What ProPublica didn’t explain and possibly didn’t even know about maternal mortality

IMG_2374

The mainstream press has been buzzing about a joint ProPublica/NPR piece about US maternal mortality. But in crafting the piece to create buzz, they’ve fundamentally misrepresented the problem.

It’s starts with the title, The Last Person You’d Expect to Die in Childbirth. Yes, Lauren Bloomstein was the LAST person you’d expect to die in childbirth and, arguably, she died of malpractice, not childbirth. Therefore, she is not representative in any way of the real issue.

Everyone involved in the care of women giving birth should have a high index of suspicion for life threatening complications and instead they’ve been fooled into developing a low index of suspicion.

The truth is that black women bear the brunt of pregnancy related deaths and they die for different reasons than white women, including lack of access to the technology that many white women take for granted.

What else did they get wrong?

1. It’s not clear that the US maternal mortality rate has even risen, let alone risen dramatically.

The ProPublica has a very impressive graph that shows US maternal mortality rising gradually from 1990 to 2000, and then rising steeply between 2000 to 2010, an overall increase of more than 56%. What the piece fails to mention is that US death certificates were changed twice over those years (in 1999 and again in 2003) in an effort to capture a greater proportion of maternal deaths and to capture deaths far longer after birth (one year, not 42 days) than previously. Other countries did not institute the same changes.

How much of the purported increase is due to changes in reporting? According to this 2017 paper, Factors Underlying the Temporal Increase in Maternal Mortality in the United States: all of it.

Recent increases in maternal mortality ratios in the United States are likely an artifact of improvements in surveillance and highlight past underestimation of maternal death.

A 2016 paper, Is the United States Maternal Mortality Rate Increasing? Disentangling trends from measurement issues, reaches a slightly different conclusion.

most of the reported increase in maternal mortality rates from 2000–2014 was due to improved ascertainment of maternal deaths. However, combined data for 48 states and DC showed an increase in the estimated maternal mortality rate from 18.8 in 2000 to 23.8 in 2014 – a 26.6% increase.

2. What are the leading causes of maternal mortality?

The ProPublica piece presented a bar graph from Report from Maternal Mortality Review Committees. That report looked at data from only 4 states. The data for the entire US is available from the CDC:

IMG_2372

Hypertensive disorders of pregnancy, which is what killed Lauren Bloomstein, used to be a leading cause of maternal death, but has dropped down to seventh. The most important message in this graph is that fully 41% of US maternal deaths are caused by cardiovascular (including cardiomyopathy) and non cardiovascular diseases. And that reflects the fact that pregnant women are now older, more obese and suffering from more chronic diseases than ever before. This is yet another way that Lauren Bloomstein’s story is not representative of the issue of maternal mortality.

3. The dirty little secret about pregnancy: it’s dangerous.

If you have been reading the mainstream media over the last few years, you might have come away with the impression that pregnancy is safe and technology is being overused. Millions of gallons of ink have been spilled over the C-section rate (which is a process) and relatively little has been written about maternal mortality (which, as an outcome, is far more important).

ProPublica notes that 60% of maternal deaths are (potentially) preventable. But in order to prevent a death you have to suspect that something is going wrong, diagnose it and correct it. In other words, you have to use technology. There has been a relentless trend in the US and other developed countries to promote “normal birth.” Hospitals emphasize their decor and the availability of waterbirth, women bring their doulas and their birth plans, and doctors are cautioned repeatedly to reduce the routine application of technology like fetal monitoring and C-sections. It’s as if everyone has developed collective amnesia of the fact that pregnancy, in every time, place and culture (including our own) has ALWAYS been one the leading causes of death of young women.

Everyone involved in the care of women giving birth should have a high index of suspicion for life threatening complications and instead they’ve been fooled into developing a low index of suspicion. As ProPublica notes:

Earlier this year, an analysis by the CDC Foundation of maternal mortality data from four states identified more than 20 “critical factors” that contributed to pregnancy-related deaths. Among the ones involving providers: lack of standardized policies, inadequate clinical skills, failure to consult specialists and poor coordination of care. The average maternal death had 3.7 critical factors.

Lauren’s death involved a myriad of these factors, but the most important is the one that isn’t mentioned: the low index of suspicion. In other words, no matter what happened, the doctor and nurses kept insisting that everything was fine while she was dying before their eyes. Instead of investigating her symptoms, everyone kept assuring her that she was fine. There’s a word for that kind of complacency: the word is malpractice.

