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.
I think whoever mentioned “intersectionality” is spot on. If sexism is in play, then black women are more likely to be impacted negatively than white women. Agreed there is more to it, if Hispanic women fare better. I think another factor is that the God of American medicine, no matter what is said, is $$$. For one thing, the pressure to see more and more patients and dispo them as quickly as possible can’t help but pressure some providers to push patients through faster than they should. What happened to Shalon Irving is appalling, disgusting. You have to look at racism, sexism, negative attitudes to overweight people, negative attitudes toward poor people also. And train, train, train. Childbirth is dangerous.
Malpractice and maltreatment of black patients is often rooted in racism. Doctors and other medical providers dismiss their symptoms as “drug seeking”.
https://www.alternet.org/personal-health/medical-racism-and-ignoring-black-pain
So is the lack of access. White legislators & white voters don’t really care if black communities have hospitals, grocery stores, or mass transit. They are perfectly willing to build polluting businesses in them tho.
http://www.futurity.org/black-places-racism-1290002-2/
I can’t remember the name of the public hospital that is closing its L&D unit in Washington DC, in an area with a large black population. Look to $$$ on that. Gone are the days when hospital administration thought of their mission as providing a service to the community. I mean, maybe not completely gone, but…
How incredibly awful.
Black women are dismissed even more than white women are. And we get dismissed often.
I am not black, but I too was told that my high BP was not an emergency. A few days before giving birth with my first, it was 174/110 in the doctor’s office. They let me go home. A few days later, the night before I went into labor, it was 190/115 at home. I called the L&D ward and told them how high it was and they told me I had likely made a mistake while taking it. I was having spots in my vision and was grossly swollen.
Luckily I survived with no ill effects, and in subsequent pregnancies the medical professionals took me seriously when I told them my symptoms.
But I could have died, and no one listened.
I’m so heartbroken reading these women’s stories. My last pregnancy was so dangerous (tachycardia, undiagnosed pulmonary hypertension, and transient blood pressure highs) and my child and I nearly didn’t survive. I didn’t fit the pre-e bill and even a specialist ob couldn’t figure out what was going on and said not to treat me with anything because it could obscure a symptom that would mean immediate delivery. My baby was born at 35 weeks to a nurse because they could not find an MD fast enough to attend the birth, and the cord was wrapped around my newborns neck. I, in PH fashion, had stopped being able to breathe. I have no idea how we survived that. It’s hard to believe in our medical system with this experience and then hearing these stories. I did have good providers who all communicated with each other eventually, but not while pregnant. This has to change. It absolutely has to change.
Oh. My.
No call for *increased* access to necessary medical interventions.
Sigh.
“Black Women Birthing Justice is a collective of African-American,
African, Caribbean and multiracial women who are committed to
transforming birthing experiences for black women and transfolks. Their
vision is that every pregnant person should have an empowering birthing
experience, free of unnecessary medical interventions and forced
separation from their children.”
http://www.prweb.com/releases/2017/12/prweb14996050.htm
Also, a blood pressure of 174/110 or so is an emergency, even if the patient has no other symptoms. Even if pre-eclampsia is not an issue. Blood pressure that high is in and of itself a life threatening problem, especially if it’s acutely elevated.
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
Actually, they do, but not as bad. The CDC gives the stats in 2013 as 12.7 deaths per 100,000 pregnancies for whites, 43.5 for blacks, 14.4 for other races. Shalon clearly was the victim of malpractice, but did her race make her caregivers take her complaints less seriously? It’s not at all impossible.
Actually, my bad. It looks like they were not taking ethnicity (Hispanic/non-Hispanic) into account in those numbers. Elsewhere there are data suggesting that Hispanic people have a lower maternal mortality. I wonder how those numbers would look after age adjustment though.
Well, there you go. Check out figure 2.
http://journals.lww.com/greenjournal/fulltext/2015/01000/Pregnancy_Related_Mortality_in_the_United_States,.3.aspx
I had post-partum pre-eclampsia about two weeks after my third was born. My BP measured about the same as Shalon’s. I don’t recall if I had a headache. I don’t recall how I got the hospital. I don’t think it was an ambulance, I must have had my husband drive me. I wouldn’t have been driving. I do recall I was sent straight to the hospital, put on another mag drip (Hey, it’s nowhere near as awful when it’s not RIGHT after birth), and taken seriously. I live in a high-resource area, and had a great OB, but this makes me mad and scared. It so easily could have been me.
Oh, and 5 years later, I’m still on BP medication. 3 of them.
There are a few places in the post (including the sidebar) where Shalon Irving is referred to as Shonda.
Sorry, I’ll fix it.
You shouldn’t have to have ALL possible symptoms of an illness in order to be taken seriously. Having any of them should draw the attention of professionals. Having some of them should call for deeper investigation.
It seems that healthcare workers sometimes focus on the one symptom a patient doesn’t have – in this case blurred vision – to justify ignoring what could be a very dangerous situation.
Yes, in total agreement. I kept reading and going “stop talking about blurred vision. Her BP alone should be enough to get further investigation!”
