American women are still dying at alarming rates while giving birth

Advocates across the U.S. are working to reduce the number of maternal deaths

Photograph by Lynsey Addario
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Brittany Ferrell, 29, is a community activist and high-risk obstetrics nurse from St. Louis, Missouri who was prominently featured in the 2017 Netflix documentary “Whose Streets?” about the 2014 protests that erupted in Ferguson, Missouri after the police-related shooting death of teenager Michael Brown. Ferrell co-founded Millennial Activists United, "an activist collective created by queer black women," and is pursuing a Masters of Public Health degree at Washington University’s Brown School.
Photograph by Lynsey Addario

When Brittany Ferrell earned her pediatric nursing degree from the University of Missouri St. Louis in May of 2014, she’d already had lots of experience as a community activist.

During two years as president of the Black Students’ Nursing Association, Ferrell helped develop community outreach programs and workshops about sexual, mental and nutritional health, and used social media to publicize them widely.

Ferrell’s desire to link activism with neighborhoods came to an explosive head in August of 2014, after an unarmed 18-year-old black youth named Michael Brown was shot and killed by police in the St. Louis suburb of Ferguson, Missouri.

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Shavanna Spratt, office manager of Jamaa Birth Village, attends a mothers' group meeting with Denicia Billups and Jocelyn Lee at Jamaa Birth Village in Ferguson, Missouri. Jamaa, a word that means “family” in Swahili, is a self-proclaimed “sacred and safe space" for expectant mothers and families. It has helped more than 250 families in North St. Louis and nearby suburbs with perinatal care. Jamaa focuses on lowering maternal and infant death rates by providing doula services, nutrition education and breastfeeding support.

 

During nationally-televised protests, advocacy moved from the academic to the neighborhoods for Ferrell. She says she participated in the outcry about Brown’s death for 100 straight nights. Her vocal, prominent presence led to her being one of the central subjects of the 2017 Netflix documentary about the Ferguson uprising entitled “Whose Streets?”

Ferrell is known throughout Missouri and the Midwest for her community organizing and activism. She’s most passionate about the challenges for pregnant women of color in St. Louis and beyond.

“There’s absolutely no reason why black women should be dying at the rate we’re dying,” Ferrell says. “Just like state violence is allowing black folks to be shot dead in the street, and no one’s being held accountable or even having to atone for the death of black bodies, the same thing is happening in these medical institutions.”

That Ferrell’s reproductive health activism is unfolding in a town that made international headlines for social justice is no coincidence.

Missouri’s status as the state with one of the highest maternal mortality rates in the U.S. makes it a prime stage for America’s burgeoning “birth equity movement,” which suggest that factors like poverty, racism, social and economic policy impact African American mothers and babies from the moment they’re born.

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Minoksho Gonzales and her son Kaleb are with nurse Jessica Garrett at the Family Birthplace at SSM Health St. Mary’s Hospital in St. Louis, the regional hub for maternal services and high-risk obstetrics. It is fully equipped with a Level III neonatal intensive care unit.

More than 700 women die each year in the U.S. from causes related to pregnancy or childbirth. Black women have a maternal mortality rate three times higher than that of white women. At least 60 percent of maternal deaths are preventable.

The House of Representatives unanimously approved a bill this week, the Preventing Maternal Deaths Act, to fund state committees to review and investigate deaths of expectant and new mothers, to train providers to improve the quality of care and to make a summary of each maternal death available to the public. The bipartisan legislation, which authorizes $12 million a year in new funds for five years, would pay for research that would yield more accurate data and identify the specific factors fueling the death of mothers, enabling states local and state governments to develop more effective strategies to address the issue. The bill still must be approved by the U.S. Senate.

In fact, the past few years have yielded an unprecedented focus on the issue of maternal health—and death—for black American women. At the forefront of this movement are organizations like the National Birth Equity Collaborative, and the group Black Mamas Matter, both comprised of academicians, medical professionals and community health activists who have collaborated to develop compelling personal stories, research and policy strategies to reinforce the message that black women face serious, quantifiable risk of death or major disability related to pregnancy. The crisis is so real that a coalition of black women mayors from across the nation have formed a coalition intended to direct policies and resources to address the problem, without waiting for federal intervention.

“We can’t just talk about our reproductive health and rights from a single issue lens. Our lives are much more complex than that,” says Monica Simpson, executive director of the Sister Song Women of Color Reproductive Justice Collective based in Atlanta, GA. “The way that the multiple layers of oppression show up in our world is not the same way that privileged communities get to experience these issues. This is why black women came up with the term ‘reproductive justice,’ which is looking at connection between the very real social justice issues that come into our lives every single day.”

MOTHERS AT RISK

The United States struggles with pregnancy-­related deaths, many of which are preventable. The causes range from a rise in pregnancy-­related medical conditions and the age of women giving birth to a lack of standardized protocols across hospitals. The U.S. fares better than most developing nations (Sierra Leone has the world’s highest maternal mortality rate, at 1,360 deaths per 100,000 live births) but is one of only two developed nations whose rate has worsened in recent decades.

