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Credit...LaToya Ruby Frazier for The New York Times. By The New York Times Magazine
April 19, 2018

In last week’s cover story for the magazine, Linda Villarosa wrote masterfully about how the intertwined crisis of black infant and maternal mortality is related not to the genetics of race but to the lived experience of being a black woman in this country. We asked readers to share their stories of struggling to receive proper prenatal and postnatal care, and hundreds of people responded. Below is a selection of some of the stories.

  
I Had to Diagnose My Own Life-Threatening Brain Bleed 
Image Credit...Courtesy of Joneigh Khaldun  

I am a black woman, an emergency-department physician, and the director of the Detroit Health Department. I am also the survivor of a life-threatening postpartum complication — a brain bleed (bilateral subdural hematomas) that was delayed in diagnosis, three weeks after I delivered my first child 11 years ago.
I originally had planned a natural labor and enlisted a doula, but after a day and a half of labor, I failed to progress and ended up having a C-section. After the delivery, I had excruciating headaches and told both my OB and my anesthesiologist several times. I felt brushed off and did not know what to do. It was not until I told one of my fellow residents about the pain I was experiencing that I went into my own ER where I worked and received a CT scan that diagnosed my life-threatening brain bleed.
I ended up having an urgent surgery on a Sunday afternoon to save my life. This experience has made me a better physician, and it is why I have committed myself to improving the lives of mothers and babies in my work in Detroit. Dr. Joneigh Khaldun, Detroit

‘I Felt Dismissed Throughout My Postnatal Care’
Image Credit...Courtesy of Whitney Polk  

I’m a black first-time mom and also a Ph.D. student in education at Harvard University. I gave birth in November 2017 to a beautiful baby girl. My pregnancy was tough throughout. I complained about my heart rate and shortness of breath toward the end of my pregnancy, but my health care providers chalked up my condition to regular pregnancy symptoms. My heart rate remained high during and after labor. I felt dismissed throughout my postnatal care, and even after I was sent home, I felt that I could barely breathe or carry my baby.

I saw my primary-care physician and my nurse practitioner, who told me that I was fine and that I needed anxiety medication. The next day, I was admitted to the hospital for postpartum pre-eclampsia. An echo of my heart revealed dilation and a reduced ejection fraction. I saw a cardiologist for a few weeks after discharge and thought I was getting better with blood-pressure medication, until I began to experience severe, crushing chest pain and shortness of breath.
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After weeks of feeling as if I were going to die, I emailed a cardiologist I found through a peri-partum cardiomyopathy Facebook group. If I didn’t have my Harvard email address, I often wonder if he would have emailed me so quickly. But he did. An MRI led to a diagnosis of peri-partum cardiomyopathy — a type of pregnancy-induced heart failure. I am receiving better care now, but it’s been hard physically and psychologically.
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​Whitney Polk, Salem, Mass.

By Roni Caryn Rabin  New York Times  May 7, 2019

African-American, Native American and Alaska Native women are about three times more likely to die from causes related to pregnancy, compared to white women in the United States.
A pregnant woman at a medical appointment at a clinic in Orlando, Fla.Credit...Zack Wittman for The New York Times
By Roni Caryn RabinAfrican-American, Native American and Alaska Native women die of pregnancy-related causes at a rate about three times higher than those of white women, the Centers for Disease Control and Prevention reported on Tuesday.

The racial disparity has persisted, even grown, for years despite frequent calls to improve access to medical care for women of color. Sixty percent of all pregnancy-related deaths can be prevented with better health care, communication and support, as well as access to stable housing and transportation, the researchers concluded.
“The bottom line is that too many women are dying largely preventable deaths associated with their pregnancy,” said Dr. Anne Schuchat, principal deputy director of the C.D.C.
“We have the means to identify and close gaps in the care they receive," she added. While not all of the deaths can be prevented, “we can and should do more.”main story

Maternal health among black women already has emerged as an issue in the 2020 presidential campaign. Senator Kamala Harris, Democrat of California, and Senator Elizabeth Warren, Democrat of Massachusetts, have both raised the glaring racial discrepancies in maternal outcomes on the campaign trail.
“Everyone should be outraged this is happening in America,” Ms. Harris recently said on Twitter. She blamed the deaths on racial bias in the health system.
The American College of Obstetricians and Gynecologists, which was not involved in the C.D.C. report, recently acknowledged that racial bias within the health care system is contributing to the disproportionate number of pregnancy-related deaths among minority women.
“We are missing opportunities to identify risk factors prior to pregnancy, and there are often delays in recognizing symptoms during pregnancy and postpartum, particularly for black women,” Dr. Lisa Hollier, immediate past president of the American College of Obstetricians and Gynecologists, said in a statement.
The United States has an abysmal record on maternal health, compared with other high-income countries. Even as maternal death rates fell by more than one-third from 2000 to 2015 across the world, outcomes for American mothers worsened, according to Unicef.

The C.D.C. examined pregnancy-related deaths in the United States from 2011 to 2015, and also reviewed more detailed data from 2013 to 2017 provided by maternal mortality review committees in 13 states.
The agency found that black women were 3.3 times more likely than white women to suffer a pregnancy-related death; Native American and Alaska Native women were 2.5 times more likely to die than white women.

