 I'm going to spend a little bit of time presenting some data to frame the issue so that everybody is on the same page about what it is we're here to talk about today. And I will say from a personal standpoint that this issue of the rising maternal mortality rates in our country and in particular in our state are a cause for me of an area of moral distress. Moral distress is something we try to teach our medical students to recognize when they experience it on the wards, when they're taking care of patients, so that it's a trigger to do something about the situation. But as a physician, as a Texan, and as a mother, I am experiencing moral distress about what we're seeing in maternal mortality rates in our country and in our state. So Dr. Zolot's visit actually represents the 17th installment in the conversations about ethics series, which explores ethical dilemmas that influence health care delivery throughout the life cycle. We present conversations about ethics twice annually, together with the Ecumenical Center and the Center for Medical Humanities and Ethics. And we have the generous support of Methodist health care ministries for this endeavor. So would anyone who is representing these partner organizations, Methodist or Ecumenical Center, please stand so that we can acknowledge you and thank you? I don't know if they're standing, but I know that Mary Beth Fisk is here from the Ecumenical Center. Thank you for being with us and for your partnership. So here are the housekeeping details. Dr. Zolot and the planning committee have disclosed no relevant financial relationships with any commercial interests related to this activity. And if you are seeking continuing education credit, please make sure that you sign in at the appropriate desk out in the foyer. If you're seeking continuing medical education credit, you should have received two pieces of paper. Fill out the smaller paper and return it to us as you leave. The larger piece of paper is for you and it will have instructions on how to claim your credit for ethics CME from the website. And you'll do that two to four weeks from now. So hang on to that. And you'll also get an email from us when it's time to do so. For CEU credit, please fill out the survey provided at sign in and return it to the CEU desk before you leave. And you will receive a certificate at that time. If you're unsure about any of this, please see one of the volunteers at the education tables after the event. Now to all of you here tonight, we really need your feedback. And so we want you to evaluate our program using either a paper survey which we provide or you may link to the QR code on the back of your program and fill out the survey from there. It's very important, so we know how to develop programming for the future. Tonight's presentation is titled The Thief of the Future, The Ethical Puzzle of Maternal Mortality. And before I bring up Dr. Morrow to introduce Dr. Zoloth, I'm going to spend a few minutes unpacking this issue. So to make sure that we all are using the same terminology, when we talk about maternal death, we are talking about the death of a woman while pregnant or within 42 days of the termination of that pregnancy irrespective of the duration and the site of the pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. So this is a term of art and that is its proper definition. There's some confusion in the field or to the casual observer because you'll see reports that discuss maternal mortality rates and maternal mortality ratios. For the most part, the numbers you're going to hear referred to this evening are going to be maternal mortality ratios, which is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management. All right, so I'm going to leave maternal mortality rate aside, but you'll often see maternal mortality rate labeling a graph that is actually meaning to be the maternal mortality ratio. Oh, by the way, the image. The image there is taken from a grave in Dresden in the 1800s and it represents a woman who's just given birth and is dying and as the midwife is carrying away her infant, the angels have arrived to tend to the woman. So the issue of maternal mortality is one that has been with us since the beginning of humankind and we began tracking maternal mortality historically some time back. Sweden actually has the most longitudinal data and you can see maternal mortality ratios used to be quite high in excess of 1,000 and then we began to have some progress and maybe you can tell by looking at the dates down on the timeline on the X axis what events may have correlated with the beginnings of the decline. Remember I told you at the beginning of this that maternal mortality was causing me moral distress. Well, there was a guy back in the 1800s by the name of Semmelweis and he also experienced moral distress. He discovered that if you just simply washed your hands before delivering a baby that you could greatly decrease the risk of death due to puerperal sepsis but he had a heck of a time getting his colleagues to believe this and actually died in an insane asylum because he was so distressed that people wouldn't listen to him and wouldn't simply wash their hands. So after the 1860s we began to see a decline just simply from hand washing. In the 1920s they introduced gloves and masks in the United Kingdom. In the 1930s we had sulfas of the first antibiotics. In 1945 we started to have mass production of penicillin. In 1948 we started to have the availability of blood transfusions so we dealt with the problem of postpartum hemorrhage and what happened in the 1960s it was the availability of birth control. So women now could control their fertility. They had smaller families. They were in better nutritional condition when they would come to the next pregnancy. They had fewer abortions and maternal mortality fell further still. Now what's alarming here? If you look at the big kind of pipeline that kind of goes down and starts coming back up that actually represents the United States. And so you see this nice decline all the way to the 1980s and then we start to see a rise. You can see what happened in Sweden around that time is a leveling off but you don't see the continuing rise. You actually see that in Sweden it continues to go down. And not far away from the United States in terms of current day maternal mortality is Cuba. Way up high there in the far right hand corner in blue you see countries like Haiti and Afghanistan for comparison. So I backed into this problem that we're having United States and in Texas in a kind of a strange way. I was actually asked by our medical students to speak about global maternal mortality as a global health issue because I teach global health. And I was proud to tell them that as a result of the world's decision to have millennium development goals that there actually has been from 1990 to 2015 a 44% reduction in maternal death. That wasn't the two thirds or 75% reduction that was ambitiously prescribed by the Millennium Development Goal but nevertheless globally we saw a reduction by 44%. So imagine my distress when I learned that that was not the case in the United States. And here's just a few comparators to see where we stand these are the other countries. So Sweden is amongst the countries with the lowest maternal mortality with four. Japan has five, Germany six, France eight, the United Kingdom nine and here we are at 14. Two to three times the rates that are seen in countries that I think many of us would argue might be our peers when it comes to healthcare delivery. And we're not really very far away from our neighbor Mexico or across the water not very far Cuba. I threw Nicaragua in there just for comparators because I just returned from Nicaragua with medical students. So this paper that came out by McDormand et al in obstetrics and gynecology last fall caused a great stir because it documented not only ongoing rises in maternal mortality in our country but it singled out Texas for some pretty distressing numbers. Overall, in 2014 nearly 24 mothers died for every 100,000 live births in 48 states and Washington DC excluding California and Texas. By the way, there's one state that has had declines in maternal mortality at California. There's one state that leads all the other states in rising maternal mortality that would be Texas. So, but this figure nationally represented a 26% increase from the rate in 2000. So are you with me now? The world has seen a 44% reduction and the United States is seeing a 26.6% increase. And here my friends is the thing that really pains me and I hope you feel pain when you look at this because the green line shows the steady rise across the continental United States and Washington DC and the red line is our state of Texas. At least you start to see the leveling off and the coming down a little bit since 2012. Unpacking that, I got some slides from our Texas Department of State Health Services. And by the way, I asked them to be present with us today to present, I asked Dr. Lisa Olea who is an obstetrician gynecologist and the incoming president of the American College of Obstetrics and Gynecology. How about that? They got a woman from Houston to be the president of ACOG which is wonderful. Dr. Olea chairs the Texas Commission that the legislature has appointed to review this problem that we're having in Texas due to her new obligations as the president of ACOG Dr. Olea couldn't join us but she has helped me find the data to put some credibility to the alarm bells that we are raising here this evening and what you can see from this graph broadly speaking is that depending on whose data you look at and what method they're using you might see slightly different numbers. So I didn't want anybody to go away from this presentation thinking that we were biased and showing you exaggerated numbers but the McDormand paper published in obstetrics and gynecology showed that from 2010 to 2011 there was actually a 77% increase in Texas while the CDC would say there was a 62% increase and the Texas Department of Health would say that there was a 42% increase. 