The Square: Maternal Health in America



we're gonna die from pregnancy related complications in America than in any other developed country in the world and african-american women are the most at risk racism it acts both explicitly and implicitly some hospitals aren't prepared for maternal emergencies and patients say they're not being listened to here in New York the square starts now welcome to Times Square I'm Sally I hang on this show we'll be talking about the issue of maternal mortality in America and we want to hear your thoughts you can send us your questions and comments on Twitter and Facebook at T on T world and be part of the conversation the maternal death rate in America is on the rise the u.s. spends more money on health care than any other country but more than two women died during childbirth every day and pregnancy related complications are disproportionately affecting African American women so why is the death rate so high in America and what can be done about the problem with me on today's show denise bowls she's a daughter who works with pregnant women and new mothers in new york city and dr. Keisha Gaither she's the director of perinatal services at New York City Health and Hospitals Lincoln in the Bronx welcome to you both thank you for having us now Denise let's start with you can you just tell us exactly what a doula is and what kind of services you provide for a pregnant woman in a nutshell birth sure a dual is a person that provides emotional physical spiritual and resource support to the mother who's giving birth the person who's giving birth as well as their families why might a woman need that a woman might need that for advocacy they might need it for enhanced services and resources to be connected within their community they might be a single mom they might just want that extra support in the birth room because they really feel that they may not be properly heard or they may not really be in the know of all the intricacies of birth so doctor Gaither let's look at some broader national statistics here women today are 50% more likely to die in childbirth or pre birth or postpartum than their mothers were 50 odd years ago why is it that given modern medicine medicine today we're seeing an increase in maternal mortality rates rather than a decrease when you look at what's happening today compared to our foremothers number one there's a lot more women electing to wait until they become pregnant thus increasing the morbidity that's associated with age-related diseases such as diabetes such as hypertension so they're going into pregnancy with issues already secondly you a lot of women who are electing to have IVF and assisted reproductive technologies having multiples so that increase is certainly the cesarean section rate and all those things that go along with that let's just pause the discussion for a moment and look at some broader statistics here so I'll point your attention to the screen approximately 700 women die each year from pregnancy related complications African American women are three times more likely to die from pregnancy related causes than white women and 60% of all pregnancy related deaths are preventable I mean that's quite extraordinary there especially given the fact that African American women up to four times more likely to have this sort of response to childbirth and that seems irrespective of age education socioeconomic background what about some of the diseases like preeclampsia which are more prone in african-american women diabetes cardiovascular issues can you talk to us a little bit about those concerns absolutely there's a high propensity of obesity in the african-american community obesity really sets forth a complex series of interconnected issues there's an increased risk of inflammation there's an increased risk of you developing diabetes there's an increased risk of you having hypertensive disorders as well as heart problems certainly when I was training I did not see the cardiovascular issues that I see now but again I also did not see women who are coming in who are three four five six and seven hundred pounds either which is what I see now a lot the root causes behind some of these statistics are often misunderstood a lot of deaths occur pre birth and also in the postpartum period can you give us a little bit of a flavor about why that is today's environment really does not support a healthy pregnancy we have moms who are giving birth and as soon as they give birth they're talking about when they have to go back to work or they have to work up until the last minute or they're expected to work the 14 16 hour day shift not getting the proper rest not getting the proper nutrition not being fully engaged with their prenatal care provider everything is rushed everything is time and there's a clock that women are expected to beat and to do well and not to complain and you know be a great mom through all of that it's interesting dr. Cathy you've done some specific research on the role that stress plays in in african-american women and child birth given the fact that you know racism is deeply woven in u.s. society how does stress medically relate to different reproductive outcomes stress chronically causes an increase in a hormone called cortisol okay that's your stress hormone cortisol causes a whole host of interrelated complications for instance cortisol high cortisol increases inflammation in your body and decreases your immune response when you're pregnant your immune system already becomes depressed simply to allow the baby to develop and say hey I'm here you know and not have your body attack the developing fetus so that's the first thing when you're stressed and you already are at a loss that increases your propensity to develop infection so let's talk about the hypertensive portion of it stress with the cortisol increases how your vascular tone or your blood vessels act high cortisol tightens those vessels tighten vessels equals hypertension hypertension increases your risk of preeclampsia I think