If I had been at the same hospital she was I probably would have died too. The differences were that a BP of 180/100 was enough to get me admitted, despite my vision being fine. I was lucky – if I hadn’t had the appointment then my rapid BP rise would undoubtely still have happened, it just wouldn’t have been stopped by the three drugs and no one woukd have been watching it.
I cannot understand how oedema, high BP and having recently given birth were not major red flags or enough to get her admitted and properly investigated and treated.
The amount of malpractice around hypertensive disorders of pregnancy scares the snot out of me.
I’m alive and well today because the CNM who examined me at maternity triage ran the correct blood tests to test for HELLP when my blood pressure measurements were through the roof and didn’t let us leave until after that blood test came back. Far too many women who have HELLP lose their babies when someone fails to test a woman with pre-e for HELLP and she has a massive placental abruption – or she strokes out – or blows a liver hematoma….
I had no clinical symptoms prior to arrival at the hospital. I went to the hospital because I was having cyclic and painful Braxton-Hicks contractions that my OB wanted checked out. I didn’t develop edema in my legs until after Spawn was born by CS. I never had a headache. I did start seeing halos in my right eye a few hours after I knew I had HELLP – but only if looking at a recessed light or other columned light source. I don’t know if I would have noticed that at home. Never developed right-side abdominal pain for that matter either. I was tired, gassy, and had had a nosebleed a few days before; IOW, I was pregnant.
I spent a full week hospitalized after Spawn was born because my blood pressure wouldn’t go down. My body has no response to labetalol – but we only know that because I was put on it in the hospital and monitored closely. My OB found a second-line oral medication that worked well enough and watched my blood pressure closely until my 6-week check-up. Then she handed me off to my PCP who switched me to a different medication that was better suited for long-term, not-pregnant women. So now my PCP is watching me like a hawk.
Women and babies shouldn’t be dying from this. We know how to treat hypertensive disorders of pregnancy and have for some time.
Yes! I developed pre-eclampsia while pregnancy after my BP had been creeping up all throughout the 3rd trimester. Not only did my providers literally refuse to discuss induction with me (after I asked them when would be the point to pull the trigger) but they also ignored my BP after delivery. My BP did go back to normal, but nobody counseled me about monitoring it. I only knew it was OK because I kept on asked when they monitored my vitals.
Everyone should read the original article. We need to stop this from happening!
Perhaps it’s because I worked for the PRB in Detroit at a hospital with nearly 90% African American patients. Or perhaps because I’m a CNM and had memorized the criteria for hypertensive disorders of pregnancy. It was part of the criteria for determining the diagnosis for the chart reviews for the PRB studies. But, as soon as the story mentioned the swelling I knew where this was going.
It was not uncommon to perform a chart review at the PRB and be able to see that the diagnostic criteria had been met, but that the attending and resident physicians, and the CNMs did not diagnose the problem. Most of the time they did, but I always wondered how they could also frequently not see what was so plainly obvious.
Were they too rushed, had they previously been told they were overdiagnosing, was there a lack of continuity of care, or was it negligence and malpractice?
I don’t know about follow-up or M&M at the hospital for those cases. I just know that we saw the bigger picture during the chart reviews and it was always appalling.
The thing that I find most outrageous (among the many outrageous events in this case) is that the hospital wouldn’t pay for an autopsy. A young woman died at their hands; didn’t they want to know what happened? Or was it possible that they wanted to avoid finding out what happened?
But it seems a possibility that she might have been taken seriously had she been white: that is, that the malpractice was at least partially because of her blackness?
(edit) Even if not specifically, the overarching idea that low tech equals better is disproportionately disadvantageous to black women. Thus the ideology itself that killed her is arguably racist.
I agree. We can’t stop at simply naming it “malpractice” and not follow through to ask why the very clear indications for emergency intervention were ignored.
Yes. There’s a parallel here with malpractice against female patients. We know doctors tend to dismiss women’s pain and complaints, causing them to fail to diagnose or misdiagnose. Of course it’s malpractice; however there is the factor of sexism that is influencing that.
This! I have endometriosis. My story is very common: severe, debilitating period pain being dismissed by doctors for years. In my case, 10 years of being unable to function, curled up in the fetal position for 2-3 days every time I menstruated, taking the only medication they would prescribe: naproxen. Finally, when I ended up in the hospital, in severe pain and vomiting from it, did the OB/gyn on call suspect endometriosis, and booked me in for a laparoscopy to definitely diagnose it, and excise any endometriosis implants that he found. My story is certainly not unique. I believe the Endometriosis Association reports an average of 7 years of pain and suffering until diagnosis. All because women’s pain is minimized and dismissed. Even by female physicians (from age 12 to age 22 my OB/gyns were female, simply because I was young, a virgin, and more comfortable with a female physician. Now, at 45, I couldn’t care less – I simply want a competent physician!)
That’s certainly possible, but remember that Lauren Bloomstein was white and privileged and she died the exact same way; she was begging people to help her and they kept telling her she was fine.
It’s possible that this happens MORE to black women … intersectionality.
