When I attended my first Birth Doula training in Baton Rouge in 2010, I imagined the celebrations of new life that would soon enrich my own. Baby showers, blessingways, naming ceremonies, brises—community rituals where those who have given birth and parented envelop the new parent in tales of strong birth experiences, crafty parents, and their cunning, healthy children. Indeed, I have attended many of these rituals over the last 12 years. But what I could not yet imagine, back then, were the death stories. For the past four years, I have been listening to the stories of those who do not survive to tell their own tale.
In 2018, I received an e-mail inviting me to serve as a volunteer member of Louisiana’s newly revitalized Maternal Mortality Review Committee (MMRC). The CDC defines MMRCs as multidisciplinary teams at the state and local level that “perform comprehensive reviews of deaths among women within a year of the end of pregnancy.” The primary goals of these committees are to review maternal deaths and to “identify prevention opportunities.”
As a birth justice advocate, I knew this work could be meaningful. In Louisiana, we suffer from one of the highest rates of maternal mortality in the United States—itself the nation with the worst maternal death rate in the entire developed world. The overall rate of pregnancy-associated deaths in Louisiana was 92.5 deaths per every 100,000 live births in 2018, according to the most recent Pregnancy-Associated Mortality Review report. Black women make up a disproportionate majority of these deaths. I wanted to be a part of this group of people learning from these losses, and putting those lessons into action. But I was also afraid of the invitation. I knew that the majority of the dead would be Black mothers, and that I would be faced with stories of families who looked and sounded like my own, or those of the communities I serve.
As in much of the United States, Louisiana had gone many years without any consistent, comprehensive review of its maternal deaths. Across the nation, the high point of functioning MMRCs was in the 1960s, after which a lack of funding, inconsistent operational guidance, and even a lack of shared terminology to interpret results, led to fewer and fewer reviews. Decades passed. People were dying during birth or in the months after, but no one was listening to their stories. Only in the last decade has the outcry against the injustice of the Black maternal mortality crisis grown loud enough to invigorate a national effort to reinstate MMRCs.
I wanted to be a part of that movement. I RSVP’d “Yes.”
Most of what happens around our MMRC table is confidential and anonymous. But each year the committee releases a public report explaining overall trends in the deaths reviewed that year and making recommendations for prevention. Much of the data that we report confirms what we have already known for too long. From 2018–20, the committee reviewed and reported on maternal deaths that occurred in 2017 and 2018, finding that:
- The majority of maternal deaths are preventable. In Louisiana, between 67 percent and 100 percent of maternal death cases were deemed preventable. Factors contributing to these deaths existed at patient/family, provider/facility, and community levels.
- We already know how to treat the leading causes of death. Hypertension and hemorrhage consistently top the list for pregnancy-related deaths. Upon review, many of these deaths are linked to a failure to perform an adequate risk assessment and/or provide evidence-based treatment. Facilities and providers that use data-driven maternity care bundles and risk assessments decrease the likelihood of these deaths.
- Those who die are disproportionately Black. Over five Black women died for every one white pregnancy-related death in Louisiana in 2017, and the ratio was over 3:1 in 2018.
- The postpartum period after giving birth is just as deadly as birth itself. Over half of maternal deaths occurred between birth and 42 days post-delivery in Louisiana in 2017. Factors contributing to many of these deaths include a lack of care coordination and timely follow-up for those who experience complications in childbirth. We also lack adequate screening and follow-up for postpartum mood disorders, contributing to the one in nine deaths caused by a mental health condition.
Death reporting is not without human bias, of course. The people who make up the MMRCs—the worlds they come from and represent—can affect how the deaths are categorized and, in turn, what recommendations are made.
As part of a national trend to change how we assess the deaths (and the lives) of birthing people, MMRCs have redefined their membership criteria. In addition to physicians, Louisiana’s revamped multidisciplinary committee includes social workers, nurses, midwives, addiction and mental health specialists, family violence experts, and community birth workers, like me. While physicians bring the expertise needed to understand physical causes of death, our community-based experts address the multifaceted social, cultural, and systemic factors influencing the maternal death crisis today. In short, doctors give us the “what,” while community experts give us the “why.”