77, 42, there is a big difference there but I hope you're with me, 42% is pretty unacceptable particularly when we compare ourselves to the rest of the country and indeed the rest of the world. Once again the news isn't all dire because you see there these minus one, minus seven, minus 3% along the bottom shows you that we've leveled off and are starting to see decreases at least from 2013 to 2014. Who is dying? Well here's the numbers. This is Texas, maternal mortality ratio and it's broken out from 05 to 2014 according to race. The orange is the black population, the dotted line is the overall population in Texas, the blue line is the white population and the gray line is the Hispanic population so I don't know what preconceived notions you might have brought with you to this presentation but what we've learned is that a disproportionate number of the black population bears the burden of maternal mortality as you see in the comparison of these two columns with the light blue being the black population on the left maternal deaths and the right Texas births and so whereas Hispanic women have 48% of the births they only have 30% of the mortality. So they're racial disparities and that's who's dying in one way of looking at it and what are the risk factors and so let me just really, really briefly summarize what we learned from these graphs which is looking at again broken out by race, Texas mothers at risk factors from 05 to 14 and the orange line across the top is the rise in obesity, the blue line is the maternal mortality rate overall and according to race, the green line is high blood pressure and the gray line is diabetes. So we're getting fatter and with that we have rises in hypertension as well as diabetes and these are risk factors for maternal death as my OBGYN colleagues will attest. So what are we dying of in Texas? We will think about maternal death, it's cardiac events, drug overdoses, hypertension and eclampsia, hemorrhage, sepsis, homicide and suicide. I wish I could tell you I had great confidence in those numbers but this is a very small subset of the charts that got redacted for the 2011-2012 timeframe. Why didn't we have all of them and why don't we have 13, 14, 15 and 16? There's a really good reason. Although this is a Texas legislator mandated review, there is a requirement that every page of every chart of every mother who has died be redacted of her identity so that the nurses who then review the charts and abstract them are not put into conflict with their professional duties to report if they find some evidence of malpractice. So this is a very big barrier that we're facing to just even understand what's actually going on. And this is my last slide. This is just an overview of maternal death both confirmed and unconfirmed from 2011 and 2012. Again broken out by race. So you see the disproportionate representation of hypertension and eclampsia, highly treatable, highly preventable conditions affecting the black population and the purple with the drug overdose which I found astonishing that we had such an important amount of drug overdose contributing to maternal death. So are you upset? Are you experiencing moral distress? I certainly am. But I'd like to help us think about this not from a political soapbox but rather far, far upstream of political views and to look at this through the lens of an ethicist. To look at this while we think about what are our values as a society. I can think of nobody better to help us learn how to look at this and how to talk to one another about this issue than Dr. Zoloth. And I'm gonna ask Dr. Jason Morrow to come on over and take the mic from me and introduce Dr. Zoloth. Well, thank you, Ruth. I'm definitely mad as hell. I just don't know who to be mad at. And I think I really hope all of you share my admiration and confidence in Dr. Bergeron to bring really tough issues to our attention and I appreciate the Center for Medical Humanities and Neck Medical Center and Methodist Healthcare Ministries for really supporting this kind of public forum. This topic is really hard to talk about. And I really hope that you'll share my enthusiasm for our guest speaker, Dr. Lori Zoloth, who is a leader in the field of religious studies and has a particular scholarly interest in bioethics and Jewish studies. She was recently appointed Dean of the University of Chicago Divinity School. Dr. Zoloth began her career as a neonatal nurse working in impoverished communities. This beginning is central to how she views religious studies and bioethics and approach that brings together theory with understanding of how theology and moral philosophy can address societal challenges. Dr. Zoloth holds a bachelor's degree in women's studies from the University of California Berkeley and a bachelor's degree in nursing from the University of the State of New York. She received a master's degree in Jewish studies and a doctorate in social ethics from the Graduate Theological Union. Zoloth also holds a master's degree in English from San Francisco State University. Dr. Zoloth's research explores religion and ethics drawing from sources ranging from biblical and Talmudic to postmodern Jewish philosophy. Her scholarship spans the ethics of genetic engineering, stem cell research, synthetic biology, social justice and healthcare and how science and medicine are taught. Dr. Zoloth is author of Health Care and the Ethics of Encounter, a Jewish discussion of social justice and co-editor of five books including Notes from a Narrow Ridge, Religion and Bioethics and Jews and Genes, the Genetic Future and Contemporary Jewish Thought. Dr. Zoloth has been the president of the American Academy of Religion and the American Society for Bioethics and Humanities. She was the inaugural director of the Jewish Studies Program at San Francisco State University and director of graduate studies and religious studies at Northwestern. She is an elected member of the Hastings Center and a life member of Clare Hall University of Cambridge. Her work on bioethics and healthcare led her to serve on the NASA Advisory Council, the space agency's highest civilian advisory board, the interplanetary, I'm sorry, the International Planetary Protection Committee, although her musings may be interplanetary. The National Recombitant DNA Advisory Board and the Executive Committee of the International Society for Stem Cell Research. She served as chair of the First Bioethics Advisory Board at the Howard Hughes Medical Research Institute and has testified in front of Congress, bless you. The President's Commission on Bioethics and State Legislatures. She is the proud mother of five, a brilliant conversationalist and I hope you'll help me welcome her. She's gonna be great. Good question, right? It's the International Planetary Protection Association which is like called P-PAC and the theme is protecting earth in the scum of the universe and vice versa. And when you join, you get little black glasses. I am not making this up, so. So let's see if we need an official person to do this. Many, many things to hold on to. Yeah, right. I just want to say, I too do not have moral distress. I have something like righteous anger. This is like, it's so much more than sort of just sort of an upset, it's that there is a tragedy that could completely be avoided and has been avoided in other countries and this is far beyond it. So I want to start by saying thank you. You'll see in a minute why I call the thief of the future. And this is the thing that clicks forward. Nope, this isn't the thing that clicks forward. This is the thing that clicks forward. Okay, so I want to start by saying thank you. The organizers of these meetings in the University of Texas, I've been to San Antonio before. It's a terrific place to live. It's a beautiful city. But the collaboration between UT and the Ecumenical Center has been extraordinary and I'm extraordinarily grateful to have been asked this question and to Ruth to you for raising this question of maternal mortality in America. I also want to also quote, thank