It was chaos as I got off the elevator. I was coming back on duty as a resident physician to cover the labor and delivery unit. And all I could see was a swarm of doctors and nurses hovering over a patient in the labor room. They were all desperately trying to save a woman's life. The patient was in shock. She had delivered a healthy baby boy a few hours before I arrived. Suddenly, she collapsed, became unresponsive, and had profuse uterine bleeding. By the time I got to the room, there were multiple doctors and nurses, and the patient was lifeless. The resuscitation team tried to bring her back to life, but despite everyone's best efforts, she died. What I remember most about that day was the father's piercing cry. It went through my heart and the heart of everyone on that floor. This was supposed to be the happiest day of his life, but instead it turned out to be the worst day.
當我踏出電梯,院裡正是一片混亂 身為住院醫師的我回院值班 去增援分娩生產部門 我看到產房裡一大群的醫生和護士 圍在一個產婦身邊 拼命地搶救她的生命 她已經休克了 在我抵達的前幾個小時 她剛產下一名健康的男嬰 突然,她虛脫休克,沒有反應 並伴有嚴重的血崩(子宮出血) 我進入產房時 裡面聚集了不同的醫護人員 但她已沒有了生命跡象 醫療團隊嘗試搶救她的生命 但儘管每個人都盡了最大的努力 她還是走了 我仍記得那個父親悲傷欲絕的哭聲 穿透了我和那層樓所有人的心 那本該是他人生中最快樂的一天 但卻變成了最痛苦的一天
I wish I could say this tragedy was an isolated incident, but sadly, that's not the case. Every year in the United States, somewhere between 700 and 900 women die from a pregnancy-related cause. The shocking part of this story is that our maternal mortality rate is actually higher than all other high-income countries, and our rates are far worse for women of color. Our rate of maternal mortality actually increased over the last decade, while other countries reduced their rates. And the biggest paradox of all? We spend more on health care than any other country in the world.
我多希望這個悲劇只是個單一事件 但很遺憾,它並不是 在美國,每一年 有 700 至 900 位女性 死於妊娠相關的疾病 最令人震驚的是 我們的孕產婦死亡率 遠高於其他高收入國家 且非白人女性更為嚴重 在過去十年中 我們孕產婦死亡率攀升 然而其他國家都在下降 這其中最大的悖論是什麼? 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, I became a mother myself. And even with all of my background and training in the field, I was taken aback by how little attention was paid to delivering high-quality maternal health care. And I thought about what that meant, not just for myself but for so many other women. Maybe it's because my dad was a civil rights attorney and my parents were socially conscious and demanded that we stand up for what we believe in. Or the fact that my parents were born in Jamaica, came to the United States and were able to realize the American Dream. Or maybe it was my residency training, where I saw firsthand how poorly so many low-income women of color were treated by our healthcare system. For whatever the reason, I felt a responsibility to stand up, not just for myself, but for all women, and especially those marginalized by our healthcare system. And I decided to focus my career on improving maternal health care.
大約是我當住院醫師遇到 那位母親往生的那段時間 我自己也成為母親 即便擁有這個領域的背景和知識 我對鮮少人會關注提供孕產婦 高品質的保健而感到吃驚 我思考著這意味著什麼呢 不僅為我,更為千千萬萬的女性 或許是因為我的父親是位民權律師 我的父母很有社會意識 也要求我們要堅守自己的信念 或是因為出生在牙買加的他們 移居美國 並得以實現美國夢 又或我在接受住院醫師培訓時 親眼目睹 低收入的非白人婦女 在我們的醫療體系下 如何被惡劣地對待 不論如何,我有責任站出來 不僅為我自己 更為所有的女性 尤其是那些被醫療體系邊緣化的人 於是我決定致力於改善孕產婦保健
So what's killing mothers? Cardiovascular disease, hemorrhage, high blood pressure causing seizures and strokes, blood clots and infection are some of the major causes of maternal mortality in this country. But a maternal death is only the tip of the iceberg. For every death, over a hundred women suffer a severe complication related to pregnancy and childbirth, resulting in over 60,000 women every year having one of these events. These complications, called severe maternal morbidity, are on the rise in the United States, and they're life-altering. It's estimated that somewhere between 1.5 and two percent of the four million deliveries that occur every year in this country are associated with one of these events. That is five or six women every hour having a blood clot, a seizure, a stroke, receiving a blood transfusion, having end-organ damage such as kidney failure, or some other tragic event.
