Reducing Maternal Mortality, In Particular Reducing Black Maternal Mortality
700-900 women a year die in the US from complications during delivery, the highest rate among developed nations. For each woman that dies, hundreds suffer from life threatening complications. But black women are at particular risk: they are 243% times more likely to die. Black maternal mortality in the US is a national tragedy and disgrace, and we as a nation need to fix it.
But if you are an individual pregnant mother, you don’t have time to wait. You need to know what to do now. This blog is gives you working knowledge of what to look out for, and what to do if you have a post-partum health crisis. This information is valuable for all post-partum moms, and in particular black post-partum moms.
Remember: Most Pregnancies And Post-Partum Moms Are Fine
Remember, most women have normal pregnancies, and everything is fine. Hope for the best, plan for the worst, and know that it is always better to understand and be prepared.
Who Takes Care Of Mom Post-Partum?
Postpartum care is focused on the child, but you, mom, need to be taken care of and monitored too. Unfortunately, there are no nation-wide tracking systems, and no standards for post-partum care. Most women see the OBGYN 6 weeks after birth: but most of the problems happen between birth and the follow up appointment. There are state and national policy initiatives to reduce maternal mortality in the works (see the resources section below). But for an individual pregnant person, self-advocacy still the best option.
The information in this blog is important knowledge for all pregnant people, but particularly for black pregnant people. The health risks are particularly devastating for them. In this time of focusing on #BLM and rising awareness of the profound racism black Americans, and particularly American black women, face on a daily basis, it’s critical for everyone to understand the health consequences of racism.
The Toll of Racism On Black Mothers’ Health
Black women have worse pregnancy outcomes no matter their education level, nutrition, prenatal care, or economic status. The stress of being a black woman in America imprints on a deep cellular level because of increased stress hormones, and results in subtly (and not so subtly in some cases) altered pregnancy hormones. This increases the risk of complications for every pregnant black woman. Black women, because of poor health care, are more likely to have complications if they get Covid-19 during pregnancy (more on the effects of Covid on pregnancy here and on fertility here.) Pain complaints in black women are often dismissed by health care providers. Unfortunately, C-Section rates are higher, which often leads to more postpartum complications. And finally, black babies have lower birth weights, and are at higher risk of preterm birth. All around, the health care black mothers get is generally lower.
Too often, health providers dismiss the concerns of black women and don’t listen to black women when they feel that something is wrong.
Reducing black maternal mortality means black women and their advocates need to be firm, be persistent, be assertive. Racism is institutional, structural, and personal, and it can significantly, negatively impact the health care black women receive.
Racism is Structural: What Does That Mean?
Black mothers die at 4.5 times the rate of white mothers. That injustice is racism in action. A significant number of black maternal deaths are PREVENTABLE. That is structural racism in action. It isn’t just the decisions of one doctor or one family, it isn’t just the racism of one doctor or hospital. It’s the way doctors are taught to dismiss symptoms and concerns of black women. It’s the way hospitals encode into operating procedures the lack of awareness of particular risk factors for black mothers. It’s the lack of training given to health care providers about what to look for in post-partum cases. It’s ignoring signs of a health crisis despite clear and alarming symptoms. I have seen a page in a medical textbook, published in 2015, that stated that black people do not feel pain as intensely as Caucasians do. That is structural racism.
Post-partum care in the US is terrible for all mothers, but black mothers bear a higher burden. Because the lack of post-partum care puts all mothers, and especially black mothers at risk, the fundamental way to deal with it is to be personally aware, and not rely on the system to look out for you. If it’s available, you can find professionals who are knowledgeable about the risks you face (more on this in a later section).
The following is a guide of symptoms to look out for, what to do if you have them, questions to ask your doctor and hospital before you give birth to find the best care you can, and resources for you.