Northwestern University for many years, they've let me study and think about almost anything and that's been terrific. And the University of Chicago who's just made me their dean. I'm excited to be going there. And if any of you or you Chicago alum see me afterwards, you can talk. And also find me, I work as a nurse, a NICU nurse for many years and I learned much from the staff and family and patients of course in the Kaiser Permanente system. These were lessons to which I'm always grateful, forever grateful. So this is the questions that reporters ask bioethics. These are, you can see the list is New York Times, Washington Post, Fox, yes indeed, they even asked me that. Science and nature, new scientists, HHMI, NIH and National Academy all asked me about cloning and artificial genomes and designer babies like 44 zillion questions. And then Ruth was the only person to ask about maternal mortality. So I'm very grateful to you. You have a place of honor here in the questions. And now when all these people call me I'm gonna say, you should talk to Ruth because she's got some real questions there. By the way, cloning artificial genomes and designer babies, nothing not happened, never. Probably won't ever happen. But maternal mortality, a pressing urgent issue. I also wanna thank Lauren Blumstein, someone I know only because she allowed her story, she, her husband, Dr. Larry Blumstein allowed their story to be discussed on National Public Radio. And this is a picture taken right after the birth of her daughter and 20 hours later she was dead of eclampsia in a modern American hospital in New Jersey. 20 hours later after this picture. And I also wanna say thank you to the 65,000 women who die, or nearly die each year in the United States because of complications of childbirth. So you've seen a lot of statistics I'm gonna throw some more at you. The catastrophe is the rising rates of maternal death. And these are the highest rates of any developed industrialized country. And it is in fact, mostly affecting the most vulnerable populations, which is why it's not only distressing, it's completely frustrating and unfair. It's a tragic circumstance to be sure. But then the question emerges, why is it an ethical issue? Why isn't it just plain sad or annoying or terrible? Why ethical? So let me start here by talking about what Bioethics does for medicine. Bioethics is here to ask the question, what is the right act and what makes it so? And there's several ways of answering these questions about this, of course. And each of the answers comes from a particular philosophical or theological argument. The task in part for Bioethics is to first find the common language and Ruth began that by defining maternal mortality. Though I had to admit that you were very careful to say accidents don't count, but then there's homicide and suicide, which suddenly are in the mix as well. Coming from Chicago, I can tell you that homicides of pregnant women have gone up as well. The next task is to describe in this common language the nature of the problem, and then finally to create a normative argument about what we should do and how we should go forward that then undergards the best argument is the one that undergirds the policies to address the problem. So that's the structure of what Bioethics is asking. It's both descriptive and normative in this sense. And by beginning with description, you can call attention to a problem that could have gone unrecognized. In fact, it went unrecognized for me. When I got the phone call from UT, I was like, they want me to talk about maternal mortality? Like, really? That's such an obscure issue. Why would that be? Because it had not been brought to the forefront of our attention. And of course, it should be. Focusing on maternal mortality is rising. It's declining elsewhere. It's not a private tragedy. It's a critical public health issue and deserves to be talked about in that way. If you focus on the issues of the vulnerability in that kind of cohort and poverty in the cohort, then you see how the problem shifts from a personal tragedy to a justice issue. There's a deep injustice in this story. So I want to start with the descriptive and epistemic tasks. These questions come from Emmanuel Kant. And Bioethics has been asking him ever since the 1700s. What can I know? How do we define the problem? How can you know? The critical medical or scientific facts always begin with the case of Bioethics. And then we have to clarify the competing moral appeals in the dilemma of how we respond. So we can appeal to consequences. We can look at our classic principles of beneficence and non-maleficence. And we can consider what's the effect of this rising rate of maternal mortality on women, on families, on what I call the future, that's the theft of the future. How, what's our response? And how does our response make sense in light of the appeal to consequences? Appeal to consequences, arguments, always worry about the future. What's gonna happen in the future? And how we should frame our arguments about creating the best future for the most people. We can also appeal to rights. We could say it's a harm, it's a wrongness. The wrongness emerges from the fact that we have denied our own duties towards women. We haven't allowed women to fully express their autonomy. We say, are there essential rights? Are there essential duties? What sort of duties emerge in childbirth and have we met them? Another way to look at the problem is to look at our, look at the past and promises we've made to women in the past and to the promises of obligation of society. And how are we planning to keep those promises? We could look to justice. We could say it's wrong. We're angry or distressed because we have to look at issues of distributive justice. And then we look to see how goods and services are distributed. This is one example of the ill distribution of goods and services like access to prenatal care. We look at issues of fairness and equality and we explore how people are both similar and different and what counts as a valid distinction between them. And in justice theory, we pay particular attention to vulnerability. We understand that there is inherent in many theologies and many philosophies and essential obligations to those who are most in need. Now there's problems with any of these approaches. Who's gonna define the good and what if you disagree this fight about what's going on with the good and who defines it and what it entails going on even as I speak in Washington DC as the Congress is debating healthcare reform and trying to think about what is a good act and what makes it so there. There's problems with autonomy. Anyone who's a physician understands that bioethicists who love the principle of autonomy and love the idea of freedom have to raise the question of how far does the freedom go? Is freedom a negative right or a positive right? Should you interfere with someone's freedom to live their lifestyle as it unfolds? How far can you go as a physician to interfere with someone's choices even if they're terrible ones? There's even problems with justice because we live in a society that's unclear about which justice system we use. Are all goods subject to the sphere of the market? Is healthcare a market-based phenomena or not? Should the goods and services of healthcare be within or outside this particular system of justice? What do we make of the market being the determinant factor for healthcare itself? Because we have struggled with those principles, bioethicists have turned to classic values and said, what does this act make of me? What does it mean to each of us in this auditorium to live in a state, to me to visit a state, of Texas with this kind of maternal mortality rate? What does the participation, the partaking of the system make of me? This is a virtue theory question, and here we look at the virtues of veracity or truth-telling fidelity or promise keeping, integrity or acting in accordance with one's values or courage, acting bravely even when it might be scary to act bravely or speak out fully. And in Europe, when people look at this question, and one of the reasons it goes well if you're in Swedish, is that people appeal to a principle of solidarity, asking not what's the freedom of the individual but what's the health of the community? How does this action, this policy, this procedure create or destroy communities in a place like Sweden that are concerned about issues of sociability or social contracts and look on what values the social contracts are based? Now, yet these principles fail us when we look at the enormity of this problem. We are the most ethnologically advanced country in the world, and women are dying in childbirth and increasing numbers as if we're living in the 18th century. It's really quite astonishing. And there's the, one of the key factors, there's the U.S., and it's better to be living in Portugal and Germany or France or Canada or the Netherlands or Spain, any of these other countries than the United States if you're planning to give birth. These statistics