Additionally, the racial disparities between white and black women in both Los Angeles County and California as a whole remain.
"I don't think anyone can be too enthusiastic about what gains we've made until we confront that inequality," Allen said.
Another caveat: studying maternal deaths in general can be challenging and there can be some limitations with data collection and surveillance -- including that some hospitals are hesitant to promptly report a maternal death prior to its own internal investigations, which would be needed to track deaths and their causes, said Alice Benjamin, a clinical nurse specialist based in Los Angeles
"There's not a culture in the health care community that allows us to freely, without stigma, be able to share and learn from each other," Benjamin said. "Even if those data are shared with the CDC and state department of health, they don't go to other peer health care providers or entities to learn. Many times non-disclosure agreements in settlements preclude the very details we need to learn from, from ever being shared."
As a black mother, Benjamin says that her hope for the future is for greater attention to be paid to women's health overall -- and for hospitals to have better reporting and surveillance systems when it comes to maternal mortality.
"Information is good, but it's only as good as what you're going to do with it and that's where I get frustrated," she said. "What happens once you do identify cases? What are we doing internally to actually change things? Where's the bite in the bark?
"As a clinical nurse specialist, I got to see many types of the medical errors, snafus and near misses. ... And it's not uncommon when something goes down, even in the most reputable institutions, people become silent."
'Nothing went according to my plan'
One of those near misses could have been six-time
Olympic gold medalist Allyson Felix. In 2018, Felix was pregnant with her first child. She stayed healthy, continued training as an elite track and field athlete, and didn't have any issues, she said.
"I was working closely with my doctor to make sure I was doing the right things," said Felix, who now holds the
record for the most gold medals at the track and field World Championships.
"At 32 weeks I was going in for my routine check-up and that's when the doctor wanted to do further tests. She was noticing some things that were concerning her and so she sent me over to the hospital right away to be further monitored," Felix said.
She was admitted to a hospital in California, near where she lives.
"And that's when things quickly went downhill," she said.
Doctors noticed that Felix had extremely high blood pressure and they diagnosed her with a severe case of preeclampsia, characterized by the development of high blood pressure and protein in the urine or other problems during pregnancy and other symptoms. Women with preeclampsia are at increased risk of organ damage or failure, preterm birth, pregnancy loss and stroke.
Research suggests that rates of
preeclampsia and eclampsia are about 60% higher for black women than for white women. Eclampsia is diagnosed when a woman with severe preeclampsia starts to have seizures.
"It was just really scary. I had never imagined myself in that situation," Felix said. "The doctor came in and let me know it was an emergency situation and we were going to have to do an emergency C-section so that both me and Camryn could make it."
Felix's daughter Camryn was born early on that day in early December and she spent a month in the hospital's neonatal intensive care unit.
Felix said that she did not know to look for signs of preeclampsia -- which could include headaches or swelling of the hands and face -- or that being African American put her at higher risk.
"It was just this eye-opening experience that it doesn't matter how great of medical care you have or you could be of privilege and still be in this situation," Felix said. "This is a problem that women of color are facing."
Felix returned to training on the track after giving birth, but she also became a maternal health advocate.
"When I thought about starting a family and what it looked like to come back to training, I had this perfect plan in my mind. I thought everything was going to go smoothly. I thought I'd be back on the track four weeks after birth and nothing went according to my plan," Felix said.
Last May, Felix shared her birthing experience during in a
congressional hearing held by the US House Ways and Means Committee on Capitol Hill. She urged lawmakers to take national action to address the racial disparities seen in the maternal mortality crisis.
Since then, there's been a step in the right direction, she said, referring to the California bill requiring perinatal health care providers undergo implicit bias training.
"I would love to see more of that across the country," Felix said.
It may be starting.
In March, a group of lawmakers -- led by Illinois Rep. Lauren Underwood, North Carolina Rep. Alma Adams and California Sen. Kamala Harris -- introduced bipartisan legislation in Congress aimed at reducing the maternal death rate in the United States.
The measure, called the Black Maternal Health Momnibus, is composed of nine bills, some of which support "a 12-month postpartum Medicaid coverage expansion, investing in rural maternal health, increasing the diversity of the perinatal workforce -- so that would be your physicians, midwives, doulas -- and implementing implicit bias training," Underwood said.
"We have until the end of the calendar year to do this work in the 116th Congress."
