By Raquel Shulman

Kim Kardashian, Serena Williams, Gwyneth Paltrow, and Beyoncé. Regardless of being characterized as celebrities, these women have something else in common. All four have had traumatic birthing experiences—teetering the outcome of maternal death. This is what is medically known as maternal mortality.

“The maternal mortality ratio is the number of deaths of women during pregnancy and within forty-five days of the birth of the baby,” said Francoise Grossmann, RN, MPH, and Tulane University Clinical Assistant Professor. “In the United States, we have two indicators: pregnancy related mortality and pregnancy associated mortality.” Creating two indicators, these numbers can be compared state-by-state and even county-by-county—revealing patterns and discrepancies. With the ability to categorize types of deaths, the data becomes more specifically applied. This allows for necessary research to be conducted. “Pregnancy related mortality measures death during the pregnancy up to one year after pregnancy that is aggravated by the pregnancy itself. For example, if a woman has high blood pressure, the pregnancy could aggravate the preexisting high blood pressure, possibly resulting in death,” said Professor Grossmann. Measuring a different indicator, “pregnancy associated mortality is death caused by anything up to one year after the birth of the baby. For example, a car accident or homicide.” 

When measuring this ratio more generally, data analysts look at “the number of maternal deaths per 100,000 live births,” said Tylar Williams, Maternal and Child Health Program Manager and Research Coordinator in the Research & Evaluation department of the Institute of Women and Ethnic Studies. Important for research, these more general statistics can help discover maternal care deserts. “A maternal care desert is any county in the US that has no hospital or birth center offering obstetric care and without any obstetric providers,” said Williams. In order to begin to improve these statistics, researchers must first seek out the gaps that need to be filled. “The entire state is not considered to be a maternal care desert, but about 1/3 of Louisiana is considered to fall under this classification. This leads to birthing people receiving inadequate prenatal care,” said Williams. Affecting women across the nation, although the desert concept is extremely significant in Louisiana, it is not unique.  

One of the leading causes of these deserts is the lack of hospital care. According to March of Dimes, most pregnancy-related deaths can be prevented with regular care before, during, and after pregnancy. Without hospitals and birthing clinics, this quickly becomes impossible. This leaves women without the critical medical care they need—leading to the development of fatal undiagnosed conditions before and during pregnancy. As a result, women are not receiving the care they need to survive birthing their children. Through this, maternity wards see many near-death experiences—causing traumatic and emergency Cesarean (c-section) births. Creating the need for surgery, the healing process for the mother is further expended. Additionally, after these surgeries, mothers must stay at a hospital longer—creating further revenue for the institution. Here, it is key to remember that most of these traumatic and fatal emergency surgeries could have been prevented. Due to these deadly deserts, healthy pregnancies are quickly turning into high risk pregnancies. 

“And then I got pregnant at forty-three [years old] with my youngest son… That pregnancy was really difficult,” said Ingrid Jansson, mother of three. “I had pubic synthesis disorder, which is where your body starts creating the hormones that make your ligaments softer too early in the pregnancy. Mine started kicking in at about eight weeks,” she said beginning to tell her intimate story. Known medically as relaxin, this hormone is crucial for preparing soon-to-be mothers for giving birth. Typically releasing towards the final stages of pregnancy, this necessary increase in relaxin release allows for the baby to pass through the mother’s birth canal. Without this evolutionarily developed hormone, women would have never been able to naturally give birth. 

“It was severe pain. I could feel my pubic bones rubbing together, and the doctors just did not know what to do. The doctors said, ‘Oh you’re fine, you are just old. Everything will be fine,”’ said Jansson. Invalidating her pain, doctors disregarded the extra care she needed. Allowing her to suffer in extreme pain throughout the entirety of the pregnancy, this was Jansson’s first experience of being treated “as a number on a list, not a human,” as she said.

 “Hospitals are businesses that are trying to make money. When a hospital is dealing with a population that is poor and uses Medicaid or sparse without enough babies, hospitals will not make enough money to stay open,” said Professor Grossmann. “Maternity care is expensive, and Medicaid reimbursements are low,” added Williams. As corporations, hospitals must have sick and critical mothers like Ingrid Jansson in order to be able to open their doors every day.

Finally reaching full term, “Two days before I went into labor, I had gone to the OBGYN, and he was head down. When I got to the hospital, they never did an ultrasound to make sure he was still head down,” said Jansson, foreshadowing what is to come with her own traumatic birthing experience. “Once I was dilated to ten centimeters, a nurse came in to check me and immediately called for another nurse. The nurses quickly discovered that my son was coming out feet first. He had flipped in the two days since I had seen my OB.”

“Instantly, they announced that they would need to do an immediate c-section at 2:00 am. They were doing the pinprick test to make sure my epidural was working while they were wheeling me into the operating room. It was all very emergent,” said Jansson. “The way that my son was positioned, they still couldn’t get him out. The doctor had to cut a larger incision in my uterus. She ended up cutting my uterine artery, and there was a lot of bleeding.”