say they're very clear, more American women are dying of pregnancy-related complications than any other developed country. And only in the U.S. has the rate of women who died then rising. There's confusion about what's the best protocol for women in labor. It's done as, again, a free market system of justice. So each hospital, each state has its own principles for dealing with potentially fatal complications. The hospitals, including those with very good NICUs, can be woefully unprepared for maternal emergency because the idea is that child care, that the mother in the equation is not at risk, right? The federal and state funding grants only have 6% of the block grants for maternal and child health. They actually go to the health of mothers. They're very directed to the health of infants. And in the U.S., in some medical schools, I hope not this one, some people are going to the specialty of maternal fetal medicine, focus almost entirely on the fetal medicine component and never spend time learning and attending normal labor and deliveries. We're 50th Glovery, only eight countries in which maternal mortality has been on the rise. The others are all in Sub-Saharan Africa. It's increasing, as you know, the ratio to all cross populations. And as I said, black women are three times more likely to die than white women. Three times more likely to die than childbirth. Okay, so why here? Why us? Why America? Well, first of all, we have relied on the private sector to deliver health care with using our changes in insurance from the early systems of Lanzmann-Schapten societies or company doctors or church societies that all focused on a single payer. A Lanzmann-Schapten society was people who had immigrated from similar areas of the world, Italy, Eastern Europe, paid dues to a particular doctor who would take care of all their needs in advance and prepaid medical care. Church doctors did the same thing and some company doctors did it too. This was all dismantled by the combination of Medicare, Medicaid and the growth of the private insurance sector. We're the only country in the developed world that uses this complicated insurance system to pay for health care, individually paying for health care. Meanwhile, since so many people do depend on the Medicaid and Medicare, when the federal budget gets in trouble, as it did in 2008 and other times, you can see that affects the rate. When there's cuts in federal and state funding for food, for instance, or restrictions on support or housing, that's where the budget cuts are made. These are called entitlements. Non-essential entitlements can be cut and they are cut and they have been cut. We live in a society with no inherent obligations to the poor or to the working class. We have a hard time even saying the term working class, but we could live in a society where there's absolute priorities or preferential options for the poor. Many societies have made that decision, but Americans have gone deeply towards freedom. The way to achieve justice in an American society is by being independent, by being an independent moral agent, and by stressing freedom, free moral agency. Bioethics has that as well. We're deeply committed to freedom, we're deeply committed to independence, and we're not as profoundly committed in an absolute way as you would be if you were primarily coming from theological positions to a preferential option for the poor or the vulnerable. And policy is often set by older people, people like me who vote all the time who are the constituencies who are people making these decisions. More reasons why has there been cutbacks and skilled staff at every level in the hospital growing use of LVNs and LPNs on the use of foreign nurses and travel nurses filling in even for intensive care and labor and delivery suites. There's been a reduction in the number of covered visits even for Kaiser Pervodenti and other good healthcare plans, how many times you get to see the doctor. There's a lack of a strong mandate or a social movement for care because often there's a declining birth rate, there's other issues. As I said, young people don't vote as much as old people. Often it's not well taught in medical training programs and the idea that childbirth is not a risk is an increasingly familiar sound. People don't feel like you're at risk when you're giving birth to a child. And a little example from religious studies is that there's a prayer that said, we'll talk about a little later, after childbirth, as a prayer for surviving childbirth. It's coming through a near-death experience. And after the war, childbirth was not seen as dangerous and in reform, Judaism, and in Protestant traditions, this sort of prayer and Thanksgiving ritual completely disappeared. There's also been a historical turn away from midwives and I wanna say a little bit about Chicago history here because I'm proud to say that it is all Chicago's fault in why this happened. So this is the Kikyo here. So this is Joseph Boulevard de Ville, de Lille, Northwestern and University of Chicago. He taught at my two institutions as well. Is anyone ever hear of this man? Raise your hand. Okay, why do you know him? Every pediatrician should know this, right? What? You're a house officer. All right, so he's revered. I know he's still revered. Anybody else? What's a de Lille suction? Any? Nicky Nurse? Yeah, de Lille suction. Okay, that's that de Lille. That's Boulevard de Lille. Okay, so he goes well. He's revered in university. And here's a quote from him. I often wonder, he says, whether nature did not intend women to be used up in the process of reproduction in a manner analogous to the salmon who dies after spawning. Perhaps laceration, prolapse and the evils are in fact natural to labor or in fact normal. If you adopt this view, I have no ground to stand on. But if you believe that a woman after delivery should be as healthy as well as economically perfect as she was before and the child should be undamaged, then you'll have to agree with me that labor is pathogenic because experiences prove that such ideal results are exceedingly rare. This begins the great understanding that labor is pathology, childbirth is pathology, and you need positions, highly trained positions to intervene. Certainly having babies is a natural process, yet no one here can deny, he says to his colleagues, that it's a destructive one. We all know that even natural deliveries damage both mothers and babies often and much. If childbearing is destructive, it is pathogenic. And if it's pathogenic, it is pathological. If the professor would realize that parturation, viewed with modern eyes, is no longer a normal function, but that it is imposing pathological dignity, the midwife would be impossible even to mention. So his is in his speech. In 1917, he goes on a crusade against midwives as barbers, and he does this even though he knows, look at that first sentence, that women are safer with midwives than with doctors. Even though he knows this and he cites it, he still says, oh, that just tells you, it doesn't tell you that you should use midwives, it tells you, oh, I guess the doctors need more training. And then he says, and then he has this little thing about these doctors, see women do get in there because obstetrics is a jealous and exacting mistress, there are women involved here. And, but the probabilities are not paid well enough. And then he goes off after this to suggest that $10 of birth is the right amount to get paid. If you are gonna control the pathology, you need to control it with forceps. And he had, he puts out a pamphlet called the prophylactic forceps operation, and he says midwives can't do this kind of birth, and so therefore they need to be destroyed because they destroy obstetrical ideals of perfection, of course. It's a relic of barbarism, right? In civilized countries, the midwife is wrong, has always been wrong, and it is impossible to make her right. So you might think that in fact you could teach midwives how to do this but no, it was impossible, they were barbaric. Now his method is one, if you've ever studied if you're in my era, and you went to nursing school or medical school, this was what birth was. Everybody got scopalamine, and he invented the fetoscope. Everybody got ether or anesthesiology. Everybody got nepeziotomy. Everybody got a forceps delivery. Babies were all suctioned with his, and then afterward he would manually extract the placenta. It is amazing to me that this process actually saved lives, but weirdly enough it did. He was part of this, what's still seen in University of Chicago is the great advance in obstetrics, but, and he wrote the book, Principles and Practice of Obstetrics, which is eight million copies sold until 1987, one of the most, single most important textbooks in the history of medicine altogether, this one book. It's enormously expensive, and I bet you read it, I know I read it, so there you was, this is what birth was. And as a young nurse, I attended birth after birth after birth, exactly like this, every single birth. By the time I was