As the committee diversified its membership, its interpretations of death cases also transformed. In 2010, the Louisiana review committee, which then comprised mostly physicians, found that 45 percent of maternal deaths reviewed were considered preventable (or that 55 percent of maternal deaths were inevitable). In 2018, with a multidisciplinary team and new guidance from the CDC to recenter social determinants of health, the review committee found 80–90 percent of maternal deaths reviewed to have been preventable. Our review committee leaders also found that Black women are much more likely to die from preventable causes than their white counterparts.
To reveal the preventability of Black maternal death is significant. When we view maternal deaths as inevitable, we see the Black bodies who died as inherently flawed—their deaths somehow a product of their race. When we recategorize these deaths as preventable, we realize that Black women are dying of injustice, from a lifetime of social determinants of illness before pregnancy to disproportionately untimely and inadequate maternity care.
While absolutely tragic, the fact that these Black maternal deaths could have been prevented is also a cause for hope. If we listen to the stories, and learn from them, we will save Black lives.
Toward this essential end, our committee’s recommendations focus on interrupting racism, addressing health care system inadequacies, and getting care into the community. We call on health systems to implement evidence-based levels of care and risk assessment, and to incorporate psychiatry, cardiology, and addiction specialists into standard maternal-child health care. We challenge our health care providers to acknowledge and address racism and bias system-wide, from clinics, to hospitals, to Emergency Medical Services. We demand an end to the culture of postpartum neglect by expanding community-based postpartum care, such as home visitation by doulas, nurses, and counselors. The announcement just this month that the Biden-Harris administration will allow states to extend mothers’ Medicaid coverage for a full 12 months after giving birth was certainly informed by the recommendations of MMRCs. Prevention is our light at the end of the tunnel; if taken seriously, it will be our way out of this crisis.
In November, I had the opportunity to speak on a virtual panel on “How Community-Based Birth Workers Can Engage with Maternal Mortality Review Committees to Promote Equity” at the Decolonize Birth Conference in New York City. For over an hour, I conversed with Black birth workers from around the country, who like me, were invited to serve on their local MMRC. Like me, their voices were sought because of the documented impact of birth doulas on perinatal outcomes. Like me, they felt a duty to honor the lives of their own lost community members, and to speak truth to power.
Also like me, they were emotionally exhausted, triggered, and angry. Many had quit their committees. We talked about the fear: As doulas, we were trained to trust birth, but the more death stories we hear, the more danger we see for every mama. We talked about the anger: How many times can we review the same unyielding data and make the same recommendations? How many more mamas have to die? Heartbreakingly, despite our efforts, we have seen Black maternal mortality rise by a shocking 25 percent during the Covid-19 pandemic.
Our maternal death case review happens once a quarter. After six hours of listening, I go home, I get straight into my shower, and I cry. I turn the water as hot as it will go, so that the sensitive skin on my lower back stings a little, and I can feel something real, before I float away. My tears fall and are lost in a swirl of tap water, as I let the images I’ve created of each and every mother from that day pass before me.
When I was pregnant with my second child in 2020, I considered the statistics of being Black and pregnant in Louisiana. I considered my desire to show up and listen to the stories of these Black mamas who didn’t have to die. And I considered my life. I decided not to serve on the MMRC while pregnant. I could not take the risk of internalizing more fear and more loss while gestating a new life. Instead, I spent my pregnancy recalling the hundreds of beautiful, empowered, Black births I have witnessed in my career. I chose to remember that positive birth experiences are far more bountiful than devastating losses. And when I gave birth in June, I added one more birth story to this narrative of joyful resistance.
For this Black Maternal Health Week, I challenge us in three ways. We must continue to provide robust resources for maternal mortality review committees in all communities, so that every maternal death story is heard. We need Black community experts and birth workers leading the review process to ensure that Black maternal mortality is understood as a preventable injustice, not an inevitable tragedy. And, for our collective sakes, we need to champion the stories of positive birth experiences just as loudly as we mourn our losses.