Birth and Post-Partum Resource: Dr. Nicole Calloway Rankins
I also highly recommend you check out Dr. Nicole Calloway Rankins’ website at https://ncrcoaching.com. Dr. Rankins is black woman who is a board-certified OBGYN, and she knows her stuff. She offers free downloads for creating birth plans that work, pain management, information on warning signs of post-partum health issues; Dr. Rankin also has a podcast on healthy birth, offers affirmations to help calm you during labor, and offers an online birth class. In fact, it’s rare for an OBGYN to teach patients what they need to know about labor in a comprehensive way, and how to communicate with your OB effectively. Please take a look.
You Know Your Body: Trust It
So you are post-partum, and something feels….off. You may be able to express what it is (headache, swelling, fever, shortness of breath) or you may just feel like something isn’t quite right. Listen to your body. Call your OBGYN. Don’t worry about feeling like a bother: most doctors would rather have you call and have it be nothing, than not to call and have it be an emergency.
What should you do?
Be persistent. Always. If your doctor is dismissive, not responsive, and it doesn’t feel like they are listening and you still feel like something is off, go to the ER.
When you have symptoms post birth, get to an ER in a hospital with a labor and delivery unit. (Thanks to Dr. Nicole Calloway Rankins at https://www.ncrcoaching.com/ for this insight.) The staff in the ER will know how to assess your condition better.
Be persistent in the ER until you find someone who will listen. If they don’t listen to you, discharge yourself and go to a different hospital. You know your body, and while it will feel different after birth, if you have any of the symptoms listed below, you aren’t being alarmist.
Part 1 Learn The Symptoms Of The Two Main Causes Of Black Maternal Death: Pre-Eclampsia and Hemorrhage
You may find some of the symptoms below frightening. Remember that most women have a normal birth. If you know what to look for, you can be your own best advocate and prevent unnecessary complications. In a better world, your doctor would be monitoring you, but too often that’s not how things work. So you and your partner need to know, so you can protect yourself.
Pre-eclampsia and hemorrhage are the main causes of black maternal death. Anemia, hypertension, clotting issues and obesity raise the risk of these complications. So do poverty, lack of exercise, low quality hospital care, and racial bias. Unfortunately, black women are more likely to have these risk factors.
What Is Pre-Eclampsia?
It’s high blood pressure and protein in the urine. 97% of deaths from preeclampsia happen AFTER birth. It happens generally in 5-8% of pregnancies; and it often shows up earlier in a black woman’s pregnancy. You can get pre-eclampsia even if you are healthy. If you have any symptoms, take them seriously.
How to Check for It: The most important thing you can do for yourself post-partum is monitor your blood pressure. Buy a blood pressure cuff and take your blood pressure every day for 8 weeks after birth. Keep a record.
What to do if Your Blood Pressure Goes Up: If your pressure starts to run high, tell your OBGYN, and if they won’t listen, tell your GP. Make sure someone is paying attention, because it can be life threatening. If there is any doubt, go to the ER (see the section below on how to find a good ER.)
Pre-eclampsia is not just regular high blood pressure. If you go to the ER, make sure they know you are post-partum, and get an OBGYN to treat you.
Symptoms Of Pre-Eclampsia (These Can Happen At Any Point During Pregnancy Or Post-Partum)
–high blood pressure (anything over 160/110)
–swelling in the hands, face, or feet
–blurry vision or other changes in vision or eye issues
–shortness of breath
–change in mental state or confusion
If you have any of these symptoms, go to the ER IMMEDIATELY. BE PERSISTENT. Get a second consult; or change hospitals if the doc will not listen to you if your blood pressure is high: it’s not normal.
High blood pressure is anything over 160/110. If your blood pressure is this or higher, insist that the tech/nurse calls the doctor, and insist that the doctor address it.
What Is Hemorrhage?
Hemorrhage is excessive bleeding that threatens the life of the mother.