training, they had stopped manually extracting the placenta, but just barely. Now this was an innovation, but innovations are expensive, and they required a substantially important and expensive system. He had a dedicated hospital, in Chicago lying in, he had this forceps delivery in the deletion section, he invented incubators that every baby went into, taken from their mothers and put in incubators. It needed training in childbirth, as you would train that it was a pathology that you, the physician, had to intervene in, and then midwives had no part of it. And this continues to have implications. I know there's people here who study midwifery, and who are midwives, but raising the rising maternal type rate is not equally distributed, and if you look at the charge, you'll see in rural areas, where there are no obstetricians, and obstetrical practice are decreasing, there could have been midwives there, like there was before 1915, and there aren't because of this idea that it was a pathological process, and the midwives had to be driven out as problematic. Now maternal mortality really is largely a problem of extreme poverty. It is the worst possible resort of many social decisions all at once, schools have many fewer resources than they did, and much education that used to go on in elementary and middle school doesn't happen anymore. There's also been opposition to sex ed, so there's that too. 20% of all the fatalities are women with less than a high school education. So you can see, I know this is from Global Health, if women get 12 years of education, they are safer in childbirth. It's true for the United States as well. Protective communities that should surround them are often in despair and disrepair. There's a high rate of male incarceration, there's homelessness and violence in exactly the same communities, statistically that face the worst rates of maternal mortality. And it's really interesting, you can see the difference between Hispanic and Black maternal mortality rates because of the relative more intactness of the Hispanic communities relative to African American communities. Part of that's religion, right? Part of that's the strong emphasis of Catholicism, but part of it is the attention to family that has been part of those cultural communities. The drug use can also be called an epidemic across large areas of the United States. There's been cutbacks in nearly every safety net program, including nutrition programs like SNAP and of course in Medicaid. Obesity, which is another addiction just like drug addiction, and the linked diseases of obesity, high rates of maternal hypertension, secondary to that, growing epidemic of type two diabetes, all of those things cascade and more strongly in poor British communities. The foster care system, which is this where children go when one parent passes away and they have no social support, they go right to the foster care system. At age 18, kids come out of the foster care system, oftentimes having two or three families in the short period, and then they're just out there in the world. So the rate of women who become pregnant after foster care is disproportionately high and they also end up in the same pool of extreme poverty. Now, in one sense the maternal mortality rate discrepancy between blacks and whites has been called racism made corporal, racism made physical because that cascade of decisions that puts black women on the front lines of this epidemic. In California in 2003, a study that paid attention to this said that blacks in California had four times higher risk of maternal death and were more likely to have been overweight or obese and have risk factors identified in the prenatal period. The high rates of obesity or excessive gestational weight gain were contributing factors in one of four deaths, right? So, although blacks accounted for only 6% of California births, they've represented 22% of pregnancy related deaths in 2002 and three. Hispanics have the largest number of pregnancy related deaths, 41%, 44% an account for 51% of all births statewide. So even in that, the 6% to the Hispanics come out better than the African Americans in this California study. And here they say, notice that cardiomyopathy or heart disease is the leading cause of death for blacks with pregnancy related deaths. 36% of the 22 deaths in that group and 62% of all death disease. So untreated cardiomyopathy. Now, in health affairs, in June this last month wrote a very important article about the health divide between rich and poor of all of 32 countries in which they surveyed. So the US has the world's largest healthcare disparities between the rich and the poor, they said, behind Donny Chile and Portugal. And the healthcare system and lack of social support were to blame according to these people. Number, the highest numbers of uninsured, highest out-of-pocket expenses, out-of-pocket expenses distributed less equally so the poor were more exposed to high cost of services because they were less likely to have insurance. Fewer social safety nets, the smallest GDP spent on housing, nutrition and income support. And what's interesting about this survey is that when they asked Americans if they bothered them, by and large people said, no, that's just the way it is. People need to be independent. They need to take care of themselves. And notice that instead of condemnation or moral distress, Americans are by and large content with the things. Now, maternal mortality is not always just about poverty. It would be an easier problem if it was just about poverty. The rates are going up because women are older when they have their first child. They have more complicated medical conditions yet still become pregnant. People with conditions that used to keep them homebound or used to keep them out of work or school now are being treated, living in the community treated with medication. That's widely the case. Half of all US pregnancies are unplanned across class and race lines with no attention to poverty. People with wealth still get pregnant by mistake too. And they go forward and they haven't treated an underlying disease. There's more C-sections up to 28% in some studies. The fragmentation of the healthcare system means that you might not be treated at the moment of birth by the same people that have been treating you all along so that person may not notice if you have elevated blood pressure or edema. The systems for preeclampsia, for instance, are elusive and there's little training in labor or post-mortem crises about how that happens. There's often a lack of consultation between caregivers. These are the seven critical factors in maternal mortality. Notice these are not about poverty, they're about health systems and their disrepair. And that is a problem that is amenable to bioweasers taking a look at, right? It's not so intractable. The average maternal death had 3.7 of these seven critical factors that had gone wrong. And this too is linked to the modern rise in modern, the rise in modern epidemics. We're beset by what one could call diseases of desire. Addiction spreads in many sectors and it takes many forms. Opioid addiction, obesity. People are putting things into their body because they're sad or because they're desperate. And these things, be it chocolate candy all the way down to OxyContin, right? Have gone terribly awry. It raises the question as a bioweasers about why people are still hungry and unhappy and why the turn to such desperate pleasure across such different communities, right? And this is really played out in maternal mortality. That he bears the gun. Research and funding gaps abound and there's been interesting studies about the lack of research. Why is the rate going up? It's not always so apparent. Part of it's the funding gap. At the same time that we've not done well for maternal death, infant mortality and morbidity is dramatically declining. As a NICU nurse from when I stopped working in 1989 and I've really seen when I go back to the NICU the enormous changes. We've done great on making little babies survive not so well on their mothers. The funding is focused on infant care. The black grants are a way to take care of infants and not mothers. The Title V federal state joint programs again weighed in 78% against six for its infants. Medicare covers infants for a full year after birth and only for mothers for two months. Just outside of that 48 day period. There's 20 high risk centers for babies but only one in New York Presbyterian for mothers. Now NPR did the study on Lauren Blumstein. Her husband was an MD. She was a nurse in the NICU. She had a perfectly managed pregnancy. She did everything right. She wasn't a drug addict. She wasn't obese but she got preeclampsia and it was not seen. It wasn't treated and she died in the modern American hospitals. I said 20 hours after that picture was taken. Americans like Lauren are three times as likely as Canadian women to die in that maternal period. Six times as likely to die as Scandinavian. In Great Britain, a man is more likely to die than when his partner is pregnant