The state of California has set out to eliminate complacency and their results have been impressive, particularly in cases like Lauren’s. In their initial assessment of maternal deaths in their state they found that the most preventable deaths were from “hemorrhage (70 percent) and preeclampsia (60 percent).”

The California researchers created a series of “tool kits” for doctors, nurses and hospitals and achieved impressive result. Yet the limiting factor in rolling out these programs to other hospitals is complacency.

“It’s very hard to get a hospital to provide resources to change something that they don’t see as a problem,” ACOG’s Barbara Levy said. “If they haven’t had a maternal death because they only deliver 500 babies a year, how many years is it going to be before they see a severe problem? It may be 10 years.”

4. The central role that race plays in maternal mortality.

ProPublica didn’t ignore the role of race, but by framing the piece with a story of a white woman who died as a result of malpractice, they fundamentally misrepresented the issue.

Black women bear the brunt of maternal mortality. When it comes to conveying the remarkable disparity, a picture is worth a thousand words:

IMG_2373

And it’s not just a matter of socio-economic status. According to Predictors of maternal mortality and near-miss maternal morbidity:

…In multiple regression analysis, this difference could not be explained by other risk factors… These included age, obesity, history of a chronic medical condition, prior cesarean delivery and gravidity. Education level, marital status and public medical insurance status, factors traditionally associated with socioeconomic status, could not explain the disparity…

Considerable controversy exists about the biological reality of race. Nevertheless, in our study, as in others, race or ethnicity, as defined in ordinary social terms, is identified as a substantial risk factor for adverse maternal outcome. Since race and ethnicity rather consistently emerge as important factors in both obstetric and other medical situations, investigation of the causation is strongly indicated…

This finding has been reported in women of African descent living in other countries as well. It has considerable importance when comparing maternal mortality among countries. Though ProPublica implied that countries that have lower maternal mortality rates than the US provide better care, that is not necessarily the case. It’s hardly a coincidence that the countries with the lowest maternal mortality ar the “whitest” countries. The US has the highest proportion of women of African descent. Maternal mortality may just be a proxy for race not a measure of quality of care.

The take home message about maternal mortality in the US is a lot more nuanced than the ProPublica/NPR piece implied. It’s not a problem of privileged white women who are victims of malpractice. It is a problem with profound racial disparities and changing causes of death. And it’s also a story about what happens when people forget that pregnancy is inherently dangerous and demonize technology instead of using it to save lives.

  • Lee McCain MD

    On some level I actually agreed with the premise of the article but not for the reasons you might think. One of the points that struck me is that in the U.S. our neonatal mortality is the best in the world but possibly at a cost. I see this as the “39 week rule” effect. Time and time again I watch residents and newer generation Obstetricians delay delivery in hopes of fetal gain at maternal expense. We as Obstetricians have to get past the idea that a NICU stay is necessarily a bad thing if it means managing HELLP with just magnesium to managing HELLP with every blood product your hospital has in the blood bank. But now I get a red letter for every “early term” delivery” I perform against national mean, another for every time my section rate tips above the state and national norm. Lauren’s death easily could have been prevented by a more aggressive mindset. But unfortunately this is not what is being espoused by ACOG and the major university programs in the 21st century.

  • andreabeth7

    “Lauren’s death involved a myriad of these factors, but the most important is the one that isn’t mentioned: the low index of suspicion.”

    This is perhaps the most important sentence in the above article. I am led to suspect that OBs and L&D/postpartum nurses tend to have a low index of suspicion because everything almost always IS fine. This can lead to complacency and denial, as is vividly illustrated in the tragic death of Lauren
    Bloomstein.
    The NCB movement has also played a role in this complacency in my opinion. Their message has no doubt influenced OBs and nurses either consciously or subconsciously. The focus has at least partially shifted from ensuring the safety of the mother and newborn to providing the ‘birth experience’ that expectant parents want in a tastefully decorated room with minimal medical equipment in view. Hospital administrators likely also exert subtle pressure in favor of keeping the parents happy as patients who are happy with their birth tend to view a hospital positively and will refer relatives and friends. L&D/postpartum is sort of a ‘gateway drug’ to the entire hospital. (Sorry if I am using outdated terms, I retired a long time ago) You can have both safety and accommodating the wishes of the parents as much as possible but there needs to be a balance and I fear we have swung too far in the ‘crunchy’ direction.
    OBs are perhaps unusual in the medical field in that they tend to garner a very high number of ‘positive strokes’ from their patients. In the overwhelming majority of cases the delivery proceeds as expected without complications of any sort and the patient is happy, eternally grateful and so on. Surgeons of any stripe, cardiologists, internists, oncologists, even dermatologist are much more likely to have patients where things did not go as they planned and/orcomplications develop, thus are perhaps more likely to entertain the notion that something may be amiss.
    In view of this culture of placing a great deal of emphasis on the ‘birth experience’, it should not be surprising that nurses who gravitate towards L&D/postpartum may also harbor this mindset and may not be the most proactive. I hesitate to use the word aggressive but had Lauren been cared for in just about any other area of the hospital, I am led to suspect that her increasingly elevated BP and uncontrolled pain would have garnered more attention from the nurses than it did on L&D/postpartum.