It usually happens at birth, most often because the uterus doesn’t contract to stop bleeding. You would think that a health care staff would easily identify and respond to hemorrhage, but they don’t always. Whether its because they are busy, understaffed or don’t believe what the patient says, it doesn’t matter. ANY kind of excessive bleeding, or bleeding that is unusual, or blood where it shouldn’t be, is cause for alarm and close medical monitoring.
Fibroids can increase the risk of hemorrhage. If you have fibroids, monitor your bleeding closely. Black women have a higher rate of fibroids, and have a higher rate of heavy bleeding from fibroids as a result.
Symptoms Of Hemorrhage
–blood in a catheter
Bleeding like a moderate period after birth is normal. Heavy bleeding is NOT normal. If you have heavy bleeding, or are noticing blood in a catheter, notify the doctor immediately. If you are at home and the bleeding is very heavy, go to the ER.
***If you are hemorrhaging, DO NOT CLEAN IT UP. Do NOT let the nurse or tech clean it up. Let the DOCTOR see it, so they can gauge the severity.
Be persistent until someone takes you seriously.
Pulmonary embolism: a blood clot that obstructs blood flow to the lungs. The main sign is shortness of breath, maybe chest pain. If you are short of breath or have chest pain, call your doctor immediately, and go to the ER. This is an emergency. (This is what tennis superstar Serena Williams had post-partum, and the doctors dismissed even her concerns: Serena Williams’s HBO Special)
Uterine Rupture (most often if there is a Previous C-Section scar, or if you are overweight): Can happen at any time. Any sharp abdominal pain needs a call the doctor to be assessed quickly.
Retained placenta: Your uterus should come out in one piece. If it breaks up, insist on an ultrasound to make sure it’s all out.
Post Birth Warning Signs Poster: Reducing Maternal Mortality
Click on the link to get a poster that easily and clearly illustrates what to look out for here:
Part 2 Strategies To Find A Health Care Team That Works With You
There are steps you can take before birth to maximize your chances of getting better health care. This is just as important as buying baby stuff and getting your home ready. Please take the time to figure out who the best members of your care team should be.
Get A Doula
A doula is a birthing assistant and advocate for the mother. Doulas are trained birthing attendants who can coach you through birth wherever you deliver, and also offer pre-and post-natal care and monitoring. They are knowledgeable birthing professionals, and worth it. Having a doula decreases the chance of a C-Section, and reduces pregnancy and postpartum complications by half in black women. Look into hiring a doula, usually by the beginning of third trimester (check out birthing Advocacy Doulas at www.BAdoulatrainings.com; the menu has a “Find a Doula” link.)
When I had my second child (a long time ago!) I had a doula, and it was the best healthcare decision I could have make for myself. In fact, she figured out the reason I had needed a C-Section my first pregnancy was because the car accident I was in at 15 had misaligned my hips. My doula recommended a chiropractor specializing in pregnancy to straighten my hips out, and the result was a successful V-BAC (vaginal birth after C-section). She coached me through labor, and made sure the doctor stuck to my (very reasonable) birthing plan. I credit my doula with not having a second C-Section.
Doulas: A New Old Idea
The idea of doulas is very old: most villages had a “birthing woman” who knew how to help with labor and birth. Having a woman to support you while going through labor is a gift: it eases anxiety and makes you feel supported. Of course, your partner loves you; but unless they have given birth, they have no idea how to help or what you are going through! A doula means you have an advocate and a birthing specialist who knows what to do and what to look for if there are complications, and can act as your advocate.
There are many doulas (and many black doulas) who can help you pre and post-partum, reducing your risk of complications. See below for more resources on finding doulas.
In particular, full-spectrum doulas are trained provide sensitive care and support to mothers-to-be and for any birthing situation. Check local listings by Googling “full spectrum doula”, or find a doula at http://www.BAdoulas.org.
Finding Good Providers And Hospitals
Finding a good hospital and good doctor can help you get the medical attention you need to avoid emergency situations. But how do you do that?
