When ACP Policy Hits Home - Annals of Internal Medicine: Fresh Look Blog


Wednesday, August 29, 2018

When ACP Policy Hits Home

My sister-in-law held me in her arms. “God saved you through you, God saved you through you,” she kept whispering to me as I sobbed into her shoulders. I was just starting to process what happened.

Six days prior, I delivered my son. Some women say that labor is a blur. This was not the case for me; I remember everything. I remember my son being moved from my chest to be weighed. I remember the cheers as I pushed. I remember the anesthesiologist next to me. I remember a team at the foot of my bed. I remember the blood pressure on the monitor. I remember looking through the room and feeling reassured my son was healthy.

But I also remember everything fading to black. I remember thinking, “I wonder if I should say something. Things are not right. Are they going to figure it out?” More moments passed, and the world was getting blacker. The internist inside of me awoke, and I screamed, “Someone cycle my pressures and give me a bolus.” I had hemorrhaged so severely that my pressures had plummeted, requiring fluids and pressors to bring light back into the room.

I always wanted to be a mother, and I always wanted to be an internist. I never imagined those two parts of my identity would be so intertwined. I faced weeks of weakness after. But as I healed, I also found new strength: I no longer waited to see whether anyone else noticed if something was wrong. I advocated for myself, and in doing so, recovered sooner than expected.

However, my experience left me wondering: What would have happened to someone who was not a physician or someone who did not speak up when they felt like something was wrong?

A few weeks after my son was born, the American College of Physicians released its position paper on women’s health policy in the United States:
[T]he United States has the highest maternal mortality rate among developed countries and is the only developed nation where that rate continues to increase. Since the Centers for Disease Control and Prevention began tracking pregnancy-related deaths (those caused by complications of pregnancy), the maternal mortality rate has steadily increased from 7.2 deaths per 100 000 live births in 1987 to a high of 17.8 deaths per 100 000 live births in 2009 and 2011. Large racial disparities also exist: Between 2011 and 2013, a total of 12.7 white women died per 100 000 live births, compared with 43.5 black women. One review of maternal deaths found that nearly 60% of pregnancy-related deaths were preventable. (1)
The statistics no longer looked like facts on a page. Instead they felt very real, personal even. Why is navigating care so difficult for woman? Why are outcomes so much worse for African American women? Why do so many female patients’ voices go unheard?

It is clear that women are not taken care of as best as they could be in today’s health care system. Where does that leave us physicians? ACP’s position statement is a step in the right direction. As internists, we are in charge of adult patients—all adult patients. If half of those patients are getting lesser care, we must advocate for their unique needs. We must also demand better preparation for this task. We need better education; we need a better understanding how we can improve care for women; and we need to make sure our female patients never feel like they are screaming into a deaf room, fading black. We need to make sure we do not have to scream at all.

  1. Daniel H, Erickson SM, Bornstein SS; Health and Public Policy Committee of the American College of Physicians. Women's health policy in the United States: an American College of Physicians position paper. Ann Intern Med. 2018;168:874-5. [PMID: 29809243] doi:10.7326/M17-3344


  1. One would wonder the outcome of child birth in Africa and some Asian countries if America has this high rate of maternal mortality.

  2. thanks for this article. it is an increasingly devastating problem particularly for women of color. What are your thoughts on going back to the old ways in the African american history of having a support system with you at the hospital of women who have delivered before or have experience and can advocate for you? unfortunately as doctors we are inundated with so many tasks, that i think we largely neglect our roles as advocates for our patients these days.

  3. Powerful commentary! Thank you for writing with such insight and wisdom.
    Patsy Sadler, MD

  4. Medical students need to be trained to listen to their patients! Data only goes so far. Physicians really have to know HOW to listen & take detailed history & physical.

  5. Thanks everyone for heir comments. I'm not sure that having others in the room gets to the core problem, which is physicians needing to see patients for the individuals they are.


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