Obstetric emergencies involving complications like severe bleeding caused most of the deaths at delivery. Disorders related to high blood pressure accounted for most deaths from the day of delivery through the sixth day postpartum.
A leading cause of pregnancy-related deaths was cardiovascular disease, which is not typically associated with young pregnant women.
Heart disease and strokes caused more than one-third of pregnancy-related deaths, the C.D.C. found. Cerebrovascular events, such as strokes, were the most common cause of death during the first 42 days after the delivery.
Cardiac disease, which disproportionately affects black women, may be present in a woman before pregnancy, but it also may appear during pregnancy. If heart disease goes undetected, it may become acute after the baby is born. main story

Indeed, a greater proportion of the deaths among black women occurred in the later postpartum period, between seven weeks and a year after the delivery, compared with white women, the C.D.C. found.
“When we look at the proportion of pregnancy related deaths by cause, the proportion due to cardiomyopathy has been increasing,” said Dr. Hollier, referring to a condition of weakened heart muscle. “It can occur in all women, but it is more common among black women.”
African-American women have higher rates of obesity and are more often overweight, which can increase the potential for problems during pregnancy and beyond. Yet obesity has risen among all Americans, noted Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative.
“That’s not the driver,” he said, referring to higher mortality among black women. “It requires a different level of awareness and attention, but you shouldn’t die of obesity. You shouldn’t die of hypertension.”
One of the surprises in the new report was how often death occurred after childbirth. More than half of pregnancy-related deaths occurred after the day of the delivery, and the heightened risk to a new mother persisted for as long as a year.
“Health issues of pregnancy don’t just end when the baby comes out, and that hasn’t gotten the attention it should,” said Lynn P. Freedman, director of the maternal death and disability program at Columbia University’s Mailman School of Public Health.
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New mothers should seek medical care if they develop symptoms such as chest pain, shortness of breath, heavy bleeding or a slow-healing C-section incision. Redness or swelling on the leg could indicate a blood clot, while a fever can be a sign of infection; headaches are another important warning sign that should not be ignored.

The physiological changes brought on by pregnancy can exacerbate underlying health problems and may increase the risk of developing other ailments after pregnancy, Dr. Hollier said.
Women who have gestational diabetes during pregnancy, for example, will face an increased risk of developing cardiovascular disease later in life.

Overall, maternal deaths are rare: Some 700 deaths related to pregnancy occur each year, while there are 3.8 million births.
While 13 white women die for every 100,000 live births, the rate for Hispanic women is even lower: 11.4.

The figure for African-American women is 42.8 for every 100,000 live births, and for Native American/Alaska Native women, 32.5.
Age also increases the risk. Mothers aged 40 and over have a pregnancy-related death rate of 76.5 per 100,000 live births.
Concern about high pregnancy-related death rates among black women has already resulted in some changes in policy.

A new federal law, the Preventing Maternal Deaths Act, provides grants to states that investigate pregnancy-related deaths, including deaths occurring up to a year after the birth. The American College of Obstetricians and Gynecologists this week released new guidelines for treating heart disease during pregnancy.
The standard postpartum doctor visit for new mothers is typically scheduled for six weeks after delivery. The college now says that postpartum care should be an ongoing process, rather than a single appointment, and that services and support should be tailored to the woman’s individual needs.
Women should have some contact with a care provider within the first three weeks postpartum, and a comprehensive visit no later than 12 weeks after birth. Women qualified for Medicaid, the government health care program for low-income people, because they were pregnant often lose coverage sixty days after giving birth.
The C.D.C. found that 18.5 percent of pregnancy-related deaths occurred one to six days postpartum, and that 21.4 percent of these deaths occurred between the seventh and 42nd days after delivery.

New York Times March 5, 2019

​Reducing Maternal MortalityA new law to help states investigate deaths from childbirth complications is a start, but experts say what is really needed is reducing C-section rates.
By Emily Kumler Kaplan

Women in the United States face a far greater risk of dying from childbirth complications than in many other wealthy countries.

Now the federal government has taken a step toward addressing the problem with the Preventing Maternal Deaths Act, signed in December, which will provide federal grants to states to investigate the deaths of women who die within a year of being pregnant.
A report released by the Commonwealth Fund in December that looked at 11 high-income countries found that American women have the greatest risk — 14 deaths per 100,000 births — of dying from pregnancy complications. The Centers for Disease Control and Prevention reports an even higher rate, 18 per 100,000.
Whereas other countries have worked to reduce the risk of maternal mortality in recent decades, including Sweden, where the death rate is 4 per 100,000 births, and England, at 9 deaths in 100,000 births, death rates in America have more than doubled in the last 20 years. The report also concluded that African-American women face similar rates of death to those of women delivering in developing countries, with rates of 40 per 100,000, according to the C.D.C.

Although cardiovascular problems account for the highest percentage of maternal deaths, complications linked to surgical deliveries are among the biggest factors. One in three American mothers delivers her baby via cesarean section, a rate that has increased more than 500 percent since the 1970s. While C-sections can often be lifesaving for both mother and baby, the surgery involved also carries serious risks.
“Caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons,” a 2015 report from the World Health Organization said. The report found that C-section rates higher than 10 percent were not associated with reductions in maternal and newborn deaths.

Article link on NYT