After the birth, the work was just beginning. “I had no support at the hospital. I had two kids at home. At that time, they closed the nursery where the nurses would come and take the baby for a few hours so that the mothers could get some sleep,” said Jansson. Now, once her husband had to return home to take care of their two other young children. This left her alone in the hospital just a few hours after emergency surgery. “I had lost so much blood during the c-section that I just felt like I was in a fog. I couldn’t keep my eyes open… At one point, I almost dropped my son off my hospital bed,” she recounted from her time in the hospital. She knew she was not healthy, but the nurses neglected her. “Within the maternal care desert, so many things will go wrong. It is life and death,” added Jansson. Due to this closure in the hospital, she could not receive the care she so desperately needed. 

“The next day, my nurse finally came in and told me that my hemoglobin and hematocrit were pretty low. They acted like it was no big deal. It was not until I asked how low that they offered me the choice of having a blood transfusion… They were leaving it up to me to decide,” said Jansson. Imperative to receive oxygen to vital organs, these two levels were dangerously low in her body. “Until they gave me the blood transfusion, I felt like I was dying. Before the three transfusions, I felt like I was going to go to sleep and not wake up again,” she said.  

Worsening the statistical evidence of maternal mortality, the overturning of Roe v. Wade has contributed to the current rates of maternal mortality across America. According to the Center for Reproductive Rights, when the U.S. Supreme Court overturned Roe v. Wade, they eliminated the constitutional right to abortion. When this occurred in June of 2022, it became up to each state to decide its own laws regarding a woman’s legal right to an abortion. As explained by Grossmann, no woman wants to have an abortion, but for some, it is necessary. “When people don’t have the option to have an abortion, they will still try and have it. Now, in the United States, they will have to travel further away to get an abortion. Or, they will stay in their home states and use more dangerous strategies,” says Grossmann. In states with harsh bans, mothers are resorting to turning to untrained providers and online resources that are not regulated. As a result, maternal care experts have seen an increase in dangerous abortions due to the lack of safe options available from properly trained physicians. 

Adding to the complexity of statistical analysis, Grossmann shares that some states, such as Idaho, have shut down their Maternal Mortality Committees. By doing so, these states are not reporting on the results of their strict abortion bans. As a result, we can not even begin to see the real implications that the reversal of Roe v. Wade has had on the maternal mortality ratio. 

Plaguing some women on a larger scale than others, both Professor Grossmann and Tylar Williams share that in the United States, Black pregnant women are three times more likely to die than their White counterparts. Crucially, “it is important to remember that race is not a risk factor, racism is,” says Williams. Worsening the effects of factors like maternal care deserts and abortion bans, systematic racism adds insult to injury to already depressing statistics.

“Structural racism increases the stress in people from the moment that they are born until the day of death. This high level of stress affects the body and creates added inflammation, aging the body faster,” adds Grossmann. “Basically, the uterus of a 35-year-old Black woman looks much older than of a White woman because of the exposure to higher levels of stress hormones.” This makes the risk of pregnancy rise, as when a woman ages, her pregnancy becomes more risky. Proving Williams’ point, this research shows that consistent structural racism in America leads to Black women being at higher risk for many health complications, regardless of socioeconomic position. 

Beginning to try to improve these jarring statistics, Grossmann explains that research is proving that obstetric bundles are one of the leading solutions to the social issue. Clinically, hospitals can train their nurses and doctors on these bundles and the ways that mothers can safely give birth. The bundles typically include information and supplies for common medical complications during birth and in the postpartum period. These patient care bundles can support medical staff with the proper training they need while making mothers feel safer. “Looking back, I should have advocated for an ultrasound when I got to the hospital. Nobody did one, so I had a baby coming out feet first—which is not safe and not going to work,” said Jansson as she reflected back on her life-threatening experience.

With such overwhelming statistics against mothers birthing in a way that is safe for themselves and their babies, it is no surprise that maternal mortality has grown into a popular field of public health. Expanding into the popularization of doulas and midwives, there can be advocates for patients—especially if they are of the same race or ethnicity as the mother. Removing some of the implicit and explicit biases, having someone of your race care for you provides added safety and comfort. The hope here is that having professional advocates will increase the safety of the mothers and babies in the hospital rooms, preventing traumatic experiences. 

 In hindsight, because the nurses and doctors did not advocate for Jansson, she did not receive the care she deserved. “Nobody cared. I was just a number to get in and out. That is how I felt with all my children… As a registered nurse, it was disappointing and eye-opening,” added Jansson. Feeling the combined effects of maternal care deserts and the business-like institutional structures of hospitals, Ingrid Jansson felt so passionate about her experience that she decided to use her previous training as a registered nurse by becoming an in vitro fertilization (IVF) nurse. Additionally, she also felt inclined to write to the hospital administration about the lack of care she received during the birth of all her children. As an issue that is ongoing, all women remain increasingly vulnerable.