I was coming back on duty as a resident physician

當我踏出電梯，院裡正是一片混亂

to cover the labor and delivery unit.

身為住院醫師的我回院值班

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

去增援分娩生產部門

hovering over a patient in the labor room.

我看到產房裡一大群的醫生和護士

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

圍在一個產婦身邊

The patient was in shock.

拼命地搶救她的生命

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

她已經休克了

Suddenly, she collapsed, became unresponsive,

在我抵達的前幾個小時 她剛產下一名健康的男嬰

and had profuse uterine bleeding.

突然，她虛脫休克，沒有反應

By the time I got to the room,

並伴有嚴重的血崩（子宮出血）

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

我進入產房時

The resuscitation team tried to bring her back to life,

裡面聚集了不同的醫護人員

but despite everyone's best efforts,

但她已沒有了生命跡象

she died.

醫療團隊嘗試搶救她的生命

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

但儘管每個人都盡了最大的努力

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

她還是走了

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

我仍記得那個父親悲傷欲絕的哭聲

but instead it turned out to be the worst day.

穿透了我和那層樓所有人的心

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

那本該是他人生中最快樂的一天

but sadly, that's not the case.

但卻變成了最痛苦的一天

Every year in the United States,

我多希望這個悲劇只是個單一事件

somewhere between 700 and 900 women die

但很遺憾，它並不是

from a pregnancy-related cause.

在美國，每一年

The shocking part of this story

有 700 至 900 位女性 死於妊娠相關的疾病

is that our maternal mortality rate is actually higher

最令人震驚的是

than all other high-income countries,

我們的孕產婦死亡率

and our rates are far worse for women of color.

遠高於其他高收入國家

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

且非白人女性更為嚴重

while other countries reduced their rates.

在過去十年中 我們孕產婦死亡率攀升

And the biggest paradox of all?

然而其他國家都在下降

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

這其中最大的悖論是什麼？

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

我們花在衛生保健上的費用 高於世界上任何一個國家

I became a mother myself.

大約是我當住院醫師遇到 那位母親往生的那段時間

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

我自己也成為母親

I was taken aback by how little attention was paid

即便擁有這個領域的背景和知識

to delivering high-quality maternal health care.

我對鮮少人會關注提供孕產婦 高品質的保健而感到吃驚

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

我思考著這意味著什麼呢

but for so many other women.

不僅為我，更為千千萬萬的女性

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

related to pregnancy and childbirth,

遭受與妊娠和分娩相關的嚴重併發症

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.

也就是每小時有 5 到 6 位女性

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

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

來預防憾事的發生

that could prevent these bad outcomes from occurring

並拯救這些女性的生命

and save women's lives.

而這並不需要昂貴的新技術

And it doesn't require fancy new technology.

只需要運用我們已知的知識

We just have to apply what we know

並確保醫院間的標準要一致

and ensure equal standards between hospitals.

例如，如果一位產婦 在分娩過程中出現了高血壓

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

我們能及時給她正確的抗高血壓藥

and we treat her with the right antihypertensive medication

我們就能防止中風

in a timely fashion,

如果我們準確記錄 分娩時的失血情況

we can prevent stroke.

我們就能更快地發現大出血 從而拯救產婦的生命

If we accurately track blood loss during delivery,

未來我們確實可以降低 這些悲慘事件的發生率

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

但前提是我們需重視

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

對孕產婦產前、產中 和產後的醫療照護品質

but it requires that we value the quality of care

如果我們將整體醫療照護品質 提高到應有的標準

we deliver to pregnant women

我們就可大大降低 死亡和嚴重併發症的機率

before, during and after pregnancy.

好消息是

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

已經有了一些成功的案例

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

一些地區落實了這些標準

Well, there is some good news.

並取得了顯著的成效

There are some success stories.

幾年前，美國婦產科醫師學會

There are some places that have actually adopted these standards,

聯合了其他醫療機構 像我一樣的研究員和社區組織

and it's really making a difference.

他們希望在全國的醫院 和醫療體系中

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

執行標準化的醫療照護

joined forces with other healthcare organizations,

他們的方法是成立一個叫做：

researchers like myself and community organizations.

孕產婦健康創新聯盟 即 AIM 計畫

They wanted to implement standard care practices

旨在透過高品質和安全的新措施

in hospitals and health systems throughout the country.