than she is. That's what Great Britain, we'll talk a little bit about how they do it. Preeclampsia that Lauren died of is a completely treatable problem, has been for a century. The only other person that you do a search about preeclampsia, you run into Lady Sibyl of Downton Abbey. The person Lady Sibyl dies at like 1890 or something or 1915 when she died or something. And there is Lauren Blumstein dying of the same thing in about the same time period. In the UK, they've reduced these deaths to one million. But in the US it's 8% of all maternal deaths. It's 50 to 70 a year for preeclampsia. Really that's a shocking number to me. And part of this is that there's different levels of blood pressure standard still exist in different hospital systems, it's not been standardized. Baylor College of Medicine, another Texas institution, studied about the consistency of sexual care and here was another problem for poor Laura Blumstein. She had the baby on the weekend and that's dangerous. It turns out 45 million pregnancies in the US were studied at 50% harm mortality and morbidity rate if you deliver on a weekend. So we're in Texas and it has the worst you win, the worst maternal mortality rate in the US and I know it's ratio in the US for several reasons. One is you have very strict eligibility requirements for Medicaid, extremely strict, much more than in my state of Illinois. Pregnant women are only 35% of grantees unlike in my state where it's 70% of grantees. 141,000 Texas women receive prenatal care through Medicaid and each month that's $3 billion for deliveries and prenatal costs. And right now by Friday, we're gonna be, because Congress has to, it's gonna offer its recess, they're debating this new AHCA about healthcare costs and that's directly going to that number, that $3 billion in Texas deliveries. A recent report singles out Texas for special concern saying this which is on your poster, the doubly of mortality rates in a two year period was hard to explain in the absence of war, natural disaster or severe economic upheaval. So look at these rates. These have really gone up between 2000 to 2010 and 14. Look how they're consistently going up. Maybe, but look at how 600 women died for reasons with their pregnancies. Four conditions like preclampsia and eclampsia that are preventable. Now someone asked me about how this works out in your state, you can see what San Antonio is right here. This is the percent of lagers with zero prenatal care in the first trimester in the state of Texas and the percentage of births to obese mothers, slightly different in 2014. Again, these are two very high risk categories. That's no prenatal care and obese mothers. So the Texas Department of State Health Services as gave this report and as Ruth said to us it might be somewhat misleading. It even says this might be a misleading report right on the report, right? But it does point out the racial discrepancy. With the changing of funding from ACA to HHCA there'll be a 1.5 billion cut a year which is half of your budget for this. Medicare federally will be down 610 billion and these are the three things that are no longer required as a result of the Republican compromise in the House. Now it's at the Senate and the question is is it essential does every employer have to provide prenatal care, substance abuse and chronic disease management? The House said no. It's unclear what the Senate will do but notice that these three things are exactly the three things that drive maternal mortality, right? If you don't have chronic disease management, if you don't have substance abuse, if you don't have prenatal care you're much more likely to die in your pregnancy than not. Okay, so that's the description. We've talked about it a lot. So what do we do? Consent in question. What are we to do? Well in the UK they do a very thorough investigation of every single death without redacting the name. And the reason they don't redact the name is because they go back to the families and they question them. They assess it. They give the caregiver assessment. They give the family assessment and they have public hearings on public inquests by the coroners about every death. So they come here and everybody discusses it. It's open. They're not as concerned with confidentiality. They're concerned with solving the problem and the public inquests then change the policies to reflect the analysis. One very important way that the UK is driven down. It's death rate. California, the one state that is the outlier and that women are not dying in increasing numbers models itself on the UK public process. Elliott Main of Stanford and UCSF have developed a toolkit to address things like hemorrhage. Preventable in 70% of cases in preeclampsia prevented in 60% of cases. And the hospitals that used it in California saw a 21% decrease in mortality just in one year. Other ideas, now it does take 17 years to change practice but here's some starts. Merck has had a program called Merck for Mothers, funding research exactly on this problem. The Association of Women's Health, obstetrical neonatology nurses, neonatal nurses have proposed a new training and funding for training nurses to be able to be closer observers of the process. And ACOG has this alliance trying to change practice as well. Now, Texas has this maternal morbidity and mortality task force in 2014. It's now up and running. And the chair is now doing something else. But this is a promise by Texans to respond to the problem. So I think as bad as it was, as terrible as that red line is for Texas, this is a good response. This is really beginning to take charge of the situation. They notice the task force and DHSH must submit a joint report on the findings of the task force and make recommendations to the governor, lieutenant governor, and speaker of the house and appropriate committees of the Texas Legislative by September 1 of each even numbered year beginning in 2016. So you can see that there's a plan to make these changes. And in Congress right now, a cosponsored bipartisan bill remarkably enough in the House Committee on Energy to make the UK process happen there at the state level. So this would make the California project true in every state with federal funding. And that HR, that the House Bill 1318, also has a section about eliminating disparities, which is really remarkable and is in fact not part of the existing California rules. They want specific research into the determinants and distribution of disparities in maternal care. And the health risks and the health outcomes doing outcome-based research on the issue of disparities in maternal mobility mentality. So this is a talk really not about these politics. So I wanted you to know that they are doing something. But it's an ethical problem. Maternal mortality steals the future. It makes the sequence of life events impossible. It's not only a problem of these structures and these systems and these laws. It's a challenge to core moral commitments. And those rise from a longstanding shared narrative of childbirth itself. Now I spent some time on this afternoon looking at Genesis 35 at this very quick shift between the most intense moments between Jacob and God who speaks to him. Jacob is cast out. He struggles in the night. He gets renamed. He's now Israel, not Jacob. And he has the promise of fecundity. He has the promise of land, the promise of everything, every promise that God can make to a human. And just as he goes to enact the promise on the road as a refugee traveling from where he had been to where he hopes to go, in the middle of the journey, Rachel goes into labor. One of his wives goes into labor. And she has a horrible labor. And she dies as she dies. She names her son, son of my sorrow, Ben Oni. And his father renames him as he himself was renamed, calling him Benjamin's son of my right hand. And she dies, and she's buried. This story is the first death in Genesis, the first maternal death in Genesis. It's not the only maternal death in Genesis. This reoccurs several times. But this is the core story. And this narrative of the tragedy of loss is commemorated physically in Rachel's Tomb, which is you can go visit today still on the road. Now the cities are closer together. This narrative that you read and you know in Hebrew Scripture is a narrative of childbirth. The whole story is about this promise, this yearning promise by women who yearn to be mothers, promise by God as the central activity of a human life. The Hebrew Scripture, the New Testament, the Quran tells us that the central point of being a human being is safe babies, is having babies, is continuing the legacy. That's what those stories are about. This yearning expresses itself in deep anxieties again and again in these stories about infertility, about interventions, and about how fragile is the survival of the Hebrew tribe. Our text that I just showed you, and one that's part of our narrative, occurs in the midst of struggles, in the midst of promises. The birth takes place without the right attendant. Two verses before Rachel gives birth