所以,造成母親們死亡的原因為何? 心血管疾病、失血 高血壓引發的癲癇及中風 血栓和感染 這些是美國孕產婦死亡的 部分主要原因 然而孕產婦死亡還只是冰山的一角 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 每年有超過 60,000 名女性 會碰到其中的一項 這些併發症稱為孕產婦重大疾病罹患率 在美國呈現上升趨勢 而且它們會改變人的一生 據估計,在美國 每 400 萬次分娩中 1.5% 至 2% 會出現這些病症 也就是每小時有 5 到 6 位女性 會出現血栓、癲癇、中風 接受輸血 終端器官損傷,如:腎衰竭 或是其他悲劇
Now, the part of this story that's frankly unforgivable is the fact that 60 percent of these deaths and severe complications are thought to be preventable. When I say 60 percent are preventable, I mean there are concrete steps and standard procedures that we could implement that could prevent these bad outcomes from occurring and save women's lives. And it doesn't require fancy new technology. We just have to apply what we know and ensure equal standards between hospitals.
這件事情最無法原諒的部分是 這當中有 60% 的 死亡和嚴重併發症 是可以預防的 60% 可以「預防」 是指有可實施的具體措施和標準流程 來預防憾事的發生 並拯救這些女性的生命 而這並不需要昂貴的新技術 只需要運用我們已知的知識 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 and we treat her with the right antihypertensive medication in a timely fashion, we can prevent stroke. If we accurately track blood loss during delivery, we can detect a hemorrhage sooner and save a woman's life. We could actually lower the rates of these catastrophic events tomorrow, but it requires that we value the quality of care 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, we could bring the rates of these deaths and severe complications way down.
例如,如果一位產婦 在分娩過程中出現了高血壓 我們能及時給她正確的抗高血壓藥 我們就能防止中風 如果我們準確記錄 分娩時的失血情況 我們就能更快地發現大出血 從而拯救產婦的生命 未來我們確實可以降低 這些悲慘事件的發生率 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 如果我們將整體醫療照護品質 提高到應有的標準 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. There are some success stories. There are some places that have actually adopted these standards, and it's really making a difference. A few years ago, the American College of Obstetricians and Gynecologists joined forces with other healthcare organizations, researchers like myself and community organizations. They wanted to implement standard care practices in hospitals and health systems throughout the country. And the vehicle they're using is a program called the Alliance for Innovation in Maternal Health, the AIM program. Their goal is to lower maternal mortality and severe maternal morbidity rates through quality and safety initiatives across the country. The group has developed a number of safety bundles that target some of the most preventable causes of a maternal death. The AIM program currently has the potential to reach over 50 percent of US births.
好消息是 已經有了一些成功的案例 一些地區落實了這些標準 並取得了顯著的成效 幾年前,美國婦產科醫師學會 聯合了其他醫療機構 像我一樣的研究員和社區組織 他們希望在全國的醫院 和醫療體系中 執行標準化的醫療照護 他們的方法是成立一個叫做: 孕產婦健康創新聯盟 即 AIM 計畫 旨在透過高品質和安全的新措施 來降低孕產婦死亡率 和孕產婦重大疾病罹患率 這個組織針對最可預防的 孕產婦死亡病因 構建了一系列的「醫療工具包」 AIM 目前應能涵蓋全美 超過 50% 的分娩所需
So what's in a safety bundle? Evidence-based practices, protocols, procedures, medications, equipment and other items targeting these conditions. Let's take the example of a hemorrhage bundle. For a hemorrhage, you need a cart that has everything a doctor or nurse might need in an emergency: an IV line, an oxygen mask, medications, checklists, other equipment. Then you need something to measure blood loss: sponges and pads. And instead of just eyeballing it, the doctors and nurses collect these sponges and pads and either weigh them or use newer technology to accurately assess how much blood has been lost. The hemorrhage bundle also includes crises protocols for massive transfusions and regular trainings and drills.
