The Stigma behind Maternal Mortality

The gender and hate note

I like words.  I like how they feel—how they can elicit a sense of being in a time and space we had no right to even imagine we might access.  They are powerful weapons and potent healers.  They weep for us when we are sorry and fly through the air like venom when we want to strike. But words also exist in a little world each unto itself and each one triggers and unfolds many pathways of thinking and perspective for each of us.

I was recently watching a physician reflect on his long career dedicated to improving patient safety and experience through helping providers develop and practice compassion towards each other.  Turns out, as you probably know, compassion is leaky and when providers regard each other and behave compassionately towards each other, patient outcomes improve.  He said a remarkable thing.  He said he had mostly, if not totally, failed at every bid he made to change the larger healthcare system.  Success in small and deeply meaningful arenas, but the system he works in as a whole really hasn’t moved much in this regard.  I pushed pause and watched him again. And that’s when I began to think about words. And about how very hard it is to learn something and then do it without the lens we have moved through our whole lives with distorting what we know intellectually, so that without intentional effort, our behaviors reflect a whole lot more of our intrinsic beliefs than our working knowledge.

This is not a post about how compassionate care might change maternal health outcomes, though it does.

This is not a post to scare you away from birth—I’m a midwife, I practice risk aversion and skills-based prevention for a living.  Birth is not inherently unsafe.  Birthing in a place where you will not be heard, believed, and responded to with appropriate and well-timed interventions is unsafe.  That is what causes “maternal health outcomes,” “morbidities,” and yes, even “mortalities.”  I have seen it first-hand.  I have wept with families and raged against an uncaring, unseeing machine designed to protect doctors from the effects of their own bias.

How do you know about maternal health outcomes?  What phrases do you think of when you think of Serena? Black women die in Childbirth?  Maternal health?  Morbidity?  Mortality?  We use these words and phrases like water balloons to cushion against what we really mean.  Death.  Injury.  Illness.  Long term complex conditions.  All those words have lost their potency—we have found a way to accept and dilute them.

So here’s a word: Stigma.  It sits like a brick in your mouth. It tastes chalky.  It feels like a parched throat. It smells like rotten milk. That’s quite a word. It means a mark of disgrace, a mark of shame, a mark of discredit. A stain “associated with a particular circumstance, quality, or person.” The word stain is particularly interesting when you think about how stains are used in microscopic examination to bring a microbe into sight.  It is both what and how we see when we look at something, or someone.

A recent article has resurfaced regarding Time Person of The Year Salomé Karwah, a Liberian woman and ebola survivor.  The title makes it seem as though she died in childbirth.  She did not.  She was unable to receive emergency treatment for a postpartum complication four days after giving birth because the healthcare workers were afraid of Ebola.  She was a walking stigma in that world.  Don’t judge the healthcare workers who would not help her—read up on the reality of this historically charged experience.  Americans, as we are want to do, missed the point of the story—we projected our own perspective right onto that cover photo.  I have dozens of posts in my social media pointing back to the title of the article with heartfelt statements about “maternal mortality issues.”  The sweep of social media outcry reflects important progress.  It demonstrates that mothers dying in childbirth has crept into the awareness of our broader society—a very good thing.  While we consider this death a tragic and preventable Maternal Mortality, it is, in reality, a Stigma Mortality.  And while Salomé died due to a stigma associated with a terrifying disease, unrelated to why women in the US die during or after childbirth, the idea that Stigma can underlie death in many different settings for many different reasons caught my attention.

And that is what this post is about.  If every time you read a story about childbirth related near-misses or maternal mortality (or for obstetric and public health professionals for every time you hear “maternal mortality” in a meeting), I challenge you to wind that back to the Stigma where it started.

You may find that the often predictable, preventable, knowable, present with symptoms reported by a mother in time to have saved her life had anyone heard, believed, and responded to her, start with Stigma.  Our greatest stigmas in OB hospitals in this country are being a black woman, followed distantly but significantly by any person who veers outside social, economic, racial, or health norms during pregnancy or after childbirth. Nothing is protective for black women against these outcomes—not even their education or income level—because nothing one person can do in their lifetime is protective against or even responsible for the lens of Stigma that others view them through.  Efforts to place and ensure adherence to toolkits for treatment of hemorrhage and high blood pressure in hospitals across America matter. But no checklist will fix the internal, intrinsic beliefs that lead providers to provide less, to listen less, to pull the first trigger that gets that checklist going less–for black women.

And we do not have examples in proximity to work towards because even outcomes for white wealthy women in the US are nothing to aspire to. Between 2000 and 2014, there was a 26% increase in the maternal mortality rate overall. Within those numbers are the confounding realities that today, all women are 50% more likely to die from childbirth than their mothers and that a black woman is more than 3 times as likely to die from childbirth than a white woman.  In his 2002 introduction to Dr. Martin Luther King Juniors’, “Where Do We Go From Here?” speech, Senator Edward Kennedy refers to childbirth disparities in 1967, stating that black women were twice as likely to die from childbirth than white women.  We are still bound up by the effects of our own historical stigmas.  When stated in this way, it is clear we don’t have work to do, we have work we should have done long ago and because we have not, disparities have only increased.

Cause of deathStigma.

Cause of death: implicit individual and systemic beliefs and behaviors that reinforce the idea that a black mother should be discredited BECAUSE she is a black person.

Cause of death:  healthcare entities that allow OR carts to remain unstocked and unqualified residents to play at physicking without intentional, meaningful supervision because it is just fine to let them practice on black bodies.

Cause of death:  Staff that do not engage and then follow protocols for blood loss or high blood pressure in a timely effective manner.  Why?  Because of the stigma with which we cloak and separate the human who is in grave need of excellent healthcare.

Next time you read a story about maternal health outcomes, roll it back and look for the Stigma from which that outcome bloomed, flowered, and went to seed.  Let that word sit with you like a brick in your mouth, like a parched throat, like the smell of rotten milk.  Call it what it is—if at the meetings you attend, in the conversations we have—we choose to call systemic racism and maternal mortality “stigmatization of and dehumanizing black women” maybe we would wake up, face ourselves, and stop talking so much around the real issue. Then we might provide meaningful timely care for the people in our labor and delivery units because we recognize a who in the room deserving of our connected compassion and in need of our very best preparation, protocols, and skills.


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