When Tatia became pregnant in 2001 — just a year after earning her Ph.D. in child psychology and marrying her husband — that glow magnified.
The blissful newlyweds, who lived in Oakland, California, were excited about having a baby girl. They’d even chosen her name: Zorah Allie Mae French.
Around that same time, “she had applied to several medical schools and it was looking like she would get into one,” Oden said about her daughter. “She was super smart.”
Tatia, 32, had a healthy pregnancy but at nearly two weeks past her due date, she still hadn’t gone into labor. Her doctor and nurses told her it was time to induce labor, said Oden, who still lives in Oakland.
Tatia was hesitant to be induced.
“When I asked her what was wrong in terms of trying to make this decision — because she usually didn’t have problems making decisions after she considered everything — she said that she just didn’t like their attitude,” Oden said, adding that she and her daughter both felt like the medical team was more focused on pushing for induction than hearing Tatia’s concerns.
Still, Tatia eventually agreed, and with the soon-to-be parents at the hospital, Oden went home to get some rest before her grandbaby was born.
Around 4 a.m., Oden woke with a feeling that something was wrong.
“I was in the kitchen making coffee and my son-in-law called me and said,’You have to come to the hospital right away. They’re going to do an emergency C-section,'” Oden said.
When Oden arrived at the hospital, she went to the room where she had last seen her daughter. There was no longer a bed in the room. Only her son-in-law.
“I said ‘Where’s Tatia?’ And he said, ‘She’s gone.’ I said, ‘Gone where?’ And he said, ‘She’s gone,'” Oden said. “Then I realized what he was talking about.”
On that cold and rainy December day — just three days after Christmas — Tatia became one of the nearly 600 women who died due to childbirth or pregnancy in the United States in 2001.
In the years since Tatia passed away, statistics on maternal deaths, especially for black women like her, have only gotten worse.
Hundreds of US women die each year in childbirth
The CDC report also found that the maternal death rate among non-Hispanic black women was 37.1 deaths per 100,000 live births, a rate up to three times the rates for white and Hispanic women — and that disparity increases with age.
“It gives us more evidence and more confidence that these maternal mortality rates that we’re seeing in the United States — that are still higher than those of our peer countries — truly represent a critical public health issue and serious concern for the health of women.”
The United States continues to have the highest maternal death rate of all developed countries, according to researchers.
Experts have noted that the racial disparity in maternal deaths remains even despite the mother’s income and education level.
Researchers often point to differences in levels of stress, community health and implicit bias, including variations in the ways in which health care is delivered to black versus white women despite their income, education and health care access.
“In hearing the stories of women who have gone through pregnancy and had a bad outcome but survived, one of the underlying themes is that they voiced their concerns … and they didn’t feel listened to or they felt their concerns were dismissed,” Johnson said.
“We need to own the fact that the practice of medicine is not immune to the influences of implicit and explicit bias.
“Race is not the risk factor,” Johnson said. “Racism is the risk factor.”
And perspectives are starting to change.
States, including California where Tatia lived, are tracking maternal deaths. Doctors are training for birth emergencies. And black women — the ones most likely to die due to pregnancy or childbirth in the United States — are speaking up.
Could California hold clues to reducing maternal deaths?
Five years after Tatia and her baby died in a California hospital, the state formed a maternal death review committee as reports of maternal deaths emerged across the state.
Between 2006 and 2013, California saw maternal mortality decline by 55%, even as the national maternal mortality rate rose, according to the collaborative’s website.
“We are one of the few states that has actually seen a decline.”
Hemorrhage carts were first promoted in California beginning in 2010, Main said. The carts were then promoted nationally a few years later.
“Currently over 95% of California hospitals have carts,” Main said.
Hemorrhage carts are similar to crash carts used for a cardiac arrest, and are stocked with medicines to slow bleeding, instruments to repair lacerations, intrauterine balloons to apply pressure and manage bleeding from a uterus that isn’t contracting normally, among other tools. Medical teams train and rehearse how to use the carts.
