Lying on a hospital bed after the birth of my first child, aware that the final stage of delivery had taken an unanticipated turn, I realized my research interests were both a blessing and a curse.
On the one hand, as a perinatal epidemiologist, I had a decent understanding of what was happening: a postpartum hemorrhage, or excessive bleeding, immediately following the delivery of my son. Only a few weeks before, I had defended my proposed dissertation research on pregnancy outcomes in New York City. My desk overflowed with data on the risks of pregnancy and childbirth. I was at least mildly equipped to combat the confusion and distress of an obstetric emergency.
On the other hand, I knew how bad it could get.
There are few events in life as salient as childbirth. That is true for me in all the conventional, wonderful ways one would imagine. However, I also recall with a vivid, visceral intensity those moments when the outcome felt suddenly uncertain. I remember the furrow in my obstetrician’s brow. I remember the realization that I was bleeding more than normal. I remember turning my head to watch a nurse examine my son, my husband radiating a unique blend of disbelief and joy as he took in the initiation rituals of modern medicine. I remember thinking “what a perfect picture” and “what is happening to me?” in the exact same moment.
I am fortunate that my complication was relatively minor. A quick injection of Hemabate—a synthetic prostaglandin, a hormone-like substance used to contract the uterus—stopped the hemorrhage. I was able to move on to recovery and new motherhood. But too often that is not the case. Missed opportunities to prevent the occurrence and escalation of obstetric emergencies have dire consequences for women, their infants, and their families. It is estimated that more than 60 percent of maternal deaths are preventable, and often attributed to health care quality failures including misdiagnosis, ineffective treatment, and poor coordination.
Two and a half years later, a slightly more experienced mother and newly minted PhD, I was back on the labor and delivery floor and my second son took his first breaths. But they were challenging breaths. Quick breaths. Shallow breaths. Again, within seconds I moved from the bliss of bringing new life into the world and of meeting my child for the first time, to the quiet suspicion that something was not quite right. The nurse lifted my newborn from my arms with a touch too much urgency and huddled over him for a bit too long. I do not remember the exact sequence of events but can hear my voice ask, “Is he ok?” on loop.
And I remember quiet. In that moment, I understood the phrase “deafening silence.” The void of chatter, of information, of assurances. A neonatologist arrived, assessed my son, and moved him into an isolette, one of those tiny plastic enclosed bassinets, for transfer to the hospital’s Neonatal Intensive Care Unit. With these few actions, the day I had anticipated for the previous 38 weeks was utterly changed. Settling somewhere between worry and frustration, I steeled myself for the journey.
I can happily report that my son is fine. He required a bit of extra TLC and a week in the NICU to acclimate to this big, wild world. Honestly, I cannot blame him.
Twice now, I can say that I tasted the stress and trauma of what too many women in this country and around the world experience in childbirth. A brief, passing taste – and for that good fortune I am eternally grateful.
But it is not just luck that allowed each of my birth stories to have a happy ending. I have insurance that affords me the choice of first-class medical providers and hospitals. I am more likely to receive high quality obstetric care, and to survive childbirth without significant short- or long-term health consequences, than women of other sociodemographic backgrounds because of differences in both where I receive my care and how I am treated in that facility. I benefitted from ready access to the medicine that got my bleeding under control, a team of providers able to step in quickly for my son, and an obstetrician who made extra efforts to support me postpartum until I could bring him home.
My experiences emphasize that there are two patients in childbirth. A recent commentary in the Journal of the American Medical Association (JAMA), discusses this unique feature of perinatal medicine—the “maternal-infant dyad”—as a priority area for clinical, epidemiologic, and health services research. The authors point out that few metrics track care and outcomes for moms and babies together or evaluate how policies and practices for one affect the other. Maternal and neonatal level of care designations, which aim to direct patients to appropriate health facilities by classifying hospital capacity for medical risk and complexity, were developed independent of each other and often do not align. We need to investigate the synergies between maternal and neonatal care and improve delivery systems to optimize resources, patient satisfaction, and outcomes.
Our team at the Blavatnik Family Women’s Health Research Institute is conducting qualitative research to understand the perinatal care experiences of women who suffered severe maternal complications or delivered high-risk infants. These analyses will provide insights into perceptions of care processes and barriers to quality when the primary concern is for a woman herself compared to when it is for her baby. Recalling the ways in which my family and I benefitted from access to comprehensive maternal and neonatal care fortifies my dedication to this work.
Kimberly Glazer, PhD, MPH is Assistant Professor in the Department of Population Health Science and Policy and the Raquel and Jaime Gilinski Department of Obstetrics, Gynecology and Reproductive Science. Dr. Glazer is a perinatal epidemiologist with research interests in obstetric care quality and perinatal health disparities. Her interdisciplinary research informs person-centered clinical practice and quality improvement across the pregnancy-postpartum continuum.