The mother-to-be labored for 20 hours before she stopped breathing. The doctor who turned to leave the room didn’t notice.
Then Zita Iwuoha, her midwife, started screaming.
“Call a Code Blue!” Iwuoha yelled, “Call a Code Blue!”
Within seconds, the hospital room filled. The woman was experiencing an eclamptic fit. The doctor had administered anti-seizure medication, but failed to see she had stopped breathing.
“Thank goodness I was there,” Iwuoha said.
The Pittsburgh mother survived. While her 2015 birth story sounds horrific, uncommon even, such close calls are the reality for many mothers in the United States. As many as one-third of women report that their births were traumatic, according to research compiled by Prevention and Treatment of Traumatic Childbirth.
Furthermore, 700 to 900 U.S. women die of complications related to childbirth each year. And if the mother is black, she’s three to four times more likely to die.
In Pennsylvania, the maternal death rate in the early 1990s was 5.1 deaths per 100,000 births.
The rate more than doubled to 11.4 deaths, according to numbers from 2012 to 2016, the most recent data available. The rate for black mothers was more than twice that, at 27.2 deaths.
The majority of these deaths are preventable, according to the Centers for Disease Control and Prevention.
Betty Braxter is an assistant professor at the University of Pittsburgh School of Nursing. She serves on the Pennsylvania’s Maternal Mortality Review Committee, which Gov. Tom Wolf established in 2018 in response to the Commonwealth’s maternal mortality. The committee works to develop programs, policies, recommendations and strategies to prevent maternal deaths.
At a black maternal mortality symposium organized by Iwuoha in April, Braxter talked about how systemic racism permeates all aspects of American society, including the labor ward.
“We live in a country that refuses to believe...that racism still exists,” she said. “It does. Whether it is conscious or unconscious bias.”
Braxter wants healthcare providers to improve their cultural sensitivity. “Just listen to a mom when she says, ‘I don’t feel well, this is not going right for me,’” Braxter said.
Iwuoha and Braxter both emphasize that black women are less likely to be believed when they say something is wrong. Even superstar Serena Williams encountered life-threatening complications after giving birth to her first daughter. One of the most famous athletes and black women in the world had to convince her medical team through gasping breaths that she needed a CT scan and a blood thinner immediately. Eventually, the medical team acted on her pleas and the CT scan showed blood clots in her lungs.
But for black women like Iwuoha’s client, the doctors may never believe them.
Iwuoha, 54, remembers worrying about three people in the hospital room that day:
The baby. Was the baby getting enough oxygen?
The mother’s husband, a blind man, clutched Iwuoha’s arms. He couldn’t see that his wife had lost consciousness, but he could hear Iwuoha’s shouts.
And, of course, the mother. Would she survive? Would she become another statistic? How would she process this trauma if she lived?
'She listened to herself'
In Africa, Iwuoha delivered close to 1,000 babies. She worked as a “home doctor” or midwife in Kenya, Ghana and her native Nigeria. After 10 years, Iwuoha moved to Ireland to become a nun. She also studied medicine in Liverpool.
Eventually, her work took her to the United States, first to California and then to Pittsburgh. From 2013 to 2017, Iwuoha said she assisted in deliveries for somewhere between 150 and 200 first-time mothers in Allegheny County. In the Pittsburgh region, she served mothers in Cranberry, Monroeville, McKeesport, McKees Rocks and Duquesne.
The origin of Iwuoha’s desires to help mothers starts with a story about her own mother. She spoke of how her mother walked 30 miles in Nigeria to save her life. Iwuoha contracted bronchitis at two months old. The men of the village advised Iwuoha’s mother not to make the trek to the hospital. If Iwuoha were to die, it was her fate. Her mother made the trip in 120-degree weather. She had no food or water and stopped to breastfeed three times. After doctors saved Iwuoha, her mother had to be hospitalized for a week due to dehydration and exhaustion.
Iwuoha’s mother didn’t listen to the men of the village. She listened to herself.
“My mother started telling me that story when I was 7,” Iwuoha said.
Now, Iwuoha is the executive director of Zita’s Healthy Beginnings, a nonprofit that seeks to reduce maternal and infant mortality by providing access to fertility education, training community health workers, prenatal care and safe delivery. Iwuoha’s ultimate goal is to construct a maternity hospital in Umuawuchi-Nigeria. She hopes the awareness she’s raising in the United States will help her raise awareness in her home country.
Iwuoha is also pursuing her doctorate in nursing practice at Saint Mary's College in Notre Dame, Ind., where she drives to take exams.
Iwuoha’s mission to save black mothers and babies began in Nigeria, but once she realized that black mothers in Allegheny County were facing a similar reality, she began to expand her scope.
Black women face a lot of risks when it comes to pregnancy and childbirth. They are at risk for increased heart rate and obesity, which can lead to high blood pressure. Iwuoha works with a lot of single mothers and said, “That stress alone increases the blood pressure in the mother.” The majority of Iwuoha’s patients who are at a high risk for a complicated birth or pregnancy are in a minority group.
Black women may also have difficulty accessing health care while pregnant. Nearly 14% of black women are uninsured, compared to 8% of white women. Midwifery services are a way to bridge that gap because their training is less rigorous, and therefore, their services are less expensive. Home births assisted by a midwife are an alternative to hospital births if the mother has a low-risk pregnancy.
‘The issue is in the tissue’
Throughout the pregnancy of the mother who stopped breathing during labor, Iwuoha talked with doctors and nurses about the threat of preeclampsia.
The woman’s sister had died six months prior during an eclamptic fit.
Preeclamptic symptoms range from swelling in the feet and high blood pressure to pain in the upper right abdomen, shortness of breath and severe headaches.