醫療工具包裡有什麼呢? 實證醫療、醫療計畫、程序步驟 用藥指導、醫療器材 以及其他相關的醫療用品 以大出血工具包為例 遇到大出血時 需要有一台治療推車 裡面裝有醫護人員急救所需的醫材: 靜脈注射管線、氧氣面罩、藥物 檢查表及其他醫療器材 接著你需要測量失血量的用品: 海綿塊和棉墊 醫護人員不僅目測失血量 還把這些海綿塊和棉墊收集起來稱重 或用更先進的技術來準確評估失血量 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
Now, California has been a leader in the use of these types of bundles, and that's why California saw a 21 percent reduction in near death from hemorrhage among hospitals that implemented this bundle in the first year. Yet the use of these bundles across the country is spotty or missing. Just like the fact that the use of evidence-based practices and the emphasis on safety differs from one hospital to the next, quality of care differs.
加州在醫療工具包的 應用上已然成為急先鋒 這就是為什麼採用了 醫療工具包的加州醫院 在第一年裡因出血死亡的 產婦人數減少了 21% 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 比如實證醫療和對安全的注重 因各醫院而異 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. Black women who deliver in this country 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, whether they were born in the United States or born in another country. Many want to think that income differences drive these disparities, but it goes beyond class. A black woman with a college education is nearly twice as likely to die as compared to a white woman with less than a high school education. And she is two to three times more likely to suffer a severe pregnancy complication with her delivery.
在美國,非白人女性的 醫療差別待遇最為嚴重 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 這個統計數據顯示的是 所有在美國妊娠的黑人女性 無論她們是否在美國出生 很多人將差異歸咎於收入差距 但這超越了社會階級 一個受過大學教育的 黑人女性的死亡率 比一個學歷不到高中的 白人女性高 2 倍 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
Now, I was always taught to think that education was our salvation, but in this case, it's simply not true. This black-white disparity is the largest disparity among all population perinatal health measures, according to the CDC. And these disparities are even more pronounced in some of our cities. For example, in New York City, a black woman is eight to 12 times more likely to die from a pregnancy-related cause than is a white woman.
人們總說「教育可以改變人生」 但在這個例子裡,卻行不通 據美國疾病管制與預防中心統計 在產前、產後所有人口的 健康基準差距中 黑人與白人間的差距最大 這些差異在一些城市中更為明顯 如:在紐約 黑人女性死於妊娠相關疾病的機率 是白人女性的 8 至 12 倍
Now, I think many of you are probably familiar with the heart-wrenching story of Dr. Shalon Irving, a CDC epidemiologist who died following childbirth. Her story was reported in ProPublica and NPR a little less than a year ago. Recently, I was at a conference and I had the privilege of hearing her mother speak. She brought the entire audience to tears. Shalon was a brilliant epidemiologist, committed to studying racial and ethnic disparities in health. She was 36 years old, this was her first baby, and she was African-American.
我想大家都聽說過 沙隆 · 歐文醫生令人痛心的故事 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 不到一年前 她的故事被 ProPublica 和全國公共廣播電台報導 最近,我在一個會議上 很榮幸地聽到了她母親的演說 所有聽衆都為她流下熱淚 沙隆曾是一位出色的流行病學家 她致力於研究不同種族、民族 所受到的醫療差別待遇 36 歲時,她產下了 人生中第一個孩子 她是非裔美國人
Now, Shalon did have a complicated pregnancy, but she delivered a healthy baby girl and was discharged from the hospital. Three weeks later, she died from complications of high blood pressure. Shalon was seen four or five times by healthcare professionals in those three weeks. She was not listened to, and the severity of her condition was not recognized.
