Barriers to prenatal health care in DC endanger women

In part five of ‘America left behind,’ Al Jazeera explores why the US is failing to reduce its maternal death rate

Megan Hollis, a medical director with the nonprofit Community of Hope, gives a prenatal checkup. While maternal deaths have declined globally since 2000, they have risen in the U.S., in part because many women enter pregnancy in poor health and don’t receive adequate prenatal care.
Caroline Preston / Al Jazeera America

At the end of this year, the targets set by the United Nations in 2000 for developing countries will expire. In this project, we take those Millennium Development Goals and examine how some communities in the United States measure up. We have applied each goal to the U.S. by looking at an indicator used to measure a country’s development success and interpreting it for a specific community in America. The eight goals are: eradicate extreme poverty and hungerachieve universal primary education, promote gender equality and empower women, reduce child mortality, improve maternal health, combat HIV/AIDS and other diseases, ensure environmental sustainability, and develop a global partnership for development. In this piece, we look at why maternal mortality is high in Washington, D.C.

The sonography clinic at Mary’s Center, a nonprofit health organization in Washington, D.C. Many of its patients are late to care, meaning they don’t receive prenatal services until their second or third trimester.
Caroline Preston / Al Jazeera America

WASHINGTON — It’s a little before 11 a.m. at the sonography clinic at Mary’s Center, a nonprofit health group that serves low-income patients across Washington. Janet Buruca, a 22-year-old mother of two boys, is filling out paperwork for the government nutrition program WIC as she waits to enter the small, windowless room to her right. There, the sonographer will press a device called a transducer against Buruca’s belly, screen for fetal abnormalities and register her baby’s length, weight and sex.

In a chair a few feet away, Delmy Magaly Aguirre reports that, after weeks of constant nausea and vomiting, she’s feeling better as she enters her fifth month of pregnancy. A petite woman with long black hair pulled back in a high braid, she left her hometown in Honduras after the sixth grade. She found a job cleaning houses but quit after having her first child, a boy, at age 20.

Now 26, she lives down the street from Mary’s Center, in the Adams Morgan neighborhood in northwestern Washington, and started going to the facility for care after walking by its blue and white sign. Like Buruca, she is hoping for a girl, though she has picked out only a boy’s name (Hernán) because she doesn’t want to jinx her chances. “If the baby’s healthy,” she says through an interpreter, “I’ll be happy.”

Buruca and Aguirre are there for their second-trimester ultrasounds, after each sought medical aid early in their pregnancies. They have received monthly checkups, nutritional advice and other support designed to ensure their health as well as their baby’s. But many of the women at Mary’s Center serves are late to care, meaning they don’t receive prenatal services until well into their second or even third trimester. Many expectant mothers are unaware of their health care options, distrustful of the system or unwilling or unable to keep appointments. Although most low-income women in the district, including undocumented immigrants, are eligible to apply for Medicaid when they become pregnant, bureaucratic and paperwork delays sometimes mean they don’t get coverage until their sixth or seventh month. High levels of poverty, homelessness and substance abuse add to the challenges.

Under the U.N. Millennium Development Goals, benchmarks set 15 years ago to reduce global poverty by 2015, member nations were expected to achieve universal access to prenatal care and reduce by three quarters the number of women dying in childbirth. Globally, maternal deaths dropped by nearly 44 percent since 1990, shy of the goal but still significant. By contrast, progress in the U.S. has been nonexistent. The number of pregnancy-related fatalities nationally has actually increased slightly in that time, according to a recent U.N. report, with black women dying at up to four times the rate of white women. In Washington, as in some other high-poverty urban areas, the numbers are particularly stark. Since 2005, an estimated 32 women (all but one of them black) have died from pregnancy-related causes, according to the National Center for Health Statistics, or NCHS. That’s approximately 40 deaths per 100,000 live births, which is nearly three times the rate nationally and slightly higher than in Mexico.