The mother-to-be had anxiety during her pregnancy because of her sister’s death — which could have contributed to her high blood pressure, according to Iwuoha. A traumatic birth can affect a mother on a cellular level, Iwuoha said, and it can stay with her long after the baby is born.
“This is not something that will go away easily. It is in your tissue. The issue is in the tissue,” Iwuoha continued, “When people say, I made it. I survived it. What happens then?”
Some mothers are diagnosed with post-traumatic stress disorder [PTSD] or related symptoms and effects.
Rebecca Weinberg is a clinical psychologist specializing in women’s behavioral health at West Penn Hospital. She sees women who meet full criteria for PTSD, “but many women have clinically significant symptoms” and may not be diagnosed because they don’t meet the full criteria, she wrote to PublicSource.
Symptoms of PTSD (or other trauma-related disorders) include: nightmares or flashbacks, strong physiological or psychological reactions when reminded of the birth or pregnancy, avoidance of doctors, hospitals or people associated with the birth experience and amnesia.
According to Weinberg, several factors can contribute to traumatic childbirth. Women with a prior history of PTSD and partner violence are at risk. She emphasized that mothers who have little support during labor, who lose control during labor or experience pain are at risk for PTSD. Weinberg said physicians should be empathetic and communicative during labor and delivery to reduce risk for these women.
A birth is considered traumatic when a mother believes her life or her baby’s life is in danger or when there’s a serious threat to the physical or emotional well being of the baby or mother.
According to research compiled by Prevention and Treatment of Traumatic Childbirth, 25% to 34% of women report that their births were traumatic. Weinberg believes the rate may actually be higher.
“...It is not routine for obstetricians to screen for PTSD in the postpartum period so many cases may go undetected and untreated,” she wrote.
Often, Iwuoha encounters black mothers who face condescension from healthcare providers. Clients have told her that doctors “...think we are too young. They think we are ignorant. They think we are irresponsible. They don’t think we are capable of becoming mothers, and we are wasting their time.”
“The majority of my clients do not have a good experience,” Iwuoha said. “It’s so painful to even listen to them share that.”
Negative talk to the mother does damage, Iwuoha said. “What happens is it lingers on.” Clients believe that if the doctor treats the mother in this fashion, “they’ll treat my baby this way.”
Bridging the communication gap
Pittsburgh’s Midwife Center for Birth & Women's Health was established in 1982 but has faced funding obstacles and shutdowns intermittently throughout the years. Executive director Christine Haas notes that the center has been growing through the past decade, and, after a $3.9 million fundraising campaign, became the largest freestanding birth center in the country in 2017.
Iwuoha would like to see less births take place at a hospital. When she moved to America, she was shocked to see how medicalized pregnancy had become.
One potential symptom of that: cesarean sections are on the rise worldwide and according to several studies, an elected C-section can raise the chance of death by at least 60%. In 2018, the World Health Organization issued a guidance aiming to reduce cesarean section rates because of the risks they pose to baby and mother.
Iwuoha said she thinks women opting for this surgery is dangerous and often unnecessary. She believes at-home, vaginal births are safer for low-risk pregnancies.
However, a study published in The New England Journal of Medicine in 2015 found a connection between out-of-hospital births and a higher rate of perinatal death (a period of weeks before and after birth). Out-of-hospital births also carried greater risk of neonatal seizures, according to the study. The study’s authors weren’t available to comment for this story.
Midwifery was long ago considered by many to be dirty and the midwives ill-equipped, Iwuoha said, “and the doctors took over.” At the turn of the 20th century, white male doctors pushed to eradicate midwifery, a predominantly black and immigrant profession.
In the South, the midwife was often an enslaved woman. In 1906, the Public Health Committee of the Association of Neighborhood Workers published a midwife study stating: “The majority of so-called midwives are foreigners of a low grade—ignorant, untrained women.”
And now, midwifery is making a comeback, but more so in the white community.
In Iwuoha’s culture, midwife work and giving birth are honorary duties. In America, she thinks there’s still a stigma. When Iwuoha came to the United States, she asked other midwives and doulas, “So why don’t we have more people?” Meaning, where are the black healthcare providers? Iwuoha would like to see “someone who looks like me taking care of me,” she said.
Mothers trust Iwuoha. Iwuoha is a black woman who mothers black mothers.
“Women share with me things that they wouldn't share with someone who looks different,” she said.
Brandy Gentry, founder of Ollie’s Angels, is a bereavement doula for mothers whose babies die before or shortly after birth. She also advocates for doula and midwifery work in Pittsburgh. Gentry lost her first son when she was 23 years old in 2010. She had called her doctor insisting that she noticed a decrease in her baby’s movements. Her doctor told her to eat ice cream and lay on her side. Gentry’s baby’s movements continued to decrease, but her doctor told her it was normal.
On Christmas Day, when she went into labor, her baby didn’t have a heartbeat. Gentry learned what a stillbirth was the day she had to deliver her son.
Now, Gentry works to stop this communication gap from happening.
“Doulas are necessary. We are a necessary part of the care team...Doulas should be encouraged. We don’t take away from anything, we simply enhance. We enhance a mother’s journey,” she said.
The education of black mothers and black health providers, Iwuoha believes, is a way to combat the maternal death rate: “I am trying to get a forum where you can educate young girls,” she said. “If you are not training a woman, you are not training a whole nation.”
Correction (6/11/2019): This story previously misstated Zita Iwuoha's age.
Update (6/17/2019): This story has been updated with additional information on the Midwife Center for Birth & Women's Health.
Brittany Hailer covers mental health and behavioral health issues for PublicSource. She can be reached at firstname.lastname@example.org.
This story was fact-checked by Harinee Suthakar.