沙隆經歷了艱難的妊娠過程 最終產下了一名健康女嬰並出院了 三週後,她死於高血壓併發症 在這三週裡 她由專業的醫療人員看診了四、五次 但沒有人傾聽她的主訴 也沒人辨識出她的嚴重病症
Now, Shalon's story is just one of many stories about racial and ethnic disparities in health and health care in the United States, and there's a growing recognition that the social determinants of health, such as racism, poverty, education, segregated housing, contribute to these disparities. But Shalon's story highlights an additional underlying cause: quality of care. Lack of standards in postpartum care. Shalon was seen multiple times by clinicians in those three weeks, and she still died. Quality of care in the setting of childbirth is an underlying cause of racial and ethnic disparities in maternal mortality and severe maternal morbidity in the United States, and it's something we can address now.
沙隆的故事只是衆多 美國不同種族的 醫療差別照護的故事之一 越來越多人瞭解到 醫療保健的社會決定因素 例如種族歧視、貧窮 教育、隔離的住宅區 導致了醫療差異的擴大 但沙隆的故事突顯了另一潛在因素: 醫療照護的品質 產後醫療照護缺乏標準程序 在那三週中,沙隆多次去醫師那看診 但她還是死了 分娩時的醫療照護品質 在美國是造成不同種族間 孕產婦死亡率和重大疾病罹患率 差異的潛在因素 而我們可以從現在開始改變它
Research by our team and others has documented that, for a variety of reasons, black women tend to deliver in a specific set of hospitals, and those hospitals often have worse outcomes for both black and white women, regardless of patient risk factors. This is true overall in the United States, where about three quarters of all black women deliver in a specific set of hospitals, while less than one-fifth of white women deliver in those same hospitals. In New York City, a woman's risk of having a life-threatening complication during delivery can be six times higher in one hospital than another. Not surprisingly, black women are more likely to deliver in hospitals with worse outcomes. In fact, differences in delivery hospital explain nearly one-half of the black-white disparity.
我們和其他的研究團隊已證明 由於各種原因 黑人女性往往會在某些特定醫院分娩 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 這種現象存在於整個美國 約 75% 的黑人女性 會在這些特定醫院分娩 但少於 20% 的白人女性 會選擇這些醫院 在紐約 女性在分娩時,發生 具生命危險併發症的機率 在不同醫院間有高達 6 倍的差距 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 事實上,產科醫院間的差異 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 if we're ever going to truly have equitable health care in this country, many of these are deep-seated and they will take some time to resolve. In the meantime, we can tackle quality of care. Providing high-quality care across the care continuum means providing access to safe and reliable contraception throughout women's reproductive lives. Before pregnancy, it means providing preconception care, so we can manage chronic illness and optimize health. During pregnancy, it includes high-quality prenatal and delivery care so we can produce healthy moms and babies. And finally, after pregnancy, it includes postpartum and inter-pregnancy care so we can set moms up to have a healthy next baby and a healthy life.
如果我們想要在美國 擁有真正公平的醫療照護 就必須設法解決這些社會決定因素 其中很多因素根深蒂固 需要投入時間去解決 同時我們可以處理醫療品質的問題 在整個醫療照護期中 提供高品質的醫護服務 意味著為生育期的女性 提供安全而可靠的避孕方法 在孕前,提供孕前保健 從而管理慢性病並優化健康狀態 在孕中,提供高品質的產前和分娩保健 從而保障母子的健康 在孕後,提供產後 和兩次孕間期的保健 可讓媽媽為下一個健康的寶寶 和健康的生活做好準備
And it can literally spell the difference between life and death, as it did in the case of Maria, who checked into the hospital after having an elevated blood pressure during a prenatal visit. Maria was 40, and this was her second pregnancy. During Maria's first pregnancy that had happened two years earlier, she also didn't feel so well in the last few weeks of her pregnancy, and she had a few elevated blood pressures, but nobody seemed to pay attention. They just said, "Maria, don't worry, you'll be fine. This is your first pregnancy. You're a little nervous." But it did not end well for Maria last time. She seized during labor.
