As a maternal-fetal medicine specialist, the fact that the United States has the highest rate of pregnancy-related deaths compared to other developed countries deeply concerns me. Yet, more shocking to me is the level of disparity in the rate of maternal death. A black woman is three times more likely to die from pregnancy-related complications than a white woman. What can be done about this disparity? Is the postpartum checklist the answer?
For several decades, the aviation industry has successfully implemented checklists for routine and emergency situations to ensure the safety of the plane and all of the precious lives it carries. Following the example of the aviation industry, many have endorsed the routine use of checklists to ensure safe and quality care in medicine.
The well-known physician and author, Atul Gawande, makes the case for the implementation of checklists in Medicine in his acclaimed book, “The Checklist Manifesto.” Has the checklist been shown to work in Medicine? Yes, it has. The use of the WHO Surgical Safety Checklist by most surgical providers around the world has significantly reduced both morbidity and mortality.
In an effort to prevent errors and ensure standardization of care, the use of surgical checklists has become routine in Obstetrics. Besides surgical checklists, obstetricians use checklists for treatment of hemorrhage, high blood pressure, and seizure, to name a few. Under intense stressful situations, checklists reduce the variations in practice that could put the patient’s life at risk.
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In other words, a checklist may allow a physician to ensure that no important step is forgotten and that procedures and treatments are performed in an acceptable and timely fashion regardless of the location or size of the hospital or clinic.
A checklist may improve communication among healthcare providers ofdifferent ranks and specialties; for example, it may empower a junior physician or a nurse to remind the leading physician of a particular step he or she may have forgotten or overlooked under a stressful condition. Detecting and verbalizing such oversight may make all of the difference in saving the life of a mother and her baby.
Pregnancy frequently is a time of immense joy for the mother and her family. Still, pregnancy is one of the most stressful times in a woman’s life. Undoubtedly physical, stress is often emotional, financial and even spiritual. Black women, in particular, experience a disparate burden of socioeconomic and racial stressors, which are often heightened during pregnancy. We still do not fully understand the negative impact that stress has on the life of the mother and fetus. But, we do know that stress is a major risk factor for preterm birth. Stress may partly explain why black mothers have worse pregnancy outcomes than white mothers.
This disparity in pregnancy outcomes is in and on itself a potential source of stress for some expectant black mothers. I recall a patient who upon learning that she was carrying a boy became overwhelmed with joy soon followed by fear. She spoke of the triple risk of attack on the life of a black man in America, an unfortunate and unjust problem that her unborn child was at risk of enduring.
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She confessed, “I have to worry about getting preeclampsia and delivering him early. I also have to worry that he is twice as likely to die after birth compared to a white baby. And then, as a young man, he will likely be perceived as a threat to a society who will see his life to be as valuable as that of a white kid.” Her words made my heart jolt with empathy and with frustration because we have so much work to do in our society to make sure that indeed all humans are created equal.
Unfortunately, a checklist will not add social capital to the life of her unborn child or to her own life. Still, if a checklist can help a pilot safely land an airplane and an obstetrician safely stop a hemorrhaging uterus, is it likely that a postpartum checklist will help healthcare providers take the symptoms of a black mother more seriously, quickly diagnose problems, and save her life? What if this checklist were to be shared directly with the patient during her postpartum visit? Could this checklist serve asvalidation for the patient to make sure that the right steps are being taken and that she is receiving the same level of care as all other postpartum women?
Certainly, a checklist alone would not be enough to protect the life of the black mother. A checklist will not sensitize our lawmakers to value her life and pass laws that provide affordable and adequate healthcare to all women. A checklist will not keep rural maternity wards open. A checklist will not eliminate unplanned pregnancies. A checklist will erase pre-pregnancy conditions, such as high blood pressure, diabetes, and obesity. A checklist will not eradicate poverty. A checklist will not provide the patient with a pregnancy support system. A checklist will not erase explicit or implicit bias in medicine. A checklist will not mentor more physicians of color. A checklist will not replace the art of medicine—if it did, robots could be physicians.
The list of what a checklist cannot do is extensive. Still, the added level of information and heightened alertness gained from the use of a checklist may empower the black mother to ask the necessary questions, seek allies, and escalate care when necessary. Moreover, it may help ensure some equity of care for all postpartum women.
Checklists might be essential tools in the struggle to achieve health care equity when basic standards of care are applied to every patient, every time, with the goal of decreasing errors and harmful events. As we redesign how we care for mothers in the postpartum period, a patient-centered checklist may be a vital tool to lowering black maternal mortality.
I am hopeful that we will come up with novel and perhaps, unconventional solutions to the problem of black maternal mortality. Yet, we may be able to use some of the already working tools to save the life of a black mother. Undoubtedly, the search for solutions will be an expensive and time-consuming endeavor. But, isn’t the life of the black mother worth the investment?
Veronica Maria Pimentel, MD is a Maternal-Fetal Medicine Specialist in Hartford, CT working with a diverse patient population, including the inner city black and immigrant community. She is also an Assistant Professor of OBGYN at the University of CT School of Medicine.