Ask questions. A lot of them. Find out which hospital Labor and Delivery units, and which ERs are knowledgeable and prepared for potential emergency situations.
What To Ask The Hospital: Reducing Maternal Mortality Risks and Getting Better Care
What are your safety protocols for adverse maternal events? Your protocols for maternal hemorrhage? For preeclampsia? (If they don’t have any, that likely means their awareness is low and they won’t respond promptly or effectively.) Ask if they have patient safety bundles or a hemorrhage cart (Thanks to Dr. Nicole Calloway Rankin for this insight.)
Is there an OBGYN on duty 24/7? If at all possible, find a hospital that has one on duty 24/7. OBGYN issues are not the same as regular issues, and a specialist will diagnose and treat them more effectively.
Finally, does the hospital have blood/platelets on hand in case of hemorrhage?
What To Ask Your Doctor: Reducing Mortality Risks And Getting Better Care
Do you have experience with pre-eclampsia, gestational diabetes, uterine atony (lack of contraction), hemorrhage?
How will you monitor me post partum? Do you educate patients on potential post partum issues and what to be on the lookout for?
Do you education pregnant patients on warning signs of serious issues in pregnancy?
Is there an OB/GYN on site 24/7 at the hospital where you will deliver?
—-Change providers if yours doesn’t listen to you. You have a right to competent doctors, and competent doctors listen to their patients.
What To Put Into Place During Pregnancy And Before You Give Birth
Have your spouse or designated support person advocate for you in an emergency. Make sure they know your medical history.
You are in a partnership with your healthcare provider. Don’t act as an adversary to your doctor, but be persistent and stand up for yourself. Make sure they are listening.
If you are in pain, then let your provider know. DO NOT minimize your symptoms: your symptoms are the only way to help your doctor figure out what is going on.
Ask for the results of your blood pressure checks and urine tests at every meeting and track them.
Severe, sustained pain is not normal. Uncomfortable is one thing: pain is another. Pain at ANY time in the pregnancy ALWAYS means call the doctor and figure out what is causing the pain.
The systemic racism baked into US society is a significant reason that black maternal mortality is so high. Until the medical system addresses that racism, your best option is to educate yourself on the signs and symptoms of pre-eclampsia and hemorrhage, and ask questions to find providers that are prepared to treat you.
If you are a woman and you have the advantage of an excellent heath care provider, health insurance, hospital and support system, consider donating to black maternal advocacy groups (see below), or donating to a local doula agency to help them provide care for a black mother who is not so blessed. Money doesn’t fix everything, but it helps.
Reducing black maternal mortality is something we all need to work to change.
As a country, we are all in this together, and as mothers, we need to support each other.
As an individual, the more you know, the better things will go.
When any child cries out for their mama, that is our child crying out for us. Maternal death is a terrible tragedy, and we all need to change it.
Please feel free to share this with anyone who might need it or who can pass it along. The more women know, the safer moms and babies are.
Preeclampsia information: https://www.preeclampsia.org/health-information/sign-symptoms
Advice from Mothers Who Almost Died: https://www.propublica.org/article/if-you-hemorrhage-advice-from-mothers-who-almost-died
Post birth warning signs poster: http://www.health4mom.org/learn-these-post-birth-warning-signs
Birthing Advocacy Doulas at www.badoulatrainings.com; the menu has a “Find a Doula” link.
Dr. Nicole Calloway Rankins: Black OBGYN offering Women’s Wellness Coaching, podcast and online courses (some free!) about birthing, at www.ncrcoaching.com
Black Mamas Matter Alliance: www.mamasmatter.org Black woman centered advocacy group that works to change policy to address Black maternal health inequity and improve black maternal health.
Birth Equity: https://birthequity.org/ creates solutions that optimize Black maternal and infant health, including research, policy and advocacy organizations.
Title Picture credit: Tomas Ratkavicius