African American women in DeKalb County and across Georgia are three times more likely to die from giving birth than the average American, studies have found.

Maternal deaths is a complex problem that obstetrics professionals in DeKalb are working to resolve.

Rose Horton, DeKalb Medical's executive director of women and infant services, has spent the past year implementing initiatives – like tracking hospital re-admission within three weeks of giving birth, quantifying the loss of blood during childbirth, and other issues – to address maternal mortality and associated factors that result in race-based disparities.

“There is actually racism in healthcare and it’s having an impact on women of color,” Horton told CrossRoadsNews in a wide-ranging interview on May 31. “We need to call it what it is and address it for what it is.”

A mother herself, Horton says one pregnancy-related death is one too many, and that Georgia’s maternal mortality rate for African-American women – 66.6 deaths per 100,000 births – is shameful.

“Poverty is part of the problem, but as we’ve looked at disparity and women of color, even after we factor out education and we factor socio-economics and salary, there’s still a larger number of women of color who’re dying,” she said. “There’s still that race factor.”

On a whole, the United States isn’t doing well either.

The nation’s maternal mortality rate has been steadily increasing, in contrast to almost every other industrialized nation, to 20.7 deaths per 100,000 births in 2018.

Nationwide, the rate among black women is more than double – 47.2 deaths per 100,000 births.

The U.S. Centers for Disease Control and Prevention says the national rate of maternal mortality among black women has been three to four times that of white women for more than a century.

Although the troubling trend isn’t exclusive to Georgia, the state also has the undesired title of having the highest maternal mortality rate of any state in the U.S. – a whopping 46.2 deaths per 100,000 births. It is also more than double the national rate.

By contrast, California, the safest state in the country to give birth in, boasts only 4.5 deaths per 100,000 births.

California is also one of a handful of states seeing an annual decline in maternal mortality.

In Georgia, and throughout much of the country, the opposite is true, despite medical and technological advances.

Georgia’s rate has increased by about seven deaths per 100,000 births since 2016, when it was 39.3.

The most recent detailed data for 2013 shows that 79 women in Georgia died giving birth. Just over half were Medicaid recipients and 37 of them, or 47 percent, were black.

Seeking a solution

During her two years at DeKalb Medical, Horton said one woman has died giving birth at the hospital. She said it is impossible to eradicate maternal mortality completely. There will always be the risk of some unforeseen medical issue or freak accident, she said.

“We’ve been very fortunate here at DeKalb Medical,” she said. “Our outcomes are very good, but I think it’s because of what we’ve put in place.”  

Horton said the patient who died during labor was doing well until she sat up in bed, clutching her chest after getting an epidural. The amniotic fluid bubble had traveled up into her lungs, she said.

“We called a code, we started compression, we oxygenated her,” Horton said. “There was absolutely nothing that we could do.”

Horton says the current national rate of maternal deaths, and especially that in Georgia, is nowhere near good enough.

“Fifty percent of maternal death is preventable,” she said, “but I feel very hopeful and optimistic, and I have every confidence that things will improve.”

Horton is behind several new DeKalb Medical initiatives  focused on improving maternal mortality rates in the medical center, in DeKalb and statewide.

Each year, about 4,800 women give birth at DeKalb Medical’s obstetrics facility on North Decatur Road.

Through a new focus introduced last year, any woman who is re-admitted to the hospital within six weeks of giving birth there is housed within the obstetrics department, to ensure continuity of care and to ensure that id  re-admission has anything to do with the pregnancy, it can be addressed and tracked by obstetricians and other members of the medical team.

“Previously, a woman could be readmitted to the ICU or main emergency department after giving birth and we’d never know or be able to connect the dots,” Horton said. “She may even die and we’d never know.”

Given that postpartum hemorrhage is one of the most common causes of pregnancy-related death, Horton and her staff of about 250 medical professionals have also started quantifying women’s blood loss during birth, rather than estimating it.

They now collect the blood that’s lost during birth and weigh any bloody materials for a more accurate gauge.