that's really interesting and it seems like a quite a specific but very vital piece of research that I wonder whether is been standardized across the board in terms of doctors training and there has been some research stating that hospitals aren't prepared enough doctors aren't getting enough hands-on training that there are random protocols and not enough standardization and I wonder Denise in your experience as a doula being inside the hospital rooms both being a health practitioner and also an observer what kind of variations do you see in the way that doctors and nurses approach their patients here in the metropolitan area there is a vast vast amount of teaching institutions all of these hospitals are teaching institutions so would the black mom is not being educated on is she can spend that – ten months with her OB doing prenatal care but when she goes into the hospital to give birth there's a chance that that doctor may not be on call to help her deliver that baby she will now be treated by residents she will now be treated by strangers she's never met before and that totally discombobulates the entire web of safety net that we have to help that mom have a good positive outcome for a black mom coming in it's even worse it's immediately assumed she doesn't have a partner it's immediately assumed that she's socioeconomically challenged it's immediately assumed that she's not going to be cognizant enough to understand the instructions given to her by the medical professionals I do want to pause a discussion there for just a moment and show you a film about women who have their own maternal health stories rural America it's fast becoming a desert for maternal health 15% of the population live in rural areas but only 6 percent of the nation's gynecologists are working there in Salisbury Maryland over half the population is african-american the Center for Disease Control says that black women are three times more likely to die from maternal related complications this area has only one ob/gyn care center so women here are even more vulnerable however they can come here to the Eastern Shore pregnancy center Misha Shockley works as a birth coach in Salisbury and volunteers at the center there's only one Hospital here there's only one OB office here that services families who are having children there's a lot of families there's a lot of people and they're kind of funneled in and out in and out they're not really being given education they're not really being given the tools to really thrive we see a lot of families that are in crisis so unplanned pregnancies which we know make up about 50% of pregnancies we see a lot of teen moms sometimes as young as 14 years old a lot of domestic violence victims Misha came to the work she does through her own experience of childbirth she was diagnosed with preeclampsia but was wrongfully discharged I knew I didn't feel comfortable with that and I knew that I was still sick I knew that something was so wrong but what do you do when the hospital tells you to go home right away she let me see my OB who had been seeing me through that duration of my pregnancy and he looked at me and he said you should have never been discharged from the hospital I'm admitting you right now Shaya IV was 16 when she had her first child eight years ago it was a traumatic delivery that scarred her earlier this year she had her second baby they treated me as I didn't know much you know because I was so young and honestly I really didn't know what questions to ask being that I was young I lost a lot of blood I started hemorrhaging he was faced up instead of face down I begged the doctor please just give me a c-section because I was in labor for 27 hours and they're like no you know no we're gonna get you got to do this you know you have to have him naturally we don't want to do a c-section it's like I didn't want to die like I thought I mean that's what I felt because I was losing so much blood and I was shaking throughout her ordeal she struggled to get the supported she needed from family so this time round she stretched herself financially to pay Misha to help her with the birth of her baby West I grew up in a single-parent home so you know all my mom was really focused on us is just making sure that we don't become single parents or we don't grow up in poverty so when I became pregnant that's all she really focused on so it wasn't no talks on what do you expect out of your pregnancy one of the things that Misha said was that you know a lot of people assume that black women are tough and they can handle anything and they can push through it and the way you talk about your mother and the way you were brought up and sort of not expressing emotion is that something that you think perhaps prohibits women like yourself back women from reaching out for more support yes because I never knew anything about a doula I never knew anything about extra support while pregnant I just thought you know you become pregnant go to the doctor and have the baby I really do think that there is in the black community like as far as just getting through it I'm not asking for help I've come to meet Alex Richardson like Misha she too suffered preeclampsia doctors know little about what causes preeclampsia but it is one of the leading causes of maternal death and is 60% more common in african-american women alex says she spent three days in labor with her cervix dilated at one centimeter so I decided to go ahead and get my epidural my first epidural the guy came in early Wednesday morning he gave me my very first one from what I was told after the fact he placed the epidural in the wrong space and he also gave me too much medicine at one time I pretty much passed out within ten minutes at one point my fiancee said they had to call the crash cart and apparently I stopped breathing they came through and gave me my second epidural the right side work the left side didn't work so a couple hours later they gave me my third one and the left side worked in the right side so after that point