    • showmesplfd

      andreabeth7:As a retired Labor and Delivery nurse, I was always taught to “look for zebras” when “hearing hoofbeats of warning” that could also just be a friendly horse and nothing unusual. Patients presenting to Triage with intact membranes got urine dipsticks for protein, vital sign monitored, reflexes checked and assessed for swelling as well as a verbal history and head to toe assessment. Laboring patients were routinely monitored with regular vital signs and changes or trends reported to the OB along with progress. We were always aware that nothing is ever “routine” and that we had a minimum of two patients-only one could be directly observed and communicated with. Your innocent (and rather ignorant) comments about the mindset of Labor and Delivery nurses and OB’s shows that you are completely unaware of the extreme high risk that working in that area entails. The cost of obtaining malpractice coverage if you are an OB is astronomical. Years ago when I first started my nursing career, one of the OB physicians I worked with shared what his annual malpractice insurance premium cost-it was more than the median income for the entire United States at that time and far above that of the local area. This same physician estimated that about 50% of the cost of his fees went to malpractice insurance. Don’t jump to an erroneous conclusion that this doctor was a poor physician and a bad risk-he was certainly not.

      As a labor and delivery nurse, I could not easily or affordably get personal malpractice coverage outside of that general coverage provided by the hospital to an employee. The reason being is that for 21 years after a delivery, the doctor and nurses can be sued by either the child or the parents for damages believed to have incurred during labor/delivery. Once a lawsuit is filed, the physician and nurse(s) are then held to the medical standards of the present day even though they clearly were not within the realm of medical knowledge or scope of practice at the time (or at least this is what was explained at multiple educational seminars attended over the years). Yes, andreabeth7, in Labor and Delivery often the outcome IS a happy one after an uneventful labor, but just as often there are the high-risk pregnancies requiring extra-careful monitoring and rapid intervention, sometimes with optimal results and sometimes less than optimal. When things don’t turn out “right” in Labor and Delivery, it is often a sudden and unexpected event (fetal demise) and may be a catastrophic event (abruption, massive hemorrhage, eclampsia, amniotic fluid embolus to name a few). In an ideal world none of these things would happen, pre-eclampsia would always respond to treatment (it doesn’t-even when carefully monitored and “all the right things are done”) and there would never be complications of pregnancy that threaten the life of the unborn or that of the mother. There wouldn’t be the anxious days and interventions trying to make a pregnancy last long enough to give that precious and much wanted baby a chance at life because things just wouldn’t “go wrong”. BUT we don’t live in a perfect world and medicine is not a perfect science (they don’t call it the practice of medicine for nothing) and in reality there are NO guarantees and so called “preventable deaths” are often based on an idealized reality.

      • andreabeth7

        I am a retired CRNA, I know quite a bit about critically ill patients.

        “Don’t jump to an erroneous conclusion that this doctor was a poor physician and a bad risk-he was certainly not.”
        I disagree.

        It is very unfortunate that the high standards of practice you adhered to were not upheld by the hospital that Mrs. Bloomstein delivered at. I find myself still shaking my head at the fact that neither the attending OB or the RNs caring for her seemed to have a clue as to the seriousness of the situation.

  • Neverletyourguarddown

    The heartbreaking story of Lauren Bloomstein is a true tragedy. The initial reaction by the public is one of disgust that something like this could happen in an age of advanced technology such as laboratory tests and automated blood pressure cuffs. However, technology in healthcare is only as good as those who use it to supplement caregiver experience and knowledge and especially vigilance and critical thinking among healthcare professionals. As a nurse, I respect the subspecialties of OB/GYN/Neonatal as particular entities that garner nurses who are passionate about what they do and stand apart for their unique knowledge base and skills. I was horrified to read in the article published in ProPublica the unfolding events surrounding the preventable death of Lauren Bloomstein. The author is right, this is not a story about death from childbirth, but rather reveals something more sinister about the modern healthcare system. This is a story about betrayal, ignorance, complacency and quite possibly a lack of education, misinformation or even pride. So many questions surface from reading the article. But one main question is a burning one that strikes me as something that should be rote for an OB nurse. Did the attending nurse know about preeclampsia?