It is certainly possible. I worry that racism impacts obstetrics in a more insidious way: the issues that motivate privileged white women are the issues that get addressed. Hospitals have turned themselves inside out to attract privileged women — birth rooms, birth centers, waterbirths, etc. —
That too. Racism is not only insidious, it’s multi-pronged. Yes, there is the catering to the affluent by providing ‘spa like services’ in OB units as well as overt and covert racist attitudes held by providers and staff and denial of care to non-white women.
Fear of malpractice lawsuits is a huge motivator as well. And the bias is that white women are more likely to sue. Young, non-white, WOC and immigrants are seen as less likely to sue – how do you think that impacts care?
I should have said …”denial of timely intervention”
Not denial of care.
I think they get care – just not the same care. The reasons for this disparity in care is multifaceted.
Yes. That doesn’t mean race couldn’t have played a part here either though, or that this isn’t more likely to happen when you’re black. Of course white women are also going to be affected too- they’re still women!
But on the whole, I’m not comfortable defining racism and malpractice as two separate things here. At absolute minimum, this happened in a wider culture of black patients getting worse treatment generally and also of NCB ideology that is particularly detrimental to black women in the US. Those things are racist.
Do you think it’s more because of sexism than racism in medicine? I’m a british doctor and so obviously don’t have the same cultural experience of medicine – but my opinion is that misogyny in medical practice is rife. There have been studies ( wish I could remember them!) about how women’s pain is under treated in emergency departments, symptoms are not taken seriously- ie pelvic floor mesh complications, endometriosis. Then there is the deliberate denial of pain relief in labour and post partum after c section ( have a friend who had a section last week – was unknowingly put on an analgesic protocol in the post natal ward – day 2 paracetamol only. Asked for stronger painkillers- denied for 5 hrs until crying in pain – and she’s a doctor!) would a post op surgical ward have a protocol for pain relief for men which put you down to paracetamol after 24 hrs without asking if you actually had pain?
I think sometimes pregnant women in this country are treated as annoying whinging women who should just get on with it – and we also have the same problems with avoidable deaths from eclampsia and a hideous still birth rate – ‘my baby’s not moving as much’ ‘there there dear it’s fine you’re just anxious (eyeroll behind back)’ sort of thing is soooo common.
I’m never sure you can reliably identify what’s racism and what’s sexism when it comes to black women getting worse treatment. It’s both, added together and multiplied and criss crossing.
That paracetamol-only setup sounds like what my UK friend got post-C/S. But she blamed the doctors for doing the C/S, depriving her of her magical VB, rather than the midwives denying her proper pain control. She had bought into the whole natural/breastfeeding stuff that the midwives fed her. I wonder if they form a key cost-cutting measure? It’s got to be a lot cheaper to give paracetamol instead of stronger drugs.
It might be, or they might have a protocol where there has to be charted evidence the patient was given paracetamol and it was not sufficient, in order to justify something stronger. I saw stuff like that in hospice and it made me NUTS. No room for the doctor’s clinical judgment at admission or at the time when orders were given.
Did racist attitudes on behalf of the provider(s) contribute to the malpractice?
Does that matter?
Do racist attitudes, in general, among the health care providers, contribute to malpractice?
I would think so, since sexist attitudes among health care providers contribute to malpractice, why wouldn’t racist ones as well?
I am a professor of epidemiology by day and (default) advocate by night. My cause is proper management of monochorionic twin pregnancies. The United States SUCKS. Women are dismissed, demeaned and even shouted at for talking to me and then going on to request bi-weekly ultrasounds, MFM care, delivery by 36+6/7, cesareans due to velamentous cord insertion/ breech presentation/previous fetoscopic laser surgery for TTTS — all things that DECADES of literature have proven are proper measures to be taken to decrease morbidity and mortality. In my case, white women are stonewalled as much as black, Hispanic, etc. Though my ESL and very young moms suffer the most and are treated the poorest. It is a problem with PROVIDERS. ACOG and SMFM suck at making committal statements regarding treatment and practice protocol – much UNlike the UK, Australia, Canada, etc. For mo-di management it’s so loosey-goosey and wan’t even written until 2013! US providers, for being some of the most well-compensated in the world, blatantly dismiss the very women they are tasked with serving. And they dismiss clear risks! I had an OB tell a mo-di mom the other day that “twins are twins are twins” – that there is no increased risk in di-di versus mo-di twinning and thus he would not alter her care. Some lie and claim insurance won’t allow the care to be altered — manipulative. She left him as a patient after trying to reason with him, but really? REALLY?!
In short, I see what you’re writing about here almost every day of my life. I empower women to battle against it and use education to do so. I am a LOVER of modern obstetrics; this is not demonizing. My moms want MORE intervention; more science; more care. They are kept at bay every. single. day. And bad shit happens as a result.
That’s one good thing about the UK model.
If you have multiples, you don’t get routine care, you go to the multiple clinic. There are protocols for HOM and all the variations of twins.
You don’t have an OB saying “oh cool, I haven’t seen a twin pregnancy in a while!”