my kidney started failing I started vomiting uncontrollably and maybe around five o'clock and my primary doctor came in and she was like you're gonna die if we don't get this baby out right now Alex says she feels that there was some racial prejudice in the way she was treated I was in pain where when they had my second epidural in and she had my monitors strapped so tight they were cutting into my skin and when I would tell her like it hurts it hurts and she was like oh it's gonna hurt because you're in labor you know like she's pretty much just blowing it off dying x4 my very first dose of my medicine and she was like no I'm not giving it to you you need to hold off and I'm like you can't physically tell me no if I'm in pain you know I'm in pain according to the other nurses they had no idea that I was I had ever even x4 my first dose same thing when I asked for my second dose she was just like you need to wait you need to wait you're not dilated far enough and I'm like but I'm in pain I've been in pain for two days I've lasted two days with no medicine I think it's time for me to get something so you didn't feel like you were being listened to no not not even a slightest bit no Misha says that African American women she works with often assumed to be alone or unmarried if we aren't getting given the tools in the education to know about certain warning signs like from me I didn't know that swelling and a headache could mean something serious I wasn't educated on that I think black women aren't heard I don't think that we're listening to there's this stigma that black women are strong and we can endure and so we're going literally and there's several cases of it we're going to hospitals and we're saying hey we don't feel good this isn't right what are doctors doing about it the rural areas of America are vulnerable but it's in the nation's capital Washington DC that is the most dangerous place for black women to give birth 17 of the 18 women who died from pregnancy related causes between 2012 and 2008 teen were black the DC Council unanimously passed a bill last year to study the causes of pregnancy related deaths and ways to prevent them dr. hugh mighty is the Dean of the College of Medicine at Howard University he says that african-american women can be vulnerable for a number of reasons diabetes high blood pressure obesity those are all things again statistically if you look at them they're going to be higher in that population so they start out being somewhat predisposed to have any complication before they actually enter the pregnancy so then they enter the pregnancy and they're carried out with them do you think that there's a link to institutionalized racism not necessarily I think that there's definitely again a disparity and how we may address the system but I've worked in different institutions and I know our doors have been open to women you know to come in and we've reached out to them at all time it's you can take again the same woman under the same condition and they have very different outcomes all right it's and so some of it has to do with obviously coming into a pregnancy or early access early diagnosis early changes in your lifestyle that has to be there lacking that access I don't think it's what I'd say is institutional racism might say what we haven't done a very good job of is stressing the importance of getting into care early or from a social perspective the determinants of care I think become very important if I don't have housing if I don't have proper nutrition if I don't have a job if I don't have all those stressors whether you're pregnant or not I tend to lead to poorer outcomes a six-month investigation by NPR and pro república found that hospitals can be highly unprepared for maternal emergencies and that American doctors entering maternal fetal medicine were able to complete training without ever spending time in a labor delivery unit dr. mighty says that while his students do spend time in real-life deliveries this simulation room prepares them for the rare complications that could arise so what you'll find is we've raised the bar by one using more simulations more drills to get people familiar with how you handle an obstetric hemorrhage when someone's bleeding and their bleeding in pregnancy they're generally bleeding a lot and you don't have a lot of time so how you handle that means you have to be able to recognize it act in a coordinated fashion to solve it which leads to your other thing is that rather than having ten different protocols around things if we have a very basic protocol that can be expanded upon everyone is acting insane maternal health is starting to be discussed more in fact it's a subject for the 2020 presidential campaign trail both senators Kamala Harris and Elizabeth Warren have discussed the stark racial disparity in 2017 to maternity wards closed in DC both were in predominantly black communities one of them was at Providence Hospital Norlin Jeffers was a midwife there most of Nolan's patients are african-american women with low incomes she says the biggest complaint is that women aren't being listening to the races only it acts both explicitly and implicitly right so that nurse who may be providing pain medications for white women but not too may be acting on what we call unconscious bias perhaps she might be assuming that the black woman is pain is medicine seeking and perhaps you may have faulty beliefs about how black women process me so and you know and this is backed up by research so at the crux of it is unconscious bias the fact that is negatively impacting the stories of the women that I've been speaking to a tragic personal experiences but there seems to be a familiar pattern while everyone agrees that education and access to health care plays a large role in reducing maternal mortality the fundamental thing that all women want is to be heard so pretty powerful piece in terms of listening to those women's stories but I wanted to pick up on you Denise I noticed you gasp there when you heard the