    • Daleth

      Do you mean, did she know anything about pre-e, or did she know about Ms. Goldstein’s pre-e?

      I’m so appalled and frankly scared by what happened there. How can so many doctors and nurses ON A LABOR WARD not notice symptoms of pre-e, and how could they have been so complacent about high BP during labor? It’s terrifying.

      • showmesplfd

        Pre-eclampsia with a fatal outcome did not just suddenly arise during Lauren Bloomstein’s relatively smooth labor and delivery. While hindsight indicated that her nurse had not reported a trend of increasing blood pressure during her labor (discomfort could have accounted for this), nothing is known or reported in the article about the prenatal trend that was the responsibility of the Obstetrician and staff to monitor throughout her prenatal course of care. Pre-eclampsia presents in subtle ways but the trained eye of the OB should have caught the changes. The “routine” weight checks, blood pressures, DTR’s,checks for swelling, urine dipsticks, assessment of fetal well-being, maternal well-being (complaints of headache, epigastric pain, visual disturbances not ignored) that should be a part of every prenatal visit are not without purpose and actually do screen for complications that often arise. IF they are now being set aside, then yes, THAT is terrifying because then this tragedy will be repeated needlessly.

        • Daleth

          Yes, that is really worrying. I was monitored like crazy, including one overnight hospital stay around week 30 to do a 24-hour urine test to make absolutely sure there wasn’t excess protein in it, and twice-weekly blood tests in the last two weeks of pregnancy (weeks 35 and 36) to monitor my platelets, liver and kidney function. They were worried because I have naturally low blood pressure, it was high-normal which was very high for me, and at some checks it was above normal, so they diagnosed me with gestational hypertension. Also, I had massive fluid retention, so they were worried,.

          They did all that to CHECK whether I was developing pre-e. The day I finally did get pre-e (suddenly went from no/trace protein in urine to high protein, and my platelets and liver/kidney function went haywire–two days earlier there had been no protein and the blood tests were somewhat worrying but not alarming), they sent me upstairs to deliver.

          THAT is how it should be done. That’s how you save women’s lives. And THAT, goddammit, is female empowerment — not munching your own placenta after giving birth in a kiddie pool in your living room.

          • demodocus

            Me too, I went to L&D because my toddler forgot that Mommy isn’t a trampoline and got induced that night not because he jumped on me but because my bp had gotten worrying.

  • Eater of Worlds

    Like I mentioned in the Consumer Reports post, we need you (or someone) to rebut this article and get it out into the mainstream press.

  • RudyTooty

    The white feminist midwives and the NCB industry try to co-opt the issue of maternal mortality and say more natural childbirth is what is going to improve outcomes. SMH.

    “…what can be done to support birth parents of color in the current moment? “I think the best way to combat the issue of maternal mortality is to continue to educate moms about their options for their childbirth experience,” Lawson said, explaining that many people are unaware that it’s possible to access birth support outside what is offered in the hospital.”

    http://www.truth-out.org/news/item/40576-motherhood-and-marginalization-the-oppressive-history-of-the-birth-industry

    • demodocus

      ugh. I’l grant you, I’m a white feminist and what I know about the black experience is pretty minimal but by Zeus I’m going to listen to that young black woman ob resident who delivered my daughter (under my Mexican-born primary ob’s eye) long before those NCB women.

      • Sue

        Let me guess: if you asked those two women what services would be most important to improve outcomes for their communities, they would NOT be saying “less obstetric services and more focus on the “childbirth experience”.

        • demodocus

          I seriously doubt it.

  • TheArtistFormerlyKnownAsYoya

    The ProPublica piece tried to attribute maternal death to rising c section rates as well.

