The letter arrived in December, nearly two years into a new program aimed at tackling the high rate of women in Louisiana who die from pregnancy.
A nurse at Natchitoches Regional Medical Center wrote that a pregnant woman had arrived for a C-section and, after the procedure, began to bleed heavily. The woman’s blood carried rare antibodies and the closest blood bank was 60 miles away. But because the hospital had implemented a new program aimed at tackling just such a scenario, staff were prepared with the training — and blood on hand — that they needed.
“The outcome could have been much different,” the nurse wrote, if not for the Safe Births Initiative.
It’s the kind of story that’s become increasingly common, said Amy Ladley, the program manager for the Louisiana Perinatal Quality Collaborative, which runs the initiative.
The program mixes training calls, in-person education and drills to give hospitals the most up-to-date best practices. Ninety-two percent of hospitals across the state have joined.
We tend to treat pregnancy and birth as predictable — but it’s far from it.
“As I say a lot of times to my patients, in obstetrics, no kidding, things go from good to bad very quickly. And so you have to be prepared,” said Dr. Veronica Gillispie, an OBGYN and the Perinatal Quality Collaborative’s medical director.
With the program, “what I've seen is that we are better prepared for high-risk patients like that, not just high-risk patients, low-risk patients as well.”
The Safe Births Initiative launched in 2018, after the state found that Louisiana had one of the highest rates of maternal mortality in the nation, and that black women were dying at four times the rate of white women, said Rebekah Gee, the former secretary of health.
“And so we resigned ourselves to address this and made a committed commitment that by Mother's Day in 2020, we would reduce by 20 percent the leading causes of maternal deaths that are preventable, and those are heavy bleeding, and management of high blood pressure,” Gee said.
The initial results are striking. From 2016 to late 2019, severe hemorrhaging declined by nearly 40 percent. Serious high blood pressure complications fell by 22 percent.
“These numbers and this type of level of reduction is almost unheard of in hospital settings for initiatives like this,” Gee said.
But on one key measure, the program has fallen dramatically short. Racial disparities between black and white women have not budged. Gillispie said the ratio has two key driving factors: “It's implicit bias and structural racism.”
The latter weaves a centuries-old web of barriers that impact health, including access to health coverage and care, poverty and education. The department of health found that 62 percent of maternal deaths were women who had Medicaid insurance.
The initiative has been working especially hard on implicit bias, but it hasn’t been easy. When it had its first meeting on maternal disparities, Gee said, “We had several members of a couple of the hospital teams who walked out of the room, just weren’t comfortable talking about race.”
Gillipsie was on the panel at the time.
“We were just talking about, I mean, equity, the difference in healthcare disparities and health disparities, the difference in equality and equity, you know, just giving basic definitions,” she said.
Those conversations have slowly become less factious.
The coronavirus pandemic has highlighted dramatic racial health disparities, but awareness among black women was already heightened by a series of high-profile stories in national media declaring that being black and a mother is a matter of life and death, and singling out Louisiana as a particularly deadly state. The state has the second-highest rate of maternal mortality in the U.S., according to the National Center for Health Statistics.
Gillespie now has pregnant patients asking her if they're going to survive.
“Asking me, ‘Are you going to be there? If you're not there, am I going to die? What's going to happen? I'm hearing about all these black women dying. Am I gonna die giving childbirth?’” she said. “And their feeling is legitimate. Their feeling is real. And it's hard to address it.”
She reassures patients that the state has been working on the problem, that hospitals have been standardizing care. But the fears are deep-rooted.
“In the black community, there's distrust of the medical system in general, way back from the Tuskegee experiment,” Gillispie said.
It seems to patients that harm is inevitable, but the overall maternal mortality rate in Louisiana is about 23 deaths per 100,000 live births. Maeve Wallace, a Tulane University researcher who studies maternal health, recently published a paper showing that homicide is the leading cause of death among pregnant and postpartum women in Louisiana. The research also found links between violence and health outcomes overall.
“Not only is living in a violent context increasing women's risk for homicide during pregnancy and postpartum, but it's increasing maternal mortality, which by definition includes only obstetric causes of death,” Wallace said.
That pregnancy increases the risk of violence and death is not new, she underlined, but it does point to the need for states to think broadly about how to improve maternal health — beyond what happens in a hospital.
It’s a sentiment shared by Nikki Hunter Greenaway, a nurse who specializes in making home visits and providing community outreach for women of color who are pregnant. Greenaway is part of the NOLA Maternal Health Coalition, and she says the failure of the Safe Births Initiative to impact disparities between black and white pregnant women shocked her.
“It hit me hard. Like, it hurt. It really did. I was like, what, what are we missing?” she said.
And she sees another problem.
“I think there is a gap between hospital care and community care,” she said. “For whatever reason, hospitals are very resistant to reach out to the community and get the pulse on how can we help our families moving forward. How can we set them up for success where they're not just surviving, they're thriving?
“But also: I need people to give a damn about black women.”
She’s had patients sent home with high blood pressure or preeclampsia but with no blood pressure cuff. When she convinced one patient, who had a blood pressure reading of 183, to go to the hospital, she was sent home with medication, but no follow-up plan, no referral to a cardiologist, Greenaway said.
“And I'm like, do they want her to die? And I can't help but think about things like this,” Greenaway said.
She worries about the coronavirus pandemic’s impact on health access, that because so much care has shifted to telemedicine, communities without access to the necessary technology will be left behind. As a result, she worries the pandemic could actually cause health disparities to rise.