這個方法運用在瑪麗亞身上時 確實造成了天大的差異 她在產檢後發現血壓增高而住院 瑪麗亞 40 歲 這是她的第二次懷孕 兩年前她第一次懷孕時 她同樣在產前最後幾週 感到身體不適 並出現了幾次血壓偏高現象 但醫護人員不以為意 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」 但瑪麗亞的狀況並沒有改善 她在分娩時癲癇發作
Well, this time her team really listened. They asked smart and probing questions. Her doctor counseled her about the signs and symptoms of preeclampsia and explained that if she was not feeling well, she needed to come in and be seen. And this time Maria came in, and her doctor immediately sent her to the hospital. At the hospital, her doctor ordered urgent lab tests. They hooked her up to multiple different monitors and paid special attention to her blood pressure, the fetal heart rate tracing and gave her IV medication to prevent a seizure. And when Maria's blood pressure got so high it put her at risk for a stroke, her doctors and nurses jumped into action. They repeated her blood pressure in 15 minutes and declared a hypertensive emergency. They gave her the right IV medication according to the latest correct protocol. They worked smoothly together as a coordinated team and successfully lowered her blood pressure.
不過這一次,醫療團隊 認真傾聽了她的主訴 他們的問診精準而詳細 她的醫生告知了她 子癇前症的徵兆和症狀 並告訴她,如果感到身體不適 她需要回診做檢查 這一次瑪麗亞回診後 她的醫生立即將她送往醫院 在醫院,醫生囑咐了立即的檢測 他們將她接上各種監視器 並特別關注她的血壓 監測胎兒心率 給予靜脈注射用藥來防止癲癇發作 當瑪麗亞的血壓過高 有引發中風的危險時 醫生和護士立即採取行動 他們在 15 分鐘內反覆測量血壓 然後宣佈高血壓危症 根據最新而有效的方案 給她正確的靜脈注射用藥 他們團隊協作有條不紊 成功地降低了她的血壓
As a result, what could have been a tragedy became a success story. Maria's dangerous symptoms were controlled, and she delivered a healthy baby girl. And before Maria was discharged from the hospital, her doctor counseled her again about the signs and symptoms of preeclampsia, the importance of having her blood pressure checked, especially in this first week postpartum and gave her education about postpartum health and what to expect. And in the weeks and months that followed, naturally, Maria had follow-up visits with her pediatrician to check in on her baby's health. But just as important, she had follow-up visits with her ob-gyn to check in on her health, her blood pressure, and her cares and concerns as a new mother.
最終,他們將一場悲劇 逆轉為成功的故事: 瑪麗亞的危險症狀得到了控制 並產下了一名健康的女嬰 在瑪麗亞獲准出院前 她的醫生再次告知 子癇前症的徵兆和症狀 以及檢查血壓的重要性 特別是產後第一週 醫生還告訴她 產後保健事項和可能發生的狀況 在接下來的幾個月 她持續到兒科醫師那裡回診 檢查嬰兒的健康情況 同樣重要的是 她之後也到婦產科回診 檢查她的健康狀況和血壓 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, and this is how it can look. If every pregnant woman in every community received this kind of high-quality care and delivered at facilities that utilized standard care practices, our maternal mortality and severe maternal morbidity rates would plummet. Our international ranking would no longer be an embarrassment.
以上就是整個醫療照護期 該有的高品質醫療服務 是可以做到這個樣子的 如果每個社區的孕婦 都能得到這樣高品質的醫療照護 並在遵循標準醫療制度的機構裡分娩 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 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 of maternal death and life-threatening complications during delivery and decades of devastating consequences for moms, babies and families, and we have not been moved to action.
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 高到令人無法接受 幾十年來母親、嬰兒和家庭 都承受著極具破壞性的後果 卻沒有人採取行動
The recent media attention on our poor performance on maternal mortality has helped the public to understand: high-quality maternal health care is within reach. The question is: Are we as a society ready to value pregnant women from every community?
近期媒體對居高不下的 孕產婦死亡率的報導 讓公衆意識到 高品質的孕產婦醫療照護 其實不難獲得 問題是: 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, we have the tools and evidence base ready to move forward.
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 往前大步邁進
Thank you.
謝謝大家
(Applause)
(掌聲)