It has been a revelation.

“We found that our estimates were very low, meaning staff were severely underestimating women’s blood loss until recently,” Horton said.

Addressing racial bias

Horton isn’t stopping at quantifying blood loss. She is implementing best-practice guidelines and toolkits developed in California, and has created the social media campaign #notonmywatch.

Horton, who is African-American, is also attempting to address racial bias among her staff.

All 21 members of her leadership team have taken an implicit-association test on race to help them identify their biases so they can be aware of whether they let that affect their decision-making about patients.

The results were surprising, Horton said.

One black employee has a bias favoring white people, while another favors other people of color.

Horton herself found that she had no bias between black or white – something she didn’t expect as a woman of color herself.

She now wants her entire staff to take the test, and is trying to convince all DeKalb Medical’s physicians to follow suit.

“I think it’s important to understand your own personal bias, and we all have bias,” Horton said. “It’s really compelling data that’s showing us that bias and racism is impacting our decision-making and our patients.”

She points to a couple of recent examples.

Last year in Atlanta, despite a relatively uneventful labor and repeated postpartum doctor’s visits, 36-year-old Shalon Irving, a black epidemiologist at the CDC, died from high blood pressure complications three weeks after giving birth to her daughter Soleil. She had been to the doctor multiple times but was not properly diagnosed.

Horton, and many others, suspect that if a white woman had been to the doctor multiple times in the three weeks after giving birth, complaining of things like high blood pressure and one leg being bigger than the other, there likely would have been a different response.

“It’s really sad,” Horton said. “There were so many opportunities to intervene and no one intervened on her behalf.”

Horton said that tennis champion Serena Williams also almost became a statistic when giving birth to her first daughter, Alexis Olympia, in September 2017.

When contractions began, the baby’s heart rate plunged and an emergency cesarean section was successfully performed. But Williams, who is predisposed to blood clots and who stopped taking her blood-thinning medication in order to heal, knew something was wrong the following day.

She flagged down a nurse, insisting she needed an IV with heparin, a blood thinner, and a CT scan to check for clots.

A doctor instead performed an ultrasound, which revealed nothing, and it was only due to 36-year-old Williams’ persistent demands that a CT scan was finally performed – revealing several small blood clots in her lungs.

Horton believes that had she been white, Williams would likely have received a CT scan at her first insistence.

“I would speculate that Serena Williams suffered from racism,” she said.

A better future

Horton encourages all pregnant women to be their own vocal advocates when it comes to their health and how they feel.

She says the two biggest things a woman of any race can do to minimize risks associated with pregnancy is to eat and live healthily, and to speak up when something’s not right.

Horton says gone are the days of eating for two while pregnant and gaining 40 pounds.

There are so many health issues associated with being overweight that doctors recommend pregnant women stick within the normal weight gain of 15 to 20 pounds.

“It’s important to stay away from things like lots of sugar, sodas, fats and salt, and drink enough water,” Horton said. “It is multifaceted and complex but I do think eating nutrient-dense food and being as healthy as you can is vital.”

She urges all women – especially pregnant ones – to make sure medical professionals listen to them when they feel ill for whatever reason, as even a simple problem can have dire consequences if neglected.

“It’s important for women to really understand their bodies and speak up or make sure their spouse or partner or a family member can speak up for you,” she says.

Horton arms her patients with information, including post-birth warning signs developed by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).

Despite the concerning maternal mortality rates in Georgia and throughout America, she says things will improve.

Horton has signed up DeKalb Medical as a member of the Georgia Perinatal Quality Collaborative, which since 2012 has worked to identify and implement quality improvement strategies to improve maternal and neonatal care and outcomes statewide.

She says that as more medical organizations join the effort, and the more obstetricians and medical staff talk about maternal mortality, the better the outcomes will be for all women.

“I do think that any change causes a ripple and I want to be part of that ripple that makes it even larger for the state of Georgia,” she said. “We’re in the era of women speaking their truths and this is the perfect time to talk about it and bring attention to it.”