Outside of what's happening in hospitals and in legislatures, midwives and doulas have moved to empower women in childbirth, even if resources remain scarce. Doulas differ from midwives in that while they
provide support and comfort during delivery, they do not provide medical advice nor can they change the clinical recommendations of a midwife or an obstetrician. But they often can help identify any concerns or problems the mother might experience.
Some experts point to doula care as being one way to reduce the racial disparities seen in maternal health -- and such action has been taken on the county-level in California.
Last year,
Los Angeles County launched a program specifically to provide doula care services to black women in an effort to address and reduce racial disparities seen in maternal health. The program is part of the county's broad African American Infant and Maternal Mortality prevention initiative.
The
LA County Department of Public Health received $1 million in funding from the state to launch the two-year pilot program, which provides doula services to black women at no cost. The services include prenatal visits, postpartum visits and continuous doula support during labor and delivery.
Mothers with support from doulas are four times less likely to have a baby with low birth weight, two times less likely to experience a birth complication and significantly more likely to initiate breastfeeding after birth, according to a study published in the
Journal of Perinatal Education in 2013.\\Black patients are often prescribed less pain medication than white patients, several studies suggest. Whereas, doula support during childbirth can help reduce levels of discomfort for the mother as a doula might suggest practices during labor to ward off pain.
In Los Angeles, "our goal is to serve African American women and families with birth doula services, provided by African American doulas. We now have a team of 12 doulas," said Helen O'Connor, health program analyst for the LA County Department of Public Health.
She added that the program's success will be measured by whether the program is associated with a reduction in preterm birth and C-section rates among women and the use of certain interventions in hospitals that could signal there was a maternal health problem.
The program has a focus on specific communities in the county: South Los Angeles, the South Bay, Antelope Valley and San Gabriel Valley.
"Usually the only women who get doula care are women who can pay for it," said Allen of the LA County Department of Public Health.
"We're both trying to increase the workforce of African American doulas and provide subsidy for African American doulas we contract with to serve women in the black community," she said.
Allen added that "there is no biological reason" for black women to die more often than white women in pregnancy or childbirth.
"There is a combination of factors at work there, all of which speak ultimately to social inequality," she said. "There's a particular message for black women and that's don't bear the burden yourself. If you've had an adverse birth outcome, don't assume it's your fault. Recognize that in a society with inequality, you are subject to stress and that you need support for that stress."
A mother mourns -- and takes action
After Tatia Oden French's death during childbirth in 2001, her mother, Maddy Oden, began to research more about maternal deaths. She learned that some
research suggests that a medically induced labor can be associated with an increased risk of AFE, the rare condition that took her daughter's life.
Oden launched the Tatia Oden French Memorial Foundation in 2003 to raise awareness around maternal health risks.
"Women of color specifically, and definitely in labor and delivery, are treated much different than white women, and the reason is that a lot of people in the medical profession are culturally incompetent," Oden said. "They have this idea that people of color, African American women, can withstand more pain than white women."
Oden petitioned the US Food and Drug Administration to restrict the use of the drug
misoprostol in labor inductions -- the drug used to induce Tatia's labor. The medication, intended to prevent or treat ulcers, has not been FDA approved for labor and delivery purposes but is still commonly used to induce labor in the United States.
Since the drug was never intended for labor induction, any use of it for that purpose would be off label. There is no law against
the "off-label" use of a drug in the United States. The practice refers to when a healthcare provider prescribes a FDA-approved drug for an unapproved use because they judge it can be helpful for their patient, even though the FDA has not determined that drug is safe and effective for the unapproved use. The
drug misoprostol has a warning label that states uterine rupture and other risks have been associated with that off-label use.
In the early 2000s, the FDA first published an alert regarding the risks of using the drug for inducing labor. Then in 2015, an
updated alert was published on its website.
It notes that while pregnant women may be offered misoprostol to induce labor or decrease blood loss after childbirth, "these uses are not approved by the FDA. No company has sent the FDA scientific proof that misoprostol is safe and effective for these uses."
Oden has continued to advocate for ways to improve black maternal health -- something that she has dedicated her life to after losing Tatia. She wanted to help women make fully informed decisions regarding the births of their children. She wanted to prevent maternal deaths from touching other families. She wanted it so much
she studied and began a new career in health, like her daughter might have done.
Oden became a doula.
[This article was originally published by CNN.]