US maternal mortality on the rise

 Kira Johnson gave birth to her second son in April 2016 according to plan: a Cesarean section at a hospital in Los Angeles. Her baby, Langston, was an eagerly awaited child who would complete their family. A few hours after the birth, Kira's husband Charles noticed blood in his wife's catheter and called a doctor over. A blood test and an ultrasound confirmed initial suspicions: Kira was bleeding internally.

She was scheduled for an emergency operation, but it kept being delayed. Again and again, Charles asked when they were going to operate on his wife. "She is just not a priority at the moment," he was told. It was 10 hours after the botched Cesarean that Kira was wheeled into the operating theater for the second time. By then, 3.5 liters of blood had already pooled in her abdomen. She went under the anesthetic and shortly afterward her heart stopped beating.

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Black women three times more at risk

Kira Johnson's is not an isolated case. In the United States, 700 women a year die during pregnancy, in childbirth, or in the months that follow. No other industrial nation has such a high rate of maternal mortality. In Germany, the proportion is less than half this.

Black women in the United States are particularly at risk. All across the country, they are three times as likely to be affected as white women. In certain states, the color of a woman's skin has even greater influence over life and death. Washington DC comes right at the bottom of the ratings.

It is unclear why Kira Johnson was operated on too late for a second time. But there are many reasons why African-American women are disproportionately affected. One is the lack of access to health care, says Aza Nedhari. Nedhari works as a midwife and is the director of Mamatoto Village, a society that runs a birth center in the south of the city of Washington DC. There are four hospitals in Washington with maternity wards, but none are in the south, where the population is predominantly black.

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Unconscious prejudice and lack of health care

Nedhari can look after only a few pregnant women in her birth center, and only if the pregnancy is without complications and the birth spontaneous, i.e. if the child is born naturally. The majority of expectant mothers, especially those with high-risk pregnancies, have to go to hospital for tests and to give birth. Nedhari explains that for most women in the south of the city, this means they have to travel for well over an hour each way. It's also often difficult for pregnant women with insecure jobs, or children, to attend all their check-ups.

Stacey D. Stewart is another who sees the lack of medical care — and affordable care in particular — as the reason why maternal mortality in the US as a whole is so high. Stewart, president and CEO of March of Dimes, an organization focused on the health of moms and babies, is calling for the status of midwives and doulas to be enhanced so that mothers can receive better care in their home districts. Her organization also campaigns for treatments in the first 12 months after the birth to be covered by Medicaid and for insurance coverage not to end with the birth itself.

Stewart says that another reason for the high mortality rate is unconscious bias. In the United States, where it costs around $200,000 (€182,800) to study medicine, there are relatively few black doctors. Research by the public-service broadcaster and by the ProPublica network of investigative journalists in 2017 concluded that African-American mothers often feel they've been treated badly in hospital and that their pain was taken less seriously. "We must confront these ingrained societal conditions in order to improve the health of moms of color," Stewart says. Starting in the fall of this year, her organization is offering training for health workers.

The gynecologist Esther Gamuchirai Madzivire from North Carolina changed the way she dealt with patients after becoming a patient herself. Both her children were premature and required intensive care for months. She, too, often felt that she wasn't taken seriously at the hospital. When she asked questions, she was given off-hand, hurtful responses instead of advice.

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No longer a 'dirty little secret'

Since then, she has been advising women to write lists of questions at home and work through them point by point during the consultation. That invites respect, she says. It also means that, as the doctor, she won't miss anything.

Madzivire is optimistic that the maternal mortality rate in the US will soon start to drop. Many initiatives have started up in recent years, she says, like Mamatoto Village in Washington DC, which is supported by the city council. All over the country, investigating committees are putting together recommendations. Democrat presidential candidates are attempting to making maternal mortality a campaign issue.

"This is a watershed moment," says Madzivire, explaining that it's finally possible to speak openly about maternal mortality and discrimination. In the past, she says, the topic was treated like a "dirty little secret."

However, Aza Nedhari and Stacey D. Stewart don't share this optimism. They're pleased that attention is being paid to the issue, but don't observe any fundamental change. "We would have to have a system where no person is mistreated on the basis of race," says Nedhari. That moment, she believes, is still a long way off. "Until we have a system where racism is no longer a reality that black people have to navigate in this country, we are always going to be treating the symptoms of that cancerous disease."

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