  • Emma

    I’m so confused as to why you have an issue with this piece? It’s about ‘The Last Person You’d Expect to Die in Childbirth’ — it is totally upfront about the fact that it’s about the most privileged type of woman, the person most unlikely to die who still does, and why that might happen.
    1. It’s true that the increase might not be as dramatic or even really exist at all, but like you say it’s a debatable subject. And the international comparison still holds — even the piece you linked (Factors Underlying the Temporal Increase in Maternal Mortality in the United States) says that the US only does better than Canada on “hypertension, hemorrhage, and circulatory system diseases” and comparable to the UK on “preeclampsia and eclampsia, hemorrhage, cardiac diseases, direct and indirect maternal deaths, and late maternal deaths”. Which presumably leaves out a chunk of deaths where the US did worse.
    2. Yes her death was not representative — the piece indeed presented it as an unusual case. And while the graph they used might have only had 4 states worth of data, it also is more recent (Feb 2017) than the CDC graph you use.
    3. Does this piece somehow suggest that pregnancy is not dangerous? When it shows how a woman with all the possibly advantages died from it? Does it suggest that she might have survived in a low-technology environment??? How is a “low index of suspicion” different from “mothers are tended by nurses and doctors who expect things to be fine and are often unprepared when they aren’t”?
    4. If a person reads this and thinks the central problem of maternal mortality is white nurses, that’s a level of stupid I can’t address. The piece says “While maternal mortality is significantly more common among African Americans, low-income women and in rural areas, pregnancy and childbirth complications kill women of every race and ethnicity, education and income level, in every part of the U.S.” The headline tells you this is about the most unusual case. You can explore the problems in a system by looking at the averages, or you can look at the weirdest case — and often the strange case is the most compelling. Being poor and black (or obese, sick, rural, less educated etc) — these all cause death outside of maternal mortality. So do you think you are “fundamentally representing the problem” by not looking at all the ways in which race plays a part in health? Of course not, you’re focusing on one issue. Just as this piece focused on the one issue of ‘The Last Person You’d Expect to Die in Childbirth’.
    Long time lurker, first time I’ve been compelled to comment — I was expecting others to bring up these issues and I’m really surprised no-one else has.

  • Davidah00

    This could have been me. For my 2nd pregnancy, I saw a family practice doctor who did O.B. because I wanted a more “natural” experience than an OB-GYN. My blood pressure was creeping up throughout the last month, but it was always below the official “normal” and then I had severe abdominal pain for the last week of my pregnancy which was written off as heartburn (but was really my liver capsule failing). The doctor never ordered any blood or urine tests. I got to the hospital with very high blood pressure and lab tests showed that I had HELLP syndrome. My doctor had completely missed the diagnosis. Luckily, I delivered within 2 hours and I was monitored closely for BP and with repeat labs for the next 48 hours. I never filed a complaint but I’m glad this doctor no longer does OB work.

    • AnnaPDE

      Did you go back and tell him/her about the missed diagnosis?

      • Davidah00

        Honestly, I’m not sure. The Dr. who missed the diagnosis was on vacation when I actually went into labor so her partner was at the birth. I assume we talked about it at my post-partum visit, but I can’t remember. Then we moved 2 months later. This Dr. also missed diagnosing a congenital genetic disorder in my daughter (admittedly, that one was a difficult diagnosis, but she does have a number of soft markers for a chromosome disorder). We’ve now moved back to the town where this Dr. lives and we’re part of the same religious community, but I keep my distance. I don’t really know how to say “Excuse me, but do you realize that your incompetence almost killed me and also delayed appropriate diagnosis for my daughter for 3 years?”

        • Sue

          Have you considered writing her a letter?

          That might help you feel you have done something worthwhile with the information and educated the doctor, but without a confrontation.

    • showmesplfd

      And you are the perfect example of why it is really not the wisest decision to have a doctor whose primary focus is not obstetrical care but who does OB as an addendum to their “regular” practice. It’s rather like going to your family doctor (general practitioner, not a surgeon) when you need knee surgery or heart surgery. They will have some understanding of the procedure and what needs to be done but will not have the expertise or experience necessary in that aspect of practice. Let them do what they excel in and trust the lives of yourself and your unborn child to one trained in their care.

  • PickAUserNameForDisqus

    I know that this is changing the subject of the problems with the ProPublica piece, but suicide is the leading cause of perinatal maternal death in developed countries. I continually cringe when that is not addressed. Yes the ProPublica piece and Dr. Amy’s chart are about non-psychiatric “medical” deaths and I wish they would point that out. Sources: WHO: http://www.who.int/mental_health/prevention/suicide/Perinatal_depression_mmh_final.pdf, BMJ: http://www.bmj.com/content/355/bmj.i6585, BJPsych: http://bjp.rcpsych.org/content/183/4/279.long. CDC stats that I unfortunatley can’t find and know I will be raked over the coals for not providing a link to.

    • moto_librarian

      You raise an incredibly important point. Postpartum depression and psychosis are beginning to get more attention, but the absence is indeed striking. I think that people still don’t want to acknowledge the frequency of suicide, and suggesting that it is related to an event routinely portrayed as “the happiest time in a woman’s life” is just not done. And that’s a huge problem.