來降低孕產婦死亡率 和孕產婦重大疾病罹患率

And the vehicle they're using is a program called

這個組織針對最可預防的 孕產婦死亡病因

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

構建了一系列的「醫療工具包」

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

AIM 目前應能涵蓋全美 超過 50% 的分娩所需

through quality and safety initiatives across the country.

醫療工具包裡有什麼呢？

The group has developed a number of safety bundles

實證醫療、醫療計畫、程序步驟

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

用藥指導、醫療器材

The AIM program currently has the potential to reach

以及其他相關的醫療用品

over 50 percent of US births.

以大出血工具包為例

So what's in a safety bundle?

遇到大出血時 需要有一台治療推車

Evidence-based practices, protocols, procedures,

裡面裝有醫護人員急救所需的醫材：

medications, equipment

靜脈注射管線、氧氣面罩、藥物

and other items targeting these conditions.

檢查表及其他醫療器材

Let's take the example of a hemorrhage bundle.

接著你需要測量失血量的用品：

For a hemorrhage, you need a cart

海綿塊和棉墊

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

醫護人員不僅目測失血量

an IV line, an oxygen mask, medications,

還把這些海綿塊和棉墊收集起來稱重

checklists, other equipment.

或用更先進的技術來準確評估失血量

Then you need something to measure blood loss:

大出血工具包還包括

sponges and pads.

大量輸血的急救方案 以及定期的培訓與演練

And instead of just eyeballing it,

加州在醫療工具包的 應用上已然成為急先鋒

the doctors and nurses collect these sponges and pads

這就是為什麼採用了 醫療工具包的加州醫院

and either weigh them

在第一年裡因出血死亡的 產婦人數減少了 21%

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

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

The hemorrhage bundle also includes crises protocols for massive transfusions

比如實證醫療和對安全的注重

and regular trainings and drills.

因各醫院而異

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

醫療照護品質也有所差異

and that's why California saw a 21 percent reduction

在美國，非白人女性的 醫療差別待遇最為嚴重

in near death from hemorrhage

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

among hospitals that implemented this bundle in the first year.

這個統計數據顯示的是 所有在美國妊娠的黑人女性

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

無論她們是否在美國出生

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

很多人將差異歸咎於收入差距

and the emphasis on safety

但這超越了社會階級

differs from one hospital to the next,

一個受過大學教育的 黑人女性的死亡率

quality of care differs.

比一個學歷不到高中的 白人女性高 2 倍

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

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

Black women who deliver in this country

人們總說「教育可以改變人生」

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

但在這個例子裡，卻行不通

than are white women.

據美國疾病管制與預防中心統計

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

在產前、產後所有人口的 健康基準差距中

whether they were born in the United States

黑人與白人間的差距最大

or born in another country.

這些差異在一些城市中更為明顯

Many want to think that income differences drive these disparities,

如：在紐約

but it goes beyond class.

黑人女性死於妊娠相關疾病的機率

A black woman with a college education

是白人女性的 8 至 12 倍

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

我想大家都聽說過 沙隆 · 歐文醫生令人痛心的故事

with less than a high school education.

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

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

不到一年前

with her delivery.

她的故事被 ProPublica 和全國公共廣播電台報導

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

最近，我在一個會議上

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

很榮幸地聽到了她母親的演說

This black-white disparity

所有聽衆都為她流下熱淚

is the largest disparity

沙隆曾是一位出色的流行病學家

among all population perinatal health measures,

她致力於研究不同種族、民族 所受到的醫療差別待遇

according to the CDC.

36 歲時，她產下了 人生中第一個孩子

And these disparities are even more pronounced

她是非裔美國人

in some of our cities.

沙隆經歷了艱難的妊娠過程

For example, in New York City,

最終產下了一名健康女嬰並出院了

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

三週後，她死於高血壓併發症

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

在這三週裡

Now, I think many of you are probably familiar with

她由專業的醫療人員看診了四、五次

the heart-wrenching story of Dr. Shalon Irving,

但沒有人傾聽她的主訴

a CDC epidemiologist who died following childbirth.

也沒人辨識出她的嚴重病症

Her story was reported in ProPublica and NPR

沙隆的故事只是衆多

a little less than a year ago.

美國不同種族的 醫療差別照護的故事之一

Recently, I was at a conference

越來越多人瞭解到 醫療保健的社會決定因素

and I had the privilege of hearing her mother speak.