“The U.S. takes such pride at being at the front of so many medical breakthroughs, but it continues to tolerate systemic failures and a haphazard approach to maternal health care,” says Rachel Ward, the senior director of research for Amnesty International U.S. and a co-author of a 2009 report, “Deadly Delivery: The Maternal Health Care Crisis in the USA.” 

‘Many of our sickest patients may not realize until quite late in their pregnancy that there are problems or complications, because they haven’t been attending routine care.’

Melissa Fries

MedStar Washington Hospital Center

The report, along with other research, suggests the problem is manifold. Many women in the U.S. enter pregnancy in ill health, suffering from diabetes, hypertension and other conditions that can complicate childbirth. A shortage of obstetricians, a lack of hospital protocols around postpartum care and high rates of cesareans (roughly a third of births, twice the rate recommended by the World Health Organization) may also play a role, according to some medical experts. The Centers for Disease Control and Prevention estimates that approximately half of maternal deaths, from conditions such as hemorrhage and pre-eclampsia, could be prevented through early diagnosis.

“Many of our sickest patients may not realize until quite late in their pregnancy that there are problems or complications, because they haven’t been attending routine care,” says Melissa Fries, who chairs the department of women’s and infants’ services at MedStar Washington Hospital Center, a facility in northwestern D.C. that serves many high-risk patients.

That hospital, the city’s largest, recorded two maternal deaths in the past year, she says. In one case, a healthy woman died of an amniotic fluid embolism, a rare condition in which the fluid surrounding the fetus enters the mother’s blood stream and triggers an allergiclike reaction. The second case involved a young, HIV-positive woman who was suffering from several infections and then developed sepsis. She ultimately died when an infection reached her brain. Pregnancy wasn’t a direct cause of her death, Fries says, but it may have been a contributing factor.

A former Air Force doctor, Fries is one of a number of medical professionals working with the D.C. government to establish a maternal health review board to study the problem. In its 2009 report, Amnesty found that 29 states and D.C. lacked such an oversight mechanism. That’s despite evidence that reviews can help reduce fatalities. After creating a review board in 2006, California saw its maternal deaths drop from 17 per 100,000 live births that year to 7.3 in 2013, according to Christine Morton, a Stanford University research sociologist and a member of the group. She attributes the decrease in part to the introduction of statewide protocols for how hospitals respond to postpartum hemorrhages.

In Washington it has been hard to focus political will on maternal deaths, doctors there say, in part because the numbers are small compared with some other types of fatalities. With a population of roughly 658,000, D.C. sees only a handful of maternal deaths each year; by contrast, there were 62 infant deaths in the city in 2013, according to NCHS estimates. And the city’s Department of Health says the maternal mortality rates among D.C. residents are roughly half those provided by the NCHS — just two per year, on average. The NCHS data capture women who receive care in the city but don’t live there, the city government says. Washington, the CDC’s Pregnancy Mortality Surveillance System and state governments sometimes do additional analyses of death certificates to cull cases in which pregnancy may not have been a direct cause of mortality; that can result in lower figures.

Still, city officials acknowledge a problem. “In our eyes, one death is one too many,” the city government said in a statement. “We are committed to addressing maternal mortality more formally in the coming year so that our residents have more information surrounding the risks.” The Health Department and the mayor’s office declined to comment on specific plans, but doctors involved in discussions about a review board say they expect the city council to introduce legislation next year to allow its establishment.