      • The weird thing is, in a lot of the fantasy that I read, women go through obvious PPD and the women around them all know that it’s a possibility. It’s like we can talk about it in a fantasy setting, or “women’s lit”, but we can’t acknowledge that this is based in reality.

      • KeeperOfTheBooks

        YES. THIS.
        After my experience with horrendous, suicidal PPD after my first kid’s birth, I have made a point of being very firm in telling new moms-to-be of my acquaintance that feeling that horrible isn’t normal, that there is help, that there is zero shame in getting it, and if you ever need me, call me at any time, 24/7, and I will come and either watch your kid or take you to a doctor or ER, whichever you need.
        I think it sometimes stuns them a bit, but I would rather give them a bit of a TMI overload than let them think that the symptoms of PPD are both normal and untreatable.

    • PickAUserNameForDisqus
    • The Bofa on the Sofa

      I wonder, if you did a survey, how many people would know that PPD-based suicide is even included as “maternal mortality”?

      • PickAUserNameForDisqus

        @thebofaonthesofa:disqus , I think you just hit the nail on the head. OBs may not feel comfortable with maternal psychiatric care, and many women see PMAD symptoms as a direct result of the baby and do not necessarily see it as a mental health emergency, and may have no experience, or poor experiences with mental health care, AND many psychiatrists are uncomfortable treating pregnant or breastfeeding mothers – so guess what… those providers would not answer on a survey that PMAD-suicide is a maternal associated mortality. (That all said, there are amazing providers out there that do say ‘the buck stops here’ and get women help)

      • Roadstergal

        And how many would say that you can prevent it by avoiding the hospital and breastfeeding?

        • Eater of Worlds

          Ugh, that annoys me. There has been recent research that shows epidurals can actually help with PPD. How? There’s a correlation between increased pain during birth and PPD. The less pain the mother is in, the fewer cases of PPD and also more mild PPD when it happens.

          Is it from less stress during birth or less actual pain? I don’t know. It was presented at a conference last year so I assume it’s been published by now. I don’t have journal access and I can’t find it with a web search (I’m likely not using the correct search terms).

  • MaineJen

    Our health care system is failing women of color. Those numbers are atrocious. Nothing helpful to add, just…that makes me angry.

  • Dr Kitty

    https://www.theguardian.com/global-development/2017/may/16/pregnancy-problems-are-leading-global-killer-of-females-aged-15-to-19

    The leading cause of death worldwide for girls aged 15-19 is pregnancy.
    Few teenage girls, no matter what their cultural background, are ready to be mothers.

    Expanding provision of contraceptive services and safe abortion, as well as ending child marriage and improving education for girls are going to do more to improve outcomes than increasing access to good quality obstetric care alone.

  • CanDoc

    YES, THIS: “There’s a word for that kind of complacency: the word is malpractice.”
    100% Agree with every bit of this opinion piece and hope that those who need to understand this, do.

  • Gæst

    Thank you for this.

  • RudyTooty

    So the area where this topic gets really messy is where black women and midwives of color are embracing the NCB ideology as a solution to the
    poor outcomes in the existing healthcare system in the US.

    http://www.blackwomenbirthingjustice.org/action-points

    MANA and NACPM have gleefully embraced this as well, as now
    they can appear non-racist, and maybe atone for some of their past sins of
    promoting CPM education by sending young white wannabe midwives to foreign countries to train on bodies of women with brown skin and oppressive life circumstances.

    http://nacpm.org/diversity-matters-what-are-our-challenges/

    https://midwivesofcolor.wordpress.com/2013/09/

    Then there’s the biggest uproar that has come out of the MERA collaboration (work group of CPMs and CNMs). It was not that the ACNM and nurse-midwives were snookered into promoting sub-standard midwifery care, but that this misguided effort excluded midwifery organizations established by women of color. MERA has now fixed this, but really, what does this do – what does promoting NCB – do to promote safer healthcare and better outcomes for women of color and their babies in the US?

    http://stylemagazine.com/news/2015/jun/09/black-org-open-letter-us-midwifery-association/

    This is all just messy, messy, messy.

    • moto_librarian

      I feel like this is just another way that white feminism screws over women of color. We know how bad the maternal mortality statistics are for women of color, and that there is nothing about NCB that is going to help with this.

