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Elise Salazar was 19 years old when she gave birth in Hawaii. She was being seen at a military hospital and, as a mixed-race Latina-American, felt early on that her opinions didn’t matter to the OB-GYN team that was providing her care.

In fact, when she asked for an epidural the anesthesiologist told her she’d have to prove she was in enough pain first.

“I had to perform labor pain to his expectations before he would authorize the epidural,” Salazar told Healthcare Website.

When an epidural was finally approved, Salazar was surprised it wasn’t the anesthesiologist who gave it to her, but a student he passed the task off to instead.

Salazar says the student missed three times, ultimately stabbing her in the spine a total of four times before the medication was delivered. She then only set the epidural for 40 minutes, saying she wanted it to wear off before Salazar went into labor.

“After the epidural wore off, I was in the most horrific pain of my life. I was screaming, having trouble breathing, and panicking. A nurse came in the room and told me to ‘shut up’ because I was scaring other patients. By the time I was ready to deliver, I’d been laboring med-free for about an hour and a half,” Salazar said.

What followed was third-degree tears after the medical team failed to give her an episiotomy (which she’d had with her first baby).

The nursing staff also cleaned her baby shortly after delivery, but left Salazar lying in sheets soaked with blood and fluids and a soiled vaginal area for more than an hour after giving birth.

Most people might hear Salazar’s story and hope it was an isolated tale. But the truth is, stories like hers are far more common in the United States than they should be.

A history of poor maternal health outcomes

The number of poor maternal health outcomes in America isn’t new news. NPR teamed up with ProPublica for a six-month investigation on maternal mortality in the United States in 2017. What they found was disturbing:

  • The United States has a higher maternal mortality rate than any other developed nation.
  • Treatable complications are often to blame for mothers dying when the right care could have prevented those deaths.
  • Hospitals remain unprepared for dealing with maternal emergencies.
  • Only 6 percent of grants slated for “maternal and child health” actually go to the health of mothers.

CNN, The New York Times, and USA Today have had similar stories with convincing data finding that, while other developed nations have seen a decrease in maternal deaths, the United States has seen a sharp rise.

Women of color at greater risk

Another facet of the recent reports surrounding maternal health outcomes in the United States is one that seems to be largely ignored: For women of color, the outcomes are even worse.

The Center for American Progress reports, “African American women are three to four times more likely to die from childbirth than non-Hispanic white women, and socioeconomic status, education, and other factors do not protect against this disparity.”

In fact, Salazar is in good company with her story of traumatic birth, as both Beyoncé and Serena Williams came out earlier this year with stories of their own.

The numbers

Gene Declercq, PhD, is a professor of community health sciences and assistant dean of doctoral education at Boston University. He’s also a researcher who has spent several years striving to compile accurate numbers on maternal health outcomes in the United States.

“The government hasn’t published an official rate since 2007,” he told Healthcare Website. “There are semi-legitimate reasons for that, because there were some measurement changes. But we thought we could develop a general estimate, and then we dug into the disparities.”

His goal is to shift the debate from just maternal health outcomes to an overall public health conversation. In his research, he’s learned that while the death rates of women under 15 and over 45 in the United States are going down, the death rates of women 15 to 44 (childbearing age), and particularly 25 to 34 are going up. He sees the issue as one related to women’s health in general.

The disparity

When asked about the disparity of outcomes for women of color, Declercq cited an issue of not listening to minority mothers, and of not taking the problems they are reporting seriously — just as Salazar experienced.

“That’s a big piece of it,” he said. “But we also can’t neglect the fact that for a lot of women in a lot of states, if they’re not on private insurance, they won’t get public insurance until they are pregnant.”

He explained that the system for Medicaid coverage is set up in many states to be easier to gain approval once a woman is pregnant. But at that point, she’s carrying all her previous, unchecked healthcare issues into the pregnancy, and she may have a hard time finding a provider who will care for her. She’ll find a place to deliver, but in most states, she’ll be dropped from public insurance within 60 days of giving birth.

“It certainly sends the message to women that their only importance is as a baby carrier, and after the baby is born, we don’t care anymore,” Declercq said. “They’re not falling through the cracks, there are no cracks. There’s no system at all for them to be cared for in.”

Lack of access and awareness

It’s an issue Rewa Thompson, a women’s healthcare practitioner at a public clinic in New York, knows all too well. Dr. Thompson recently participated in a podcast for HealthCetera on maternal health outcomes for women of color where one of the speakers was a young mother who shared her traumatic birth story.

Speaking to Healthcare Website both about the story that was shared on that podcast, and the overall maternal health outcomes for women of color, Thompson said, “I know it starts with lack of prenatal care. And then it also becomes an issue of these women simply not being heard.”

She talked about the fear she sees among Hispanic women, especially, when it comes to pursuing maternal health care. Thompson pointed out that many will avoid care for as long as they can because they’re undocumented and they’re worried about being deported.

But that’s only one small piece of the disturbing maternal healthcare picture.

“There’s also lack of awareness,” she added. “And economic factors. They may not realize they can get Medicaid, or they may struggle to find a provider once they have it. Lack of knowledge, fear, poor or inadequate access, stigma surrounding teenage or unplanned pregnancy — it can all keep women from seeking out the care they need.”

Institutional racism

Discussing the recent cases of Serena Williams and Beyoncé, as well as her own experiences in the medical field, Thompson said, “When you look at the maternal health outcomes for women of color and realize they’re poor even among women of higher socioeconomic status, that’s when you have to consider the impact of institutional racism. There is a tendency to look at women culturally, as opposed to what they are saying objectively.”

The Center for American Progress has come to the same conclusion, citing racism and sexism as issues that “compromise women’s health across time.”

However, combating these issues isn’t something that will happen overnight. According to Declercq, Universal Healthcare would be a big step toward ensuring all women have the access to care they need — not just during pregnancy, but before and after as well.

He also thinks the social system, as a whole, needs to be overhauled, citing issues like maternity and paternity leave.

The United States is the only developed nation that doesn’t have mandatory paid maternity leave policies. The result, Declercq explained, is women wait until the last possible minute to take time off work — so they can maximize what little time they do have with their baby and minimize the time they go without a paycheck.

“In terms of their health and the health of the baby,” he explained, “taking time off before and after is important. But they want the most time home with their babies, and our current social structure doesn’t support them doing what’s best for their health.”

As far as he’s concerned, “It’s not just a healthcare system problem. It’s the social system that plays a role in the better outcomes other countries are seeing.”

How we can change the system

Thompson said she’d like to see healthcare providers being more sensitive. “From the beginning of their medical care education, they should be learning about cultural sensitivity.”

She also said she wants to see an end to the limitations currently placed on healthcare providers by insurance companies dictating what they can and can’t prescribe.

“We can only do so much as providers. Our healthcare system needs to allow us to meet an individual patient’s needs,” Thompson said.

When asked what women can do to advocate for themselves and improve their own health outcomes, she said, “The best thing is education, knowledge, and developing a rapport with your health care provider from the beginning. But we have to see you early and often to be able to do that.”

Salazar, now nearly twenty years removed from her traumatic birth experience, has her own advice for women who may feel as though they aren’t being heard. “I was young and naïve. I had no idea that people in that position could be so negligent or just so mean. If I was going through that experience now I would not allow the nurse to ignore us or speak to us the way she did, nor would I allow the anesthesiologist to play God with my pain.”

She said she wished she had filed complaints about the lack of care and professionalism she received.

Salazar said she hopes sharing her story will help others speak up if they find themselves in a similar situation and realize just because hospital staff members are treating them a certain way, doesn’t mean it’s normal.