MATERNAL MORTALITY RATE

The rate is calculated as the number of maternal deaths while pregnant or within 42 days of the end of pregnancy, for every 100,000 live births.

Romania in 1990 had 120 maternal deaths per 100,000 live births.

70

IN DEVELOPED COUNTRIES

Ages 15 to 49

1990

MORE DEATHS

60

FEWER DEATHs

2015

NO CHANGE

50

THE OUTLIERS

The U.S. and Serbia are the only developed nations whose maternal mortality rates have increased since 1990.

40

30

The 2015 U.S. rate was 14 maternal deaths per 100,000 live births.

20

10

0

MATERNAL MORTALITY BY U.S. STATE

Average rate, 2011-2015

All ages

WESTERN

CENTRAL

EASTERN

40

30

20

10

0

WHICH AMERICAN WOMEN ARE DYING

Black women are 2.6 times as likely to die due to a pregnancy-related cause as white women. Older women also face greater risk.

U.S. deaths per 100,000 live births, 2011-2015

race/ethnicity

Black

47.2

Native Am.

38.8

White

18.1

12.2

Hispanic

Asian

11.6

AGE

35-44

38.5

25-34

14.0

15-24

11.0

HOW THEY’RE DYING

Heart-related problems are a leading cause of maternal death; heart attack risk increases with obesity and age.

2011-2014

15.2%

Cardiovascular disease

14.7%

Endocrine, blood, other disorders

12.8%

Infection

11.5%

Hemorrhage

10.3%

Heart-muscle disease

9.1%

Pulmonary embolism

7.4%

Stroke

Hypertension

6.8%

Unknown

6.5%

Other

5.8%

ACCESS TO PRENATAL CARE

Women with no prenatal care at all are up to four times more likely to suffer a pregnancy-­related death.

Women with no care or only third-trimester care

Native Am.

12%

Black

9%

Hispanic

8%

6%

Asian

White

4%

WHEN THEY’RE DYING

Risk doesn’t end when pregnancy ends. Potentially fatal post-pregnancy complications include blood clots and hemorrhages.

38%

18%

45%

While

pregnant

Six weeks to one year after

End of pregnancy to six weeks after

THE WORLD HEALTH ORGANIZATION MAY ADJUST U.S. AND OTHER NATIONS’ DATA TO ENSURE COMPARABILITY AT THE GLOBAL LEVEL. *DE, NH, AND WY DATA 2005-2015. DATA UNAVAILABLE FOR ALASKA AND VERMONT. RACE (WHITE AND BLACK) EXCLUDES PEOPLE OF HISPANIC ETHNICITY. HISPANIC INCLUDES HISPANICS OF ALL RACES. ASIAN INCLUDES PACIFIC ISLANDERS. NATIVE AMERICAN INCLUDES ALASKA NATIVES.

 

MONICA SERRANO, NGM STAFF; KELSEY NOWAKOWSKI

SOURCES: “TRENDS IN MATERNAL MORTALITY: 1990 TO 2015,” WHO; CDC; “BUILDING U.S. CAPACITY TO REVIEW AND PREVENT MATERNAL DEATHS”; AMERICA’S HEALTH RANKINGS

Romania in 1990 had 120 maternal deaths per 100,000 live births.

MOTHERS AT RISK

The United States struggles with pregnancy-­related deaths, many of which are preventable. The causes range from a rise in pregnancy-­related medical conditions and the age of women giving birth to a lack of standardized protocols across hospitals. The U.S. fares better than most developing nations (Sierra Leone has the world’s highest maternal mortality rate, at 1,360 deaths per 100,000 live births) but is one of only two developed nations whose rate has worsened in recent decades.

MATERNAL MORTALITY BY U.S. STATE

Average rate, 2011-2015

All ages

70

WESTERN

CENTRAL

EASTERN

60

60

MATERNAL MORTALITY RATE

The rate is calculated as the number of maternal deaths while pregnant or within 42 days of the end of pregnancy, for every 100,000 live births.

50

50

IN DEVELOPED COUNTRIES

Ages 15 to 49

40

40

MORE DEATHS

1990

FEWER DEATHs

2015

NO CHANGE

30

30

THE OUTLIERS

The U.S. and Serbia are the only developed nations whose maternal mortality rates have increased since 1990.

20

20

The 2015 U.S. rate was 14 maternal deaths per 100,000 live births.

10

10

0

0

WHICH AMERICAN WOMEN ARE DYING

HOW THEY’RE DYING

Black women are 2.6 times as likely to die due to a pregnancy-related cause as white women. Older women also face greater risk.

Heart-related problems are a leading cause of maternal death; heart attack risk increases with obesity and age.

U.S. deaths per 100,000 live births, 2011-2015

2011-2014

Cardiovascular disease

15.2%

race/ethnicity

Black

47.2

Endocrine, blood, other disorders

14.7%

Native Am.