      • lawyer jane

        Agree, and yet the reasons for seeking out the woo are absolutely intersectional. That is, possibly more rational if you’re a woman of color to be suspicious of the medical “establishment.” But no woman should be forced to chose between NCB and competent medical care. In DC there’s a (by all accounts high quality) maternity/birth center located serving an African American neighborhood — mothers can chose to give birth there, or at a hospital with an excellent reputation. They provide wraparound services, including prenatal, well woman, pediatric, lactation, legal, housing. It looks like a great model.

      • RudyTooty

        Or that white feminist midwifery is embracing ‘diversity’ as a means to promote their own image and brand.

        But another side to this is that women of color are embracing the NCB ideology as well and looking to it as a solution to the atrocious outcomes in the current system. :-/

        • moto_librarian

          Yes, this is what it is. I was struggling to figure out how to say this yesterday. There are indeed real problems for women of color in the medical system, and I can understand the appeal of “taking back birth” on a visceral level.

      • I have been called a “racist” in other forums when I point out that there are particularly high rates of certain obstetric problems for women of color, regardless of income or sociologic status.

        • demodocus

          By whites or women of color?

        • KeeperOfTheBooks

          I am, unfortunately, not shocked.
          Nonetheless, it’s a fact, if a nasty one.
          Reminds me of the recent experience of a black woman in a moms’ group I’m in. She walked into the hospital showing textbook signs of a placental abruption (plenty of bleeding, crappy monitor strip, severe pain that didn’t diminish after contractions, the lot) and was ignored and generally blown off by the staff for 10-12 hours, by which point her baby was dead. She had begged for a C-section. Completely unacceptable tragedy, and one that is very unlikely to have occurred to a white woman. I am no proponent of the NCB movement, but I quite understand why the idea of caregivers who first and foremost promise to listen to their patients (even if, of course, they don’t unless their patients fit their narrative) is damn tempting to her in the eventuality of a future pregnancy.

    • Young CC Prof

      What makes it particularly messy is that these activists of color typically have half the story right, and are fighting for some things that help, like support for new parents, building a clinic to provide prenatal care in the community with hours that work for people, or helping people sign up for Medicaid. The activists are part of the community, they are exactly the people that we need to work with if we’re going to improve outcomes, it’s just half of what they’re pushing is completely the wrong direction.

  • Cyndi

    Thank you for this. This article disturbed me so much, and I think what was most disturbing was reading about that initial severe abdominal pain. Maybe I turned into that because my area of nursing was high risk, so I was always looking for zebras rather than ignoring troubling symptoms; it was always best practice to report symptoms than brush them off. But as I’m always trying tell tell AVers, yes science and medicine does make mistakes, and we do have deaths or untoward results, but the important take away is that unlike the current midwife situation in the US, we admit our mistakes and work to make certain it doesn’t happen to any other patients.

  • RudyTooty

    “The U.S.—a country that spends more per capita on health care than any
    other developed nation—has one of the most sophisticated,
    technologically advanced health care systems in the world, but we still
    have inequities. Black women are still suffering from preventable
    maternal deaths.”

    http://www.theroot.com/the-black-maternal-mortality-rate-in-the-us-is-an-inter-1790857011

    • moto_librarian

      Jesus. This is just awful. And having lived in the South for nearly 12 years, I have no doubt that it is indeed worse here than the rest of the United States (not that this is an excuse or a suggestion that things are peachy in the North; I know they’re not).

  • lawyer jane

    Totally with you on this, except this conclusion: “Maternal mortality may just be a proxy for race not a measure of quality of care.” If black women get worse care due to their race (or alternatively, require different OB GYN care due to poorer health when they get pregnant based on a history of poor access to health care or factors that decrease health) isn’t maternal mortality a measure of the quality of care? For me, the implication of the fact that black women STILL suffer higher mortality rates even controlling for socio-economic factors, suggests that there is racism at play at every level of their lives.

    • moto_librarian

      I think that you are likely correct. We know that there is inherent bias in pretty much all of our structures, including healthcare, and I have no doubt that it plays a role in the death rates for women of color. I also wonder about the preliminary research findings that suggest that DNA itself is altered by decades of structural racism. If that holds true, women of color are doubly disadvantaged.

    • Young CC Prof

      There are plenty of studies that show Blacks are less likely to be taken seriously when they complain of pain, less likely to get aggressive treatment for potentially serious problems, etc.

      And then of course there are the obvious care access issues. Even when Black women have the same insurance and financial status, they may be less likely to live near the best clinics and hospitals.