Natasha Williams, left, says she suffered from an infected cesarean section after delivering her first child 11 years ago. Today she is pregnant with her third child and hopes to one day become a doula, or birthing assistant.
Caroline Preston / Al Jazeera America
Williams and other expectant mothers listen to a breast-feeding presentation during a prenatal class at the Community of Hope clinic in the Anacostia neighborhood of Washington.
Caroline Preston / Al Jazeera America

Any assessment of fatalities needs to examine the racial divide in care, say nonprofit officials and midwives. Aza Nedhari, the executive director of Mamatoto Village, which provides prenatal support services for low-income mothers, says her African-American patients on Medicaid receive different treatment from that given to the more affluent mothers she serves through the for-profit side of her midwifery business. “It’s a very clear-cut distinction,” she says, noting that if her black patients question having labor induced or receiving c-sections, they’re more likely to have their concerns dismissed. She recounts a case of a new mother who was sent home from the hospital with an infected cesarean wound, even after Nedhari pointed out the infection to doctors. The woman visited a second hospital a few days later, where she was sent back into surgery and told that if she had been older and in ill health, the infection would have killed her, Nedhari says.

Natasha Williams says she had complications from a cesarean with her first child, 11 years ago. A cheerful, self-assured woman who wears red eye shadow and her hair in coils above her head, she said a wound became infected two days after surgery. “That scared me,” she says. At the time, she was 18, a recent graduate of Eastern High School in northeastern D.C. Six months into her pregnancy, the child’s father, a former classmate in junior high, was shot and killed — one of 198 homicides in the city that year.

Exposure to traumatic events such as gun violence is pervasive among the women served by Community of Hope, a nonprofit health clinic, at its new facility in Ward 8, the city’s poorest section. On a recent Tuesday afternoon, Williams was among eight expectant mothers attending a class called centering, a group session for at-risk pregnant women. Over grilled chicken on paper plates, the women discussed dental care and breast-feeding. “Does it hurt?” “Can I still drink?” “How long can I do it for?” they asked Tina Pangelinan, the nonprofit’s lactation educator.

Eight months pregnant with her third child, Williams is starting over again after a recent bout with homelessness. She spent six weeks this spring at a Quality Inn through the city’s homeless services, then found an apartment a few blocks from the clinic through a rapid rehousing program run by Community of Hope. After her difficult first pregnancy, she has become educated about birth options. She goes to class with her doula, or birthing assistant, in tow, and says she hopes to one day become a doula herself. Ebony Roebuck, the director of midwifery at Community of Hope, says the group dynamic can help women overcome fears of childbirth and of taking a new baby home. Moms with more experience, like Williams, sometimes provide examples for younger women. “For this population in particular, there’s not any exposure to positive coping mechanisms, and this is a way to show positive behaviors,” says Roebuck.

At Mary’s Center in Northwest Washington, first Buruca, then Aguirre emerge from the sonogram room. They embrace; both women learned they’re having girls. Buruca whips out her cellphone to tell her husband. Aguirre will see her partner tonight, after he finishes his day at the tree-trimming company where he works. She hasn’t seen her mother in Honduras in nearly a decade, but she plans to call her to tell her the news. Perhaps her mother will someday visit and hold her grandchildren in her arms. First, though, Aguirre has to get through the rest of her pregnancy.

These 45 countries have lower maternal mortality rates than the US

The World Bank defines maternal mortality as the death of a woman while pregnant or within 42 days of the termination of her pregnancy, from any cause related to her pregnancy.

Country Name Deaths per 100,000 live births
Finland 3
Greece 3
Iceland 3
Poland 3
Austria 4
Belarus 4
Czech Republic 4
Italy 4
Kuwait 4
Sweden 4
Switzerland 5
Spain 5
Israel 5
Japan 5
Norway 5
United Arab Emirates 6
Australia 6
Germany 6
Denmark 6
Slovak Republic 6
Belgium 7
Canada 7
Cyprus 7
Montenegro 7
Netherlands 7
France 8
Croatia 8
Ireland 8
Macedonia, FYR 8
Estonia 9
United Kingdom 9
Libya 9
Malta 9
Slovenia 9
Lithuania 10
Luxembourg 10
Portugal 10
Singapore 10
Bulgaria 11
Bosnia and Herzegovina 11
Korea, Rep. 11
New Zealand 11
Kazakhstan 12
Saudi Arabia 12
Qatar 13
United States 14

Source: The World Bank

Note: Data current as of December 2015.

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