and tragically dies, the long-time nurse dies in the text. It goes there briefly. She needs to be in a place, and she's not in a place. This birth and death occurs without her right attendant, without a city, outside the borders. This is the kind of birth, the kind of tragedy that happens for refugees in our time. And the question really emerges about why a big narrative about national creation, about this collective narrative focuses on the intimacy of childbirth. It is because childbirth teaches us how fragile and contingent human life is. It teaches us about why you need communities of meaning to surround every birth. It teaches us about our duties to and our need for the fragile babies that make a meaningful life possible. And it teaches us about the rather central role of women and their enormous biological risk that they took in antiquity and that really still take in our time. The ethics of tragedy is that it all goes wrong. It can go wrong so quickly, so swiftly within hours. And it's different than an ordinary death. People die all the time in hospitals. If you work as a provider, you know that there's tragedies all the time. But the death of a woman in childbirth is particularly devastating because it goes to the heart of our ethical commitments. It disrupts the narrative of continuancy. It disrupts the narrative that where you are now, you're gonna make a world that's better for your child. It disrupts you as an actor within it. It creates a loss of faith in modernity itself. Someone like Lauren Blimstein dying in a modern American hospital shakes us very deeply about how much we can control illness, morbidity, and mortality. In many cases, it gives us confusion about causality and about blame. And blame is a problem when we think of this. It's an ethical problem because, as you said, you're angry at someone and you don't know who to get mad at. And textually and in our practice, these deaths draw our attention because of it. There's a long history of blame and I don't wanna end without discussing it briefly. There are three examples I wanna lift up. In Tamina tradition, there's this admonitions about the way you light candles has to be very proper. And if you do it wrong, you'll die in childbirth, quite the threat. In example B, there's a long textual tradition that the reason why Rachel dies in childbirth is because she has hidden her father's idols as she has left her father's house and she lies to them. In example C, we have a very similar reaction to the narrative of maternal death in art time. When you look at the statistics, it's very hard not to think obesity, drug use, those women did something bad. And here's the interesting thing, it shouldn't matter. The ethical gesture is a woman should have a safe birth no matter what, no matter what. Even if she takes drugs, even if she's had way too much candy, even if she's driven herself into a diabetic coma, she still should not die giving birth to a child because of our promises, not because of her actions, but because of our moral commitments to that. When a woman dies in childbirth in a modern American hospital, it is true that much of the time, there is someone to blame, our policies, our communities, but the heart of the ethical question is, you could do more, we could do more. Entirely preventable deaths need to stop. We have known for centuries, for instance, that pregnant women need a kind of special social attention. Mary and the Quran are different from Mary and New Testament, by the way, not endangered but blessed by abundance and food. There's a long church history of the care of women without social support by the Catholic church. Many of you have never read the Quran, so I thought I'd put it up here because it has a lovely little piece about Quranic Mary. In the Quran, which is a retelling of the New Testament and Old Testament in large part, the Hebrew scriptures and New Testament, Mary is cared for by Zachariah and Zachariah has her in a special room where she prays and when he goes there, he finds her, always supplied with food, fresh dates and grapes and he's curious about this and she says this image is that it comes always from Allah. Allah provides for them who he wills without limit, this notion of abundance that's deeply part of the Quranic promise. So of course, in Islam, the tradition of pregnant women has special access for choice for food. Oops, and now we can't go forward. Oh dear, well I'm almost at the end. Oh, there we go, lose the mouse, nope. Okay, the nature of birth is both about personal responsibility and about collective responsibility and that's what's puzzling about it. That's the puzzle of it. The puzzle of it is that the nature of birth is always proximate to death, not just because it's dangerous, because it is your participation as a woman in the long chain of being that's gonna end with your mortality, hopefully not then, as you give birth, but you're giving birth here, part of the commitment that the next generation will come that you will die and your child will outlive you and make a better world. That's the participation and that's our ethical commitment to birth because that's the moment of participation and therefore, to some extent it's animated by the power of the continuity of mortality itself, the fact that we are mortals. That's part of what birth is. There's no longer just about you, it's about your child and that notion of birth as being close to death is reified and mirrored by the fact that for most of human history, it was literally close to death. It was a time when women had to pass through a near death experience. That means that women are completely vulnerable at that moment and the responsibility for oneself is complete, but it also means the responsibility of the community is absolute and it should be enviable. Each woman, at least in this way and at that time is our personal responsibility. So that's the way we need to think about it. There's a prayer that is said in the Orthodox Jewish community after you've gone through childbirth. For women who've gone through this experience, you're supposed to say, Psalm 116, I love the Lord for he hears my voice, my pleas. For he turns to me whenever I call. The bonds of death encompass me. The anguish of the grave came upon me. I was overcome by trouble and sorrow. But then I called on the name of the Lord. Lord, I pray you save my life, for you have rescued me from death, and then the Psalm continues. The blessing that a woman does after this experience speaks to something that we think about when we think about culpability and responsibility. It's a two-part blessing. It's unique and there's no other blessing that has this particular frame. It's a blessing that can't be done without an answering community. The Gantian community doesn't just say amen, but it has to say part of the blessing itself. The blessing is blessed to you, Lord our God, ruler of the universe who bestows good things upon the culpable, upon the guilty. For God is bestowed on me much good. And then the response is amen, may the one who is bestowed much good on you always bestow you much good. So look at the alchemy of the prayer. The woman takes responsibility for being culpable, for being unworthy. But who's also been given enormous good. And the community answers her without reference to her culpability. See how this prayer actually embodies the relationship that I'm really hoping for, for how we address ethically maternal mortality, even if the person is culpable and is blameworthy, we don't care. We want much good to be bestowed upon her. So the final task of ethics in the three questions, what can I know, what ought I to do, is for what can I hope? And for what do we hope in this situation? For all the reasons of ethics, for all the theories of justice, for the problem of virtue, for the problem of agency, research and action on maternal mortality, it is urgent. It should never again be the case that America's women are dying in childbirth at at least alarming rates. And I wanna thank you for the privilege of thinking through this problem, trying to come up with some normativity and involving you in this conversation. So thank you, Ruth, and thank you all of you. Okay. So we recognize the lateness of the hour, but we do invite the audience to remain for 10 minutes or so to engage in question and answer with Dr. Zolot. Yes, go. You introduce me. You can go first. Responsibility for the government, the social responsibility. I don't see it as like a zero sound game that or the government does, like can be up. Yeah, of course. Yeah. And so I find that in the conversation what I really want is the people who are making this and you know that like there's a government level to be motivated to feel responsible. And then I find myself, especially as we have public dialogue in this course, is now a whole rise and then like I have this anger right now. And then all that really does is that the people who I wanna persuade to say, hey, the government should have some responsibility or for others, is that they just like just telling each