For such efforts and practices to be taken nationwide, however, requires a shift in thinking, said Dr. Lawrence Lurvey, regional assistant medical director of Quality, and Women and Children’s Health for Kaiser Permanente in Southern California.
“If I went back to residency — let’s say 25, 26 years ago — there was a sense in obstetrics that bad things happen and that you couldn’t do anything about it. That’s absolutely not the case anymore,” Lurvey said. “This work takes time and Kaiser Permanente has been at it for many years. A big integrated system such as ours has some advantages when it comes to standardization and data gathering.”
Dr. Michael Fassett, a CMQCC committee member and perinatologist, remembers after the collaborative first launched, he tracked data on maternal health outcomes in his hospital, Kaiser Permanente in West Los Angeles.
“I could see as I collected data, month to month to month, that things were changing,” he said. “It was pretty dramatic.”
California was also one of the first states to enroll in the Alliance for Innovation on Maternal Health or AIM, a nationwide initiative to reduce maternal mortality. It launched in 2014 with the national goal to reduce maternal mortality in the United States by 1,000 cases and severe maternal morbidity by 100,000 instances over a four-year period. Maternal morbidity is any illness or condition related to pregnancy or childbirth.
As part of the initiative, AIM established tools and protocols for hospital systems and other health care settings to adopt to help prevent pregnancy- or childbirth-related emergencies. But AIM didn’t reach its goal in 2018 and its work continues. The goals were originally set with the assumption that all 50 states would adopt AIM’s safety bundles, said Main, a member of the original AIM team.
“What we’ve also learned is that it takes time, a longer time, for the state infrastructure to be built, the data to be collected, and all of the hospitals to be engaged to achieve the full impact of a quality improvement project,” Main said.
‘When something goes down … people become silent’
Still, while the California numbers show some improvement, they are not cause for celebration, said Deborah Allen, deputy director of the LA County Department of Public Health’s health promotion bureau.
“One of the things that you find in places like Los Angeles — and many other parts of California — is that where you have very advanced health care, what you may see is that women who have extreme health crises around the time of delivery don’t show up as deaths because they get saved, but it still raises questions about what got them to that point of emergency,” Allen said.
“Certainly averting deaths is a very positive thing, but seeing it as completely cause for celebration without looking at severe maternal morbidity around the time of birth is an important question,” she said. “That’s one caveat that we have to be careful that we’re not just looking at our ability to save people before they bleed to death.”
Additionally, the racial disparities between white and black women in both Los Angeles County and California as a whole remain.
“I don’t think anyone can be too enthusiastic about what gains we’ve made until we confront that inequality,” Allen said.
Another caveat: studying maternal deaths in general can be challenging and there can be some limitations with data collection and surveillance — including that some hospitals are hesitant to promptly report a maternal death prior to its own internal investigations, which would be needed to track deaths and their causes, said Alice Benjamin, a clinical nurse specialist based in Los Angeles
“There’s not a culture in the health care community that allows us to freely, without stigma, be able to share and learn from each other,” Benjamin said. “Even if those data are shared with the CDC and state department of health, they don’t go to other peer health care providers or entities to learn. Many times non-disclosure agreements in settlements preclude the very details we need to learn from, from ever being shared.”
As a black mother, Benjamin says that her hope for the future is for greater attention to be paid to women’s health overall — and for hospitals to have better reporting and surveillance systems when it comes to maternal mortality.
“Information is good, but it’s only as good as what you’re going to do with it and that’s where I get frustrated,” she said.
“What happens once you do identify cases? What are we doing internally to actually change things? Where’s the bite in the bark?
“As a clinical nurse specialist, I got to see many types of the medical errors, snafus and near misses. … And it’s not uncommon when something goes down, even in the most reputable institutions, people become silent.”
‘Nothing went according to my plan’
“At 32 weeks I was going in for my routine check-up and that’s when the doctor wanted to do further tests. She was noticing some things that were concerning her and so she sent me over to the hospital right away to be further monitored,” Felix said.
She was admitted to a hospital in California, near where she lives.
“And that’s when things quickly went downhill,” she said.
