生和護士立即採取行動

They repeated her blood pressure in 15 minutes

他們在 15 分鐘內反覆測量血壓

and declared a hypertensive emergency.

然後宣佈高血壓危症

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

根據最新而有效的方案 給她正確的靜脈注射用藥

They worked smoothly together as a coordinated team

他們團隊協作有條不紊

and successfully lowered her blood pressure.

成功地降低了她的血壓

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

最終，他們將一場悲劇 逆轉為成功的故事：

Maria's dangerous symptoms were controlled,

瑪麗亞的危險症狀得到了控制

and she delivered a healthy baby girl.

並產下了一名健康的女嬰

And before Maria was discharged from the hospital,

在瑪麗亞獲准出院前

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

她的醫生再次告知 子癇前症的徵兆和症狀

the importance of having her blood pressure checked,

以及檢查血壓的重要性 特別是產後第一週

especially in this first week postpartum

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

醫生還告訴她 產後保健事項和可能發生的狀況

And in the weeks and months that followed,

在接下來的幾個月

naturally, Maria had follow-up visits with her pediatrician

她持續到兒科醫師那裡回診

to check in on her baby's health.

檢查嬰兒的健康情況

But just as important,

同樣重要的是

she had follow-up visits with her ob-gyn

她之後也到婦產科回診

to check in on her health, her blood pressure,

檢查她的健康狀況和血壓

and her cares and concerns as a new mother.

並幫成為新生兒母親的她 解答其關心在意的問題

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

以上就是整個醫療照護期 該有的高品質醫療服務

and this is how it can look.

是可以做到這個樣子的

If every pregnant woman in every community

如果每個社區的孕婦

received this kind of high-quality care

都能得到這樣高品質的醫療照護

and delivered at facilities that utilized standard care practices,

並在遵循標準醫療制度的機構裡分娩

our maternal mortality and severe maternal morbidity rates would plummet.

我們的孕產婦死亡率 和孕產婦重大疾病罹患率

就能大幅驟降

Our international ranking would no longer be an embarrassment.

我們的國際排名將不再令人汗顏

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

但事實是，幾十年來

我們的孕產婦死亡率 和嚴重產科併發症的發生率

of maternal death and life-threatening complications during delivery

高到令人無法接受

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

幾十年來母親、嬰兒和家庭

都承受著極具破壞性的後果

and we have not been moved to action.

卻沒有人採取行動

The recent media attention on our poor performance on maternal mortality

近期媒體對居高不下的 孕產婦死亡率的報導

has helped the public to understand:

讓公衆意識到

high-quality maternal health care is within reach.

高品質的孕產婦醫療照護 其實不難獲得

The question is:

問題是：

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

我們的社會準備好要重視 每個社區中的孕婦了嗎？

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

就我而言，我正竭盡所能地

確保當我們這樣做時 我們擁有充足的技術和實證基礎

we have the tools and evidence base ready

to move forward.

往前大步邁進

Thank you.

謝謝大家

(Applause)

（掌聲）