doctor say that he didn't believe that institutionalized racism was a factor why did you gasp I guess because the foundation of American westernized gynecological and obstetric medicine is based off of dr. Marian J Simms who's called the father of gynecology and obstetrics and dr. Mary and J Simms conducted his research and a lot of his procedure techniques on black female slaves without anesthesia and that paradigm has been carried out throughout the American Western eyes obstetric and gynecological care up to this day where you have black women who will go into the hospital and say I'm in pain and you will have that white provider say oh you know I don't think you are what's interesting though is he's an african-american doctor you know and I wonder here if there's also some gender discrimination or the fact that being a doctor a lot of the women I spoke to said that they had great care from their doctors but when the doctor would leave the room it was the nurses that they had problems with so when I when he actually said that I put that to him I said is there a chance that you're blindsided that you don't actually see some of the racism that goes on what do you think dr. Gaither I think that institutional racism exists I think that it exists across the board whether it's a male provider or whether it's a female provider it's there and why is there variations in the way that doctors provide pain medication to women so why would a doctor perhaps give pain meds to it to a white woman and not to a black woman well probably for the assumption that they might consider that the black woman is you know drug seeking drug-seeking behavior and what about the point that we picked up with some of the other women stating that you know there's this assumption that african-american women are strong and they can push through it and they've got some sort of different stamina than every other slavery mentality that this country was built off of and the one thing that is killing black women is the lack of continuity of care when it comes to maternity and reproductive health I said we do have to look at the sort of town planning aspect of it here I mean the decision to close hospitals and areas that need at most like in Southeast DC or in rural areas I mean there is an aspect of institutionalized racism there perhaps as well but who is it that's making these decisions such poor decisions the areas of people that that are literally they don't already have care as it is that's that's a really good question so what's the role of the policymaker here they need to know their constituents they really not really need to know what their constituents need and certainly the most basics of needs are health water housing and that should be you know primary focus when somebody wants to run for public office one of the other points that I've picked up in my research was that doctors feel that it's not just about the health care system here we need a better foster the community around pregnant women so that there's mothers sisters friends neighbors supporting pregnant women through their childbirth and afterwards as well because women often feel alone in the process what do you say to the community aspect and fostering better awareness around childbirth I think it's important for physicians to kind of involve themselves in the community whether it be through church related functions whether it be through health fairs whether it be through social media I think the focus should be more on educating the women certainly within the community there's always church there's always mosque or whatever religious entities exist and I guess Denise that's where your role is so vital because you are adding that extra support to a mother obviously a lot of women can't afford a doula though what do women need to do individually to sort of try and make their pregnancy in their childbirth and postpartum smoother and perhaps a bit more educated it's very helpful to shift the focus of maternity and getting ready for motherhood off of the capitalistic attitude that this country has new moms don't need a whole birth registry of I materialism things and $800 strollers they need to keep life really simple and put that money on resources and support so every woman can afford a doula there are doulas at community level that do work for free and there are higher-end duelists that get paid very well to do their support services but the woman has to be willing to see the value in giving that money for that support and that's something that the black community is lacking on if that's interesting because that's something that I came across with one of the women in the film they did mention that they felt they couldn't get the the support from their mother there was this kind of external experience where there wasn't an emotional bond and they could actually go through the journey together do you think that that african-american women need that service more than and than any other woman in in a society african-american women need it because of epigenetic inheritance because we are carrying a legacy of trauma because we are carrying a legacy of Kurt because we're carrying a legacy that is basically subdued and hidden and a lot of these emotions a lot of these feelings come up in birth in pregnancy so yes I think it is very very helpful for black women to seek out this support and embrace it for the value that it brings because it will change the actual story of birth for black women or let's hope it does thanks very much to both of you for your time thank you thanks to both of our guests we'll have to leave it there for the time being it is a difficult issue to discuss and we'd like to hear your thoughts you can contact us on Facebook and Twitter at TRT world and be part of the conversation now well that's all the time we have for today on the show thanks to our team here in New York and please join us next time on the square

1 Comment

  1. Love aos childrens. Paz e Luz a todos.

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