例如種族歧視、貧窮 教育、隔離的住宅區

She brought the entire audience to tears.

導致了醫療差異的擴大

Shalon was a brilliant epidemiologist,

但沙隆的故事突顯了另一潛在因素：

committed to studying racial and ethnic disparities in health.

醫療照護的品質

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

產後醫療照護缺乏標準程序

and she was African-American.

在那三週中，沙隆多次去醫師那看診

Now, Shalon did have a complicated pregnancy,

但她還是死了

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

分娩時的醫療照護品質

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

在美國是造成不同種族間

Shalon was seen four or five times by healthcare professionals

孕產婦死亡率和重大疾病罹患率

in those three weeks.

差異的潛在因素

She was not listened to,

而我們可以從現在開始改變它

and the severity of her condition was not recognized.

我們和其他的研究團隊已證明

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

由於各種原因

about racial and ethnic disparities in health and health care

黑人女性往往會在某些特定醫院分娩

in the United States,

排除病人自身的風險因素

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

這些醫院的黑人和白人女性 經常面臨更高的孕期風險

such as racism, poverty, education, segregated housing,

這種現象存在於整個美國

contribute to these disparities.

約 75% 的黑人女性 會在這些特定醫院分娩

But Shalon's story highlights an additional underlying cause:

但少於 20% 的白人女性 會選擇這些醫院

quality of care.

在紐約

Lack of standards in postpartum care.

女性在分娩時，發生 具生命危險併發症的機率

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

在不同醫院間有高達 6 倍的差距

and she still died.

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

Quality of care in the setting of childbirth

事實上，產科醫院間的差異

is an underlying cause of racial and ethnic disparities

解釋了近半數黑人與白人女性間 差異的原因

in maternal mortality and severe maternal morbidity

如果我們想要在美國 擁有真正公平的醫療照護

in the United States,

就必須設法解決這些社會決定因素

and it's something we can address now.

其中很多因素根深蒂固 需要投入時間去解決

Research by our team and others

同時我們可以處理醫療品質的問題

has documented that, for a variety of reasons,

在整個醫療照護期中 提供高品質的醫護服務

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

意味著為生育期的女性

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

提供安全而可靠的避孕方法

regardless of patient risk factors.

在孕前，提供孕前保健

This is true overall in the United States,

從而管理慢性病並優化健康狀態

where about three quarters of all black women

在孕中，提供高品質的產前和分娩保健

deliver in a specific set of hospitals,

從而保障母子的健康

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

在孕後，提供產後 和兩次孕間期的保健

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

可讓媽媽為下一個健康的寶寶

during delivery

和健康的生活做好準備

can be six times higher in one hospital than another.

這個方法運用在瑪麗亞身上時

Not surprisingly, black women are more likely to deliver

確實造成了天大的差異

in hospitals with worse outcomes.

她在產檢後發現血壓增高而住院

In fact, differences in delivery hospital

瑪麗亞 40 歲 這是她的第二次懷孕

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

兩年前她第一次懷孕時

While we must address social determinants of health

她同樣在產前最後幾週 感到身體不適

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

並出現了幾次血壓偏高現象

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

但醫護人員不以為意

In the meantime, we can tackle quality of care.

他們只是告訴她：「別擔心，會好的

Providing high-quality care across the care continuum

這是第一次懷孕 你只是有點緊張罷了」

means providing access to safe and reliable contraception

但瑪麗亞的狀況並沒有改善

throughout women's reproductive lives.

她在分娩時癲癇發作

Before pregnancy, it means providing preconception care,

不過這一次，醫療團隊 認真傾聽了她的主訴

so we can manage chronic illness and optimize health.

他們的問診精準而詳細

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

她的醫生告知了她 子癇前症的徵兆和症狀

so we can produce healthy moms and babies.

並告訴她，如果感到身體不適

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

她需要回診做檢查

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

這一次瑪麗亞回診後

and a healthy life.

她的醫生立即將她送往醫院

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

在醫院，醫生囑咐了立即的檢測

as it did in the case of Maria,

他們將她接上各種監視器

who checked into the hospital after having an elevated blood pressure

並特別關注她的血壓

during a prenatal visit.

監測胎兒心率

Maria was 40, and this was her second pregnancy.

給予靜脈注射用藥來防止癲癇發作