other who we met. So how do, how do we fruitfully talk to what I suspect really are well-meaning good people who say the answer to our social problems which influence childbirth, to persuade them that no one should not cut money from Medicaid or other services that allow for healthy women. And I've seen your data that it's not just the technology of the maternity suite, right? It's that healthy women make for healthy childbirth. So how do I persuade, how do you persuade, I'm persuading, I was already told that you help me understand my own views. But how do I persuade somebody who I think is well-meaning but is angry too at all the spending and has their solution to be having fun, how do we talk pretty quickly? Okay, so first of all, I actually did testify before the Texas legislature once, so I know what you're saying. People are concerned about spending money. And there's a sense that people are sickening themselves so you don't want the good government to take care of you. It's you, it's your baby, it's your body, like what are you doing with the drugs or the candy or whatever. I think you can do a lot, especially as a physician. One thing you could do, all of you here, is you could change your practices yourself around the structure of eating, right? Now, I loved being here and thank you very much and it was wonderful, but that was not a healthy meal for a pregnant woman for dinner, right? And every place you go in a hospital, there's like sweets for breakfast and there's sweets for lunch and there's like dessert everywhere. All of us, we, all we all participated in this, all of you plan programs, you could say and say very abysmally, we're gonna make, we're gonna only serve food that we would say we advise our pregnant patients to eat, right? Salads, fresh fruit, all of that, at least in your hospitals, at least in your churches, at least in your synagogues, these institutions should be paragon of virtue. That's one thing, because it's a struggle. It's a struggle to eat well, it's a struggle to maintain health, right? You should figure out what that looks like. Now, I'm an orthodox Jew, you know what varmints look like, they're just a disaster, right? So of course, weddings, varmints, it shouldn't be like that, we could change that. That's in your hands. You don't need a Texas legislature, you don't need a Congress, you as an individual could change your social practice to make at least the obesity and diabetes somewhat better, and that's a big piece, right? The problem of the opioid addiction is a Hayakian example of a good intention totally falling apart, right? And that, again, is something we have to take responsibility for, and it's not, it's an ethics problem and a social problem. We said we wanna get a different kind of pain medication so that people develop OxyContin so that they would be, and if I went around and said, you know, this is the kind of pain medication, you shouldn't let people be in pain in a modern hospital, there's this good new drug, don't use morphine, use this, and then we had the hospice movement, and we sent people on OxyContin home because we love the hospice, and now they were home with the drugs, and now there's drugs in the community, and in alarming rates, it didn't used to be there, it didn't used to be there because people didn't die at home. They were in the hospitals under lock and key much more. So a modern opioid addiction drives some of this and it's gonna get worse because we don't have a solution to that, and it's very including what a government could do. It's also a decision about what we attend to. Many of the deaths that are preventable are preventable by changes in practice, having the checklist, having attention to it, understanding what pre-eclampsia looks like, right? Having blood on hand. Lauren, Bloomstein died, of course. Finally, the last thing they did wrong was they didn't have playlists. They just didn't have them in the hospital. There was a shortage, right? So they should have closed the hospital because they couldn't do care, right? So all of these things, they're not up to the legislature, they're not political, they're practice issues. And then I think the ethical issue has to be, each of us individually, what are you willing to do and say to stop the problem from happening? We have to really think about what your commitments are and what your role is. Why is prenatal care so expensive? Are we teaching our students to be obstetricians and to live and work among the poor, right? I know in my medical school, many people in New York question, they wanna be dermatologists because they don't wanna get woken up in the middle of the night. Well, that's when you sit your students down and say, mm, this is where you need to be. And this is who we're gonna admit to hospital. This is who we're gonna admit to medical school. The people who care about the poor. And your medical school should teach you to care about the poor. If it doesn't do that, then you're gonna have high maternal mortality because you're not gonna have people in the right places. So many of these things have nothing to do with politics. They have to do with decisions and practice, personal decisions about how you're gonna forego. Because I don't know what's gonna happen in Congress. I have no idea what will happen if there's no ACA anymore or whatever. I mean, it's a very sobering thought. But it's all happening in secret. So we have no idea what's gonna happen. Yes, yes. Jumped up. Why not? The Texas legislature will remove it. That's not good. Planned Parenthood did, in addition to abortions and birth control, they did an enormous amount of prenatal care all around the country, especially in communities where there was no access to physicians. And there is a crisis in this country about obstetrics driven by the abortion debate. That's just the case. Because many, many doctors don't wanna deal with doing abortions, they don't practice. They're not going into OBGYN care because of their fear of becoming, doing politicized medicine. And I've heard that again and again and again from people that they just wanna stay away from it. So that's changed how obstetrical care is handled. And this is a political debate where women's lives should never be at stake. I was a nurse in a neonatal unit when abortion was not legal in Philadelphia. And we did, we took care of dying woman after dying woman coming in near death and then they would lose the baby. They had had septic abortions, they barely survived. Those aren't even in the statistics. Those maternal mortality rates, they're not even in, those septic abortions aren't even a piece of that. So who knows what's going on and what will go on. I have political opinions about Planned Parenthood. I think that they should have been kept open. Though I was very hard on them for that video. I thought that revealed something extremely disturbing but it's a part from the politics of it. Women need healthcare. Our commitment is a safe childbirth. And I don't care if the care is delivered by the Catholic Church or by Planned Parenthood or by the local midwife or by high-tech medicine, women need, we need prenatal care. And that should be above and beyond any political discourse. Yeah. I know that for 100,000 live births that have not been to do with maternal death or related to baby abortions. Right, nothing at all. Right, that's a different problem. Different lecture, another problem, but this really is disturbing on its own. Yes? It was a look. Right. It's really important that we give attention to this problem. And I'm someone who's guilty of it. I too participate in worrying almost entirely about global warming, designer babies, and all the big issues, the future of the world. All of this war, Syria, drought in the West. So 60 women a year, 600 women in several years, it can seem small relative to the problems, but it's not. Every single woman who dies in childbirth is unspeakable tragedy that didn't need to happen and ought not be happening in a modern American hospital. And yet it does, and there's, even though the numbers aren't enormous numbers, they're disturbingly large, actually. And that was something that Ruth pointed out. We have to draw our attention to this. And the fact that we don't talk about it, there hasn't been significant work in the field of bioethics. There hasn't been, there's not article after article in New England Journal. There was the one article. There should be dramatic and constant attention, and then it would be seen as a problem that had to be addressed. It's just not. No one speaks of it, it's not mentioned, we just go on as if it's not happening, as if we don't see those deaths. And largely because they're not in the communities, and that's why when one white nurse and her doctor husband faced it, that made the news, right? But she stood in for really hundreds of women who never had that kind of exposure, the kind of expertise, but whose lives mattered equally just as much as hers. So, any other questions? Ruth, any final thoughts? Well, please join me in thanking Dr. Zola. Thank you.