Black maternal deaths: racism is deadly but malpractice is deadlier


One of the most fascinating aspects of the ongoing ProPublica/NPR series on US maternal mortality is watching the reporters learn from their research.

To their credit, the reporters abandoned their original understanding of maternal mortality and crafted a new one. That process is still ongoing and their latest piece, Nothing Protects Black Women From Dying in Pregnancy and Childbirth, is an example of both how far they’ve come and how far they have to go.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Both Shalon Irving and Lauren Bloomstein died because medical professionals dismissed their symptoms as variations of normal when they were signs of impending death; they died of malpractice.[/pullquote]

They’ve come far enough to recognize that maternal mortality is disproportionately a problem of black women and they are correct that racism is part of the problem, but not necessarily in the way that they think. Moreover, they keep confusing malpractice with other issues.

Comparing their original article to the latest piece demonstrates progress. The original piece, The Last Person You’d Expect to Die in Childbirth used the death of a privileged white woman, Lauren Bloomstein, as the frame. The journalists didn’t explain and probably didn’t even know the most salient facts about maternal mortality.

They weren’t entirely to blame for their lack of knowledge. The natural childbirth industry — a group of Western, white, relatively wealthy women — has weaponized the tragedy of maternal mortality in order to attack modern obstetrics. I’ve written extensively about the cynical, racist misuse of the issue:

Natural childbirth advocates are positively eager to use the misfortunes of women of color to advance their own privileged agenda. They delight in pointing to relatively high rates of perinatal and maternal mortality in the US (as compared to other, “whiter” countries), yet ignore that they are the result of appalling death rates among African American women and their babies.Natural childbirth advocates and organizations have the unmitigated gall to imply that these women are dying of “too much” medical intervention when the reality is that they are dying of too little intervention for the serious complications they face.

Ina May Gaskin, a privileged white woman, has led the way in this exploitation. Gaskin never misses an opportunity to highlight mortality rates and even created a “Safe Motherhood” quilt project to draw attention to the problem. Gaskin represents herself as shocked at the current rate of maternal mortality. Yet as far as far as I can tell, homebirth midwives in general and Gaskin in particular have done nothing (no research, no education, no fund raising) to reduce the incidence of maternal mortality.

What are the salient facts about US maternal mortality?

  • It is disproportionally a problem of black women.
  • The leading causes of death are cardiac problems and other chronic diseases.
  • Pregnancy is inherently dangerous.
  • Women die from lack of high tech care, not too much of it.

Since then the ProPublica/NPR journalists seem to have come to grips with the true nature of the problem. Their latest piece is framed by the tragedy of the preventable death of a privileged black woman.

At 36, Shalon [Irving] had been part of their elite ranks — an epidemiologist at the Centers for Disease Control and Prevention, the preeminent public health institution in the U.S. There she had focused on trying to understand how structural inequality, trauma and violence made people sick. “She wanted to expose how peoples’ limited health options were leading to poor health outcomes. To kind of uncover and undo the victim blaming that sometimes happens where it’s like, ‘Poor people don’t care about their health,’” said Rashid Njai, her mentor at the agency. Her Twitter bio declared: “I see inequity wherever it exists, call it by name, and work to eliminate it.”

Much of Shalon’s research had focused on how childhood experiences affect health over a lifetime. Her discovery in mid-2016 that she was pregnant with her first child had been unexpected and thrilling.

Then the unthinkable had happened. Three weeks after giving birth, Shalon had collapsed and died.

The article goes on to discuss the role of racism in health disparities.

But it’s the discrimination that black women experience in the rest of their lives — the double-whammy of race and gender — that may ultimately be the most significant factor in poor maternal outcomes. An expanding field of research shows that the stress of being a black woman in American society can take a significant physical toll during pregnancy and childbirth.

It’s chronic stress that just happens all the time — there is never a period where there’s rest from it, it’s everywhere, it’s in the air, it’s just affecting everything,” said Fleda Mask Jackson, an Atlanta researcher and member of the Black Mamas Matter Alliance who studies disparities in birth outcomes…

Arline Geronimus, a professor at the University of Michigan School of Public Health, coined the term “weathering” for how this continuous stress wears away at the body…

That’s an appealing explanation but it’s almost certainly wrong. Racism in the US is not restricted to black people. Hispanics and Native Americans face their share of discrimination, chronic disease and poor socioeconomic status yet they don’t have the same problem with maternal mortality. The maternal mortality rate among Hispanic women is lower than that of white women.

