“Dr. Forna, I’m not going to die this pregnancy, am I?”
“No, ma’am. You’re not going to die this pregnancy. Not on my watch! We are going to do everything we can to keep you safe.”
I’ve had this conversation with pregnant women many times in my over 20-year career as an obstetrician-gynecologist (OB/GYN). Still, they have become more frequent in the last few years as more stories of Black women dying during pregnancy are being given attention.
Stories like Shalon Irving’s, a researcher at the CDC who died three weeks after she delivered her baby. She saw her doctors and nurses multiple times for blood pressure complications after delivering her baby, but her concerns were dismissed, and her worrisome symptoms were ignored.
Or Kira Johnson’s, whose internal bleeding after her cesarean section was overlooked by her doctors and nurses for hours and whose husband’s concerns about her condition were dismissed. When she received medical intervention, it was too late to save her life.
The United States has the highest maternal mortality of any industrialized country in the world, and it’s a much worse crisis for Black women, who are dying at alarming rates.
Black women are three times more likely to die than white women during and after pregnancy due to disparities in socioeconomic status, health status, and ability to afford or access health care. They also face the additional hurdles of systemic racism and discrimination that affect their access to care, health status, and quality of care.
So, Black women are worried about dying during or after pregnancy. That’s why my patients often breathe a sigh of relief when I walk into their exam rooms: I’m a Black doctor, and more to the point, I’m a Black mother in America who has survived four pregnancies. Patients know I understand what they are going through because I’ve been in their exact circumstances and felt their fears.
Black women don’t have the luxury of assuming that they will experience pregnancy with good outcomes. They must proactively work to ensure that the right services and the right systems are in place to ensure optimal outcomes for themselves and their babies.
My colleagues and I recently published an article in the New England Journal of Medicine Catalyst on The Cocoon Pregnancy Care Model, which describes the essential care and services that pregnant women need before, during, and after pregnancy. Cocoon Pregnancy Care places the woman in the center of a protective layer of a care team and services to optimize their health, enhance their pregnancy experience and achieve the best possible outcomes. This approach is necessary for all women but critical for Black women whose risk of dying in pregnancy is much higher.
Here are the ten things I’ve learned that can help.
1. Optimize health before getting pregnant. Pregnancy is very taxing on the heart and body, and women with high-risk conditions like obesity, hypertension, or diabetes can have high-risk pregnancies. One of the things that I recommend is that patients do everything they can to get medical care to make sure they are healthy before getting pregnant. That means losing weight if overweight and ensuring hypertension, diabetes, and other health conditions are controlled before getting pregnant. Women should have children early, if possible. Once a woman is over the age of 35, they are considered high-risk and of “advanced maternal age.” While it is possible to have a safe pregnancy at an older age, the risks multiply and can become life-threatening with advancing age, especially in women over age 40 who have high-risk conditions.
2. Find the right doctor and care team. Patients should assemble a care team they trust who can partner with them to ensure they have the best pregnancy outcomes. I recommend finding an OB/GYN and/or a certified nurse midwife who listens to them, genuinely cares for them, and sees them as their sister, mother, child, or friend. Discrimination and implicit and explicit biases are real contributors to the higher risk of death that Black women face in America, so women should make sure that they find a care team that can care for them without bias.
3. Mobilize a support system. Patients should mobilize family, friends, and a care team to surround them with a protective layer of support during pregnancy. They should insist on getting access to essential caregivers and services that are needed before, during, and after pregnancy to survive and thrive.
They should seek help if they are having financial difficulty, problems with housing, food, transportation, or getting health care and get a social worker to help if needed (some resources are available here). They should monitor job-related stress and try to change how they work if possible. They shouldn’t hesitate to seek counseling to help with stress, anxiety, or depression that can happen commonly during or after pregnancy. The entire community must rally around pregnant women because pregnancy, childbirth, and raising a newborn baby can be very stressful.
4. Find a health care advocate. Finding a health care advocate is critical. I recommend finding a partner throughout the pregnancy who checks in on the patient, accompanies them to appointments and their delivery, and ensures they are doing what they are supposed to be doing. Patients should find someone who advocates for them and raises hell, if need be, to get the patient or their care team to do right. A health care advocate can be a trained doula, a spouse or partner, a mother, a sister, or a friend.
5. Partner with the doctor or midwife. Once patients find the right doctor or midwife to partner with, they should listen to them and trust them. Patients shouldn’t let internet searches on Google, Instagram posts, or bad advice get in the way and convince them to refuse care that could harm them or their baby. If a midwife is providing prenatal care and delivering the patient’s baby, they must make sure that the midwife is partnered with an OB/GYN doctor to back them up if complications arise.
Furthermore, I recommend that patients deliver in a hospital or in a health facility that is attached to a hospital because if there is an emergency, they need quick access to surgery, medical care for their baby, or interventions like blood transfusions that can save their lives or the life of their baby. America is not yet set up to do home deliveries well, and home deliveries have been shown to have worse outcomes than hospital deliveries.
6. Strive for a healthy mom and a healthy baby. Many patients desire a specific pregnancy experience or have an ideal birth plan. I tell patients to give themselves permission to deviate from their birth plan if needed to ensure their health or their baby’s health. Mothers should get used to the fact that the baby is now in charge, and depending on their mood, they can upset the best of plans!
7. Prevent cardiovascular (heart) complications. Patients should look out for and try to prevent some of the major causes of maternal deaths, like high blood pressure (hypertension) and cardiovascular (heart) conditions. I recommend that patients buy a blood pressure machine and check their blood pressure at least once a week. If they develop hypertension, they will need closer monitoring to ensure their blood pressure stays within a normal range during and after pregnancy. Most Black women need to be on a daily baby aspirin starting in the first few months of pregnancy to help prevent a complication called preeclampsia. They should watch out for the warning signs of preeclampsia, which can include changes in vision, severe headaches, sudden abdominal pain, or swelling in the face and hands.
8. Prevent anemia and bleeding complications. Hemorrhage, which is heavy bleeding, is another major cause of maternal death during or after childbirth. Patients can help decrease complications from a hemorrhage if they prevent anemia while pregnant. Many pregnant women become anemic, so I recommend that all pregnant women eat iron-rich foods and take a prenatal vitamin that has iron every day. If patients are diagnosed with anemia, they will need to take extra iron tablets. If the anemia is severe, they should ask their doctor if they are a candidate for an intravenous iron infusion. When women have a normal blood count and are not anemic at the time of delivery, they are less likely to have severe complications, even if they have a hemorrhage.
9. Find a doctor or midwife that practices evidence-based medicine. Medicine is rapidly changing, and there are evidence-based guidelines that the American College of Obstetrics and Gynecology for pregnancy care recommends. When doctors and midwives use these guidelines, they are better able to promote vaginal birth and decrease cesarean sections, manage complications like hypertension, hemorrhage, and infection and ensure that their patients get the best quality care during their pregnancy.
10. Survive and thrive. Once patients find a good care team that they trust, assemble a good support system, take charge of their own health, and collaborate with their care team, they can relax and enjoy the journey through pregnancy. Black pregnant women deserve to not only survive but also to thrive and enjoy their pregnancy experience.
Fatu Forna is an obstetrician-gynecologist.