    • Gatita

      You are correct about bias at all levels but there’s also likely a genetic component as well. We know that black men are more likely to have high blood pressure and a sensitivity to salt that is believed to be caused by the fact that African men who retained sodium were more likely to survive the Atlantic crossing in the slavery​ era. Wouldn’t ​shock me at all if a similar issue was contributing to Black maternal mortality.

  • moto_librarian

    At about 5 days postpartum after my second, I developed one of the worst headaches that I have ever had. It coincided with the peak of my baby blues, and I had been crying nonstop all day. I asked my husband to take my blood pressure, and it was definitely high for me. I immediately called the nurse-midwive’s on-call line and left a message, as I had been told that both of these symptoms postpartum could be the sign of eclampsia. My call was returned within minutes. I was advised to take a pain pill, and if my bp was still elevated and/or the pain had not started to abate within 30 minutes, my husband was to take me directly to the hospital. As the pain receded, my bp went down, and all was well, but my symptoms were taken seriously. It’s just stunningly awful that no one took care of Lauren properly. Her death should not have happened, and I have a hard time not seeing it as anything other than malpractice.

    • J.B.

      Shoot, it took long enough for me to get in to see someone about vasoconstriction! I kind of wish I’d weaned then but anyway…

      Glad you were listened to! And I was definitely listened to about PPA, which is the most important part.

  • The Bofa on the Sofa

    Lauren’s death involved a myriad of these factors, but the most important is the one that isn’t mentioned: the low index of suspicion. In other words, no matter what happened, the doctor and nurses kept insisting that everything was fine while she was dying before their eyes. Instead of investigating her symptoms, everyone kept assuring her that she was fine.

    It’s almost like they kept passing it off as a “variation of normal” or something like that….

    • moto_librarian

      It’s amazing that no one took a nurse’s pain rating of 10/10 seriously either!

    • J.B.

      Another thought more broadly – African-American women are dying at higher rates, and there is a lot of history of belief that women of African descent don’t suffer pain at the same rates. From Sims, to Grantly-Reid, to Bettina Judd’s story/poem in this: http://www.npr.org/2016/02/16/466942135/remembering-anarcha-lucy-and-betsey-the-mothers-of-modern-gynecology

      How often are African-American women suffering from severe pain and complications and still ignored?

      • moto_librarian

        A white nurse’s pain wasn’t taken seriously by her male doctor or even her colleagues. It would not surprise me at all if this doesn’t have an impact on women of color. Isn’t there some thought that women of color die of heart attacks more frequently because their symptoms aren’t taken seriously?

  • moto_librarian

    Thanks for this. I keep seeing it shared by people who are in the thrall of NCB.

    • RudyTooty

      The NCB thrallists are sharing this… why? How does this promote their agenda, I wonder?

      Or is it as simple as:
      “SEEEEEE? Women die in the hospital, TOO!”

      • moto_librarian

        Because a lay midwife would surely have caught the signs of pre-eclampsia, dontcha know? This article had enough lazy reporting for them to see it as support for the homebirth cause. For one thing, I noticed that they posited it as fact that induction can lead to c-section (the research demonstrably proves no such association), and there were plenty of other things that Dr. Tuteur ably deconstructed.

        • RudyTooty

          NCB promoters believe that homebirth midwives would do a better job of diagnosing HELLP?

          I guess I’ve heard that line of reasoning. That midwives have super-special intuitive powers that make them *expert* diagnosticians. Yeah, I’ve heard that. SMH

          • ChickyDee

            My midwives (in Canada, so theoretically well-trained and competent) didn’t even know how to properly measure blood pressure. That was the first of a long line of events that made me lose trust in my practitioners. (I work in health care and have attended multiple training sessions on blood pressure measurement – in far less critical areas than maternity care).

          • Dr Kitty

            I use an old fashioned manual Sphyg, and am careful to choose the correct size of cuff.

            When I had my BP measured on the Postnatal ward it was an electronic machine and apparently they didn’t have any small cuffs, so my BP results were about 20mmHg off my baseline… which puts it in the “how are you even alive” territory.
            A small cuff was found eventually, as it was clear my systolic BP couldn’t be 68, despite what the machine said.

          • ChickyDee

            At least when kid 3 was born – long after I gave up on the midwives – hospital staff could properly measure blood pressure… But when my Systoic BP was below 65 I was also busy fainting, so who needs an accurate measure at that point ?

      • AnnaPDE

        With the kind of OB who tries to do “normal” birth no matter what…

  • Anj Fabian

    I looked for the usual suspects and found them.
    Coming in at #3 is infection/sepsis
    Right behind it at #4 is hemorrhage
    Pre-e and other hypertensive disorders lags at #7