Doctors noticed that Felix had extremely high blood pressure and they diagnosed her with a severe case of preeclampsia, characterized by the development of high blood pressure and protein in the urine or other problems during pregnancy and other symptoms. Women with preeclampsia are at increased risk of organ damage or failure, preterm birth, pregnancy loss and stroke.
“It was just really scary. I had never imagined myself in that situation,” Felix said. “The doctor came in and let me know it was an emergency situation and we were going to have to do an emergency C-section so that both me and Camryn could make it.”
Felix’s daughter Camryn was born early on that day in early December and she spent a month in the hospital’s neonatal intensive care unit.
Felix said that she did not know to look for signs of preeclampsia — which could include headaches or swelling of the hands and face — or that being African American put her at higher risk.
“It was just this eye-opening experience that it doesn’t matter how great of medical care you have or you could be of privilege and still be in this situation,” Felix said. “This is a problem that women of color are facing.”
Felix returned to training on the track after giving birth, but she also became a maternal health advocate.
“When I thought about starting a family and what it looked like to come back to training, I had this perfect plan in my mind. I thought everything was going to go smoothly. I thought I’d be back on the track four weeks after birth and nothing went according to my plan,” Felix said.
Since then, there’s been a step in the right direction, she said, referring to the California bill requiring perinatal health care providers undergo implicit bias training.
“I would love to see more of that across the country,” Felix said.
It may be starting.
In March, a group of lawmakers — led by Illinois Rep. Lauren Underwood, North Carolina Rep. Alma Adams and California Sen. Kamala Harris — introduced bipartisan legislation in Congress aimed at reducing the maternal death rate in the United States.
The measure, called the Black Maternal Health Momnibus, is composed of nine bills, some of which support “a 12-month postpartum Medicaid coverage expansion, investing in rural maternal health, increasing the diversity of the perinatal workforce — so that would be your physicians, midwives, doulas — and implementing implicit bias training,” Underwood said. “We have until the end of the calendar year to do this work in the 116th Congress.”
Doulas as a solution
Some experts point to doula care as being one way to reduce the racial disparities seen in maternal health — and such action has been taken on the county-level in California.
Black patients are often prescribed less pain medication than white patients, several studies suggest. Whereas, doula support during childbirth can help reduce levels of discomfort for the mother as a doula might suggest practices during labor to ward off pain.
In Los Angeles, “our goal is to serve African American women and families with birth doula services, provided by African American doulas. We now have a team of 12 doulas,” said Helen O’Connor, health program analyst for the LA County Department of Public Health.
She added that the program’s success will be measured by whether the program is associated with a reduction in preterm birth and C-section rates among women and the use of certain interventions in hospitals that could signal there was a maternal health problem.
The program has a focus on specific communities in the county: South Los Angeles, the South Bay, Antelope Valley and San Gabriel Valley.
“Usually the only women who get doula care are women who can pay for it,” said Allen of the LA County Department of Public Health.
“We’re both trying to increase the workforce of African American doulas and provide subsidy for African American doulas we contract with to serve women in the black community,” she said.
Allen added that “there is no biological reason” for black women to die more often than white women in pregnancy or childbirth.
“There is a combination of factors at work there, all of which speak ultimately to social inequality,” she said. “There’s a particular message for black women and that’s don’t bear the burden yourself. If you’ve had an adverse birth outcome, don’t assume it’s your fault. Recognize that in a society with inequality, you are subject to stress and that you need support for that stress.”
A mother mourns — and takes action
Oden launched the Tatia Oden French Memorial Foundation in 2003 to raise awareness around maternal health risks.
“Women of color specifically, and definitely in labor and delivery, are treated much different than white women, and the reason is that a lot of people in the medical profession are culturally incompetent,” Oden said. “They have this idea that people of color, African American women, can withstand more pain than white women.”
It notes that while pregnant women may be offered misoprostol to induce labor or decrease blood loss after childbirth, “these uses are not approved by the FDA. No company has sent the FDA scientific proof that misoprostol is safe and effective for these uses.”
Oden became a doula.