An ensemble of nurses and therapists at Baltimore Healthy Start Inc. are trying to prevent moms from dying.
The East Baltimore nonprofit holds “belly buddy” classes that teach meditation, needlework and scrap-booking to ease stress. Nurses make home visits to check on moms’ well-being. Transportation and daycare are provided so pregnant women can get to checkups. Several weeks after delivery, moms are offered gift cards as an incentive to come back to the doctor’s office. Complications can take moms by surprise weeks after delivery.
“It’s an unsettling thing to bring a new life into the world and then die,” said Maxine Reed-Vance, Baltimore Healthy Start chief of clinical affairs. “It is not expected, and it doesn’t have to happen.”
Yet the number of pregnancy-related deaths in the United States is on par with some underdeveloped countries. The U.S. is the only industrialized nation with a rising maternal mortality rate, according to one study led by University of Maryland researcher Marian F. MacDorman. Between 2000 and 2014, that rate increased 26 percent.
Maryland’s rate of maternal deaths was 26 deaths per 100,000 births for the five-year period 2011 to 2015, according to a maternal mortality review board under the state’s department of health. The state’s rate has generally been higher than the rest of the country, but was slightly lower during the time period. A federal initiative aims to bring deaths down to 11.4 maternal deaths per 100,000 births.
A sizable racial disparity exists as well, with black women three to four times more likely to die from a pregnancy-related complication than white women, according to the Centers for Disease Control. In Maryland, black moms die due to pregnancy 2.7 times more than white moms.
It is a disparity that crosses socioeconomic lines. Tennis great Serena Williams and singer Beyonce — wealthy, high-profile women with access to the best health care in the country — recently described their own pregnancy complications. Williams’ near-death experience kept her in the hospital for a week.
A day after giving birth to her daughter in Sept. 2017, Williams told CNN, she suffered from a pulmonary embolism, a condition where one or more arteries in the lungs becomes blocked by a blood clot. Her Cesarean section wound popped open because the embolism made her cough hard. In surgery to get that fixed, doctors found a large hematoma, or a swelling of clotted blood, in her abdomen. That meant another surgery to prevent the clots from moving to her lungs.
Beyonce told Vogue magazine "toxemia,” sudden high blood pressure and protein in the urine, landed her on bed rest for a month before giving birth to twins by C-section in June 2017.
The high rates of maternal mortality are a puzzling, and some say tragic, problem that has existed for decades. Why, with all the medical advances, are moms dying?
Substance abuse and unintentional overdose were the leading cause of maternal death in Maryland in 2015. Pulmonary embolisms, such as the one suffered by Williams, were the second cause.
Another reason is women are having babies later in life and with more health problems. Rates of obesity, diabetes and cardiovascular disease are higher than ever, and all can lead to complicated pregnancies.
Meanwhile, poor and disadvantaged women simply aren’t making it to the hospital to get the prenatal care they need even as the Affordable Care Act has made health care more accessible. And social factors, such as poverty and poor nutrition, are putting moms at risk before they have a chance to see a doctor.
Baltimore Health Commissioner Dr. Leana Wen said that state officials could share more detailed data about maternal deaths so that local health departments could do more to address the issue.
“Maybe that mom died during pregnancy, but what were the preventable causes?” Wen asked. “Did she not get prenatal care? Did she have a mental illness that did not get treated? We need to be able to look not at just what happened, but also those deeper social determinants that got us to where we are.”
Some studies have found doctors may too often brush off women’s health concerns, such as when they say they are experiencing pain. This is especially true with African-American women, some studies have found. Part of Baltimore Healthy Start’s approach is to train moms to be aware of their bodies and advocate for themselves.
“We encourage women to really speak up when they don’t feel right,” Vance said. “Let someone know something is wrong, and don’t just shut up.”
Data gathered from the maternal review board about deaths in the state have led to several initiatives to improve the care of pregnant moms.
“We take those cases and try to glean from them what kind of actions we should take to prevent deaths,” said Dr. Lee Woods, medical director the state’s maternal and child health bureau.
In one initiative, hospitals were required to come up with protocols to prevent hemorrhaging. The board pushed for more mental health screening of pregnant woman and more follow-up care after pregnancy, Woods said. The state is now looking at how to stop pregnant moms from dying of overdoses.
Some moms may find the fortitude to stop using while pregnant but return to their old ways after giving birth, said Dr. Robert Atlas, who sits on the state’s maternal mortality review board and is chair of the department of obstetrics and gynecology at Mercy Medical Center.
“Once pregnancy is over, they get back into the environment that led to their use, and there is not enough support to prevent them from using again,” Atlas said.
Tausi Suedi, whose nonprofit Childbirth Survival International helps disadvantaged women in Africa deliver healthier babies, called America’s maternal death rates “embarrassing.” All three of her pregnancies had major complications, including gestational diabetes. She nearly died during the first pregnancy.
Suedi had to find a different doctor for the second two births who paid better attention to her risk factors, including a condition that prevented her from keeping food down while pregnant. The doctor monitored Suedi more closely and devised a birth plan that took her condition into consideration.
The death rates are something the country has an obligation to get under control, she said.
“It is a moral question, really,” she said. “These deaths shouldn’t be occurring.”