Racism is a hideous problem in this country and an insidious problem in medicine, but Shalon Irving didn’t die because of “weathering”; she died of malpractice, ironically the same thing that killed Lauren Bloomstein, the privileged white woman whose death frames the initial ProPublica/NPR piece.

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. Pregnancy has been portrayed as inherently safe when, in fact, it is quite deadly. Medical professionals now have a low index of suspicion for pregnancy complications when they should have a high index of suspicion. You can’t diagnose complications if you don’t think about them.

Both Shalon Irving and Lauren Bloomstein died because medical professionals dismissed their symptoms as variations of normal when they were in reality signs of impending collapse and death. In other words, they died of malpractice.

Shalon Irving repeatedly presented to her healthcare team with serious postpartum complications.

What troubled the nurse most, though, was Shalon’s blood pressure. On Jan. 16 it was 158/100, high enough to raise concerns about postpartum preeclampsia, which can lead to seizures and stroke. But Shalon didn’t have other symptoms, such as headache or blurred vision. She made an appointment to see the OB-GYN for the next day, then ended up being too overwhelmed to go, the visiting nurse noted on Jan. 18… Overall, Shalon told the nurse, “it just doesn’t feel right.” When the nurse measured her blood pressure on the cuff Shalon kept at home, the reading was 158/112. On the nurse’s equipment, the reading was 174/118…

Irving should have been admitted to the hospital immediately for treatment of her blood pressure and evaluation for postpartum pre-eclampsia. Instead she was reassured and sent home.

On the morning of Tuesday, Jan. 24, Shalon took a selfie with her father, who’d been visiting for a week, then sent him to the airport to catch a flight back to Portland. Towards noon, she and Wanda and the baby drove to the Emory Women’s Center one more time. This time, Shalon saw a nurse practitioner. “We said, ‘Look, there’s something wrong here, she’s not feeling well,’” Wanda recalled. “‘One leg is larger than the other, she’s still gaining weight’— nine pounds in 10 days — ‘the blood pressure is still up, there’s gotta be something wrong.”

The nurse’s records confirmed Shalon had swelling in both legs, with more swelling in the right one. She noted that Shalon had complained of “some mild headaches” and her blood pressure was back up to 163/99, but she didn’t have other preeclampsia signs, like blurred vision… She ordered an ultrasound to check the legs for blood clots, as well as preeclampsia screening.

Both tests came back negative. As Wanda remembers it, Shalon was insistent: “There is something wrong, I know my body. I don’t feel well, my legs are swollen, I’m gaining weight. I’m not voiding. I’m drinking a lot of water, but I’m retaining the water.” Before sending Shalon home, the nurse gave her a prescription for the blood pressure medication nifedipine, which is often used to treat pregnancy-related hypertension.

The provider made the worst possible error of malpractice; she refused to believe an obviously unwell patient sitting in front of her. It’s the same error made by Lauren Bloomstein’s providers with the same deadly result.

It only gets worse from there:

They got home and sat in Shalon’s bedroom for a while, laughing and playing with the baby. Around 8:30 p.m., Shalon suddenly declared, “I just don’t know, Mom, I just don’t feel well.” She took one of the blood pressure pills. An hour later, while she and Wanda were chatting, Shalon clutched her heart, gasped and passed out.

Paramedics arrived to find Shalon on the floor near the foot of her bed “pulseless and not breathing…” They tried to stabilize her, then rushed her to Atlanta’s Northside Hospital, just a couple of miles from her home. In the emergency room, doctors discovered that the breathing tube had been “incorrectly placed,” according to the ambulance service report — into her esophagus instead of her lungs. She never regained consciousness. Four days later, on Jan. 28, Wanda and Samuel withdrew life support and she died.

Was Shalon Irving a victim of racism in her life? Undoubtedly, but racism didn’t kill her, malpractice did, specifically the belief of her providers that they didn’t need to worry about childbirth complications even though Shalon and her serious complications were sitting right in front of them. Childbirth is dangerous; women die when we pretend otherwise.