38.8

Infection

12.8%

White

18.1

Hemorrhage

11.5%

12.2

Hispanic

Heart-muscle disease

10.3%

Asian

11.6

Pulmonary embolism

9.1%

Stroke

7.4%

AGE

Hypertension

6.8%

35-44

38.5

Unknown

6.5%

25-34

14.0

Other

15-24

5.8%

11.0

WHEN THEY’RE DYING

ACCESS TO PRENATAL CARE

Risk doesn’t end when pregnancy ends. Potentially fatal post-pregnancy complications include blood clots and hemorrhages.

Women with no prenatal care at all

are up to four times more likely to suffer

a pregnancy-­related death.

Women with no care or only third-trimester care

Native Am.

12%

Black

9%

Hispanic

8%

38%

18%

45%

While

pregnant

Six weeks to one year after

End of pregnancy to six weeks after

6%

Asian

White

4%

THE WORLD HEALTH ORGANIZATION MAY ADJUST U.S. AND OTHER NATIONS’ DATA TO ENSURE COMPARABILITY AT THE GLOBAL LEVEL. *DE, NH, AND WY DATA 2005-2015. DATA UNAVAILABLE FOR ALASKA AND VERMONT. RACE (WHITE AND BLACK) EXCLUDES PEOPLE OF HISPANIC ETHNICITY. HISPANIC INCLUDES HISPANICS OF ALL RACES. ASIAN INCLUDES PACIFIC ISLANDERS. NATIVE AMERICAN INCLUDES ALASKA NATIVES.

 

MONICA SERRANO, NGM STAFF; KELSEY NOWAKOWSKI. SOURCES: “TRENDS IN MATERNAL MORTALITY: 1990 TO 2015,” WHO; CDC; “BUILDING U.S. CAPACITY TO REVIEW AND PREVENT MATERNAL DEATHS”; AMERICA’S HEALTH RANKINGS

The irrefutable data around black women and maternal death is so negative, that black women are far from the only stakeholders who are alarmed by the issue.

“What we see in maternal mortality is what we see everywhere else,” says Dr. William Callaghan, Chief of the Maternal and Infant Health Branch in the Division of Reproductive Health at the Centers for Disease Control and Prevention. “Black men are twice as likely to die from prostate cancer as white men. There’s a litany of that type of disparity. It’s certainly highlighted in maternal mortality, because you’re talking in most instances about otherwise healthy people with families, and oftentimes orphaned babies. "

Callaghan agrees with reproductive health activists that the ways race and ethnicity are encountered and processed in the medical setting directly impacts the issue.

"There’s all kinds of implicit bias, racial and unconscious bias about somebody who presents with a condition or symptoms that look a lot like something ordinary but isn’t. These judgement calls can occur around race. What they say is judged in a way that is based on their racial background.

“The other layer of fragmentation is the experience of being a black woman in America, and the intergenerational effects of racism and segregation. It all plays out through biology."

Pamela Merritt wasn’t raised to be a reproductive justice activist. Though her solid middle class upbringing in St. Louis, Missouri was fueled by parents who helped register neighbors to vote and espoused civil rights, they also worked hard to ensure that their children attended the best schools, wore the best clothes, spoke with clear, precise English.

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Lakisha Redditt gave birth to her son Landon on August 29, 2011 in Little Rock, Arkansas. Even though his heart rate dropped throughout her labor, doctors never performed an emergency c-section. During the delivery, the umbilical cord was wrapped around his neck in what was called a “true knot,” resulting in brain damage and multiple other health issues.

The “payoff for respectability,” as Merritt put it, came in the form of a six-figure job selling radio advertising in Dallas. While there, two things happened to spark her activism. The first occurred when a high-end retail client submitted a written request that their product not be advertised on “urban radio.” Merritt knew what that meant—they had no interest in black customers.

The next epiphany occurred when, at age 28, Merritt developed a severe case of uterine fibroids, along with endometriosis. She sought recommendations for an OB/GYN from her white work colleagues.

“There I sat with my perfect English, wearing my expensive suits and my expensive handbag, and I walked into that office and got treated like shit.,” Merritt says. “I was told that I needed to have a baby as soon as possible, because ‘most of you have had kids by now.’ I was spoken to like a piece of meat by specialists who never once asked me if I was in pain.”

When Merritt shared her story with her African American female friends, she discovered she wasn’t alone. “So many of them had experiences like mine and worse. And we were all what you would consider upper middle class. That’s when I drew the line from where I stood to where a young, lower-income black woman would probably go through in that same setting. And that’s when I couldn’t just turn my back.”

Watch how these women are saving black mothers’ lives In the U.S., black women are 2.6 times as likely to die due to a pregnancy-related cause as white women. Briana Green, a perinatal community health worker at Mamatoto Village in Washington, D.C., is trying to change that.

Today, Merritt is to co-founder and executive director of Reproaction, self-described as an advocacy group “upholding abortion rights and advancing reproductive justice as a matter of human dignity.” The group also monitors reproductive health spending in the Missouri, organizes rallies and demonstrations against “fake clinics,” and liaises with state legislators to make sure that reproductive health issues stay on the radar.

Reproaction seeks to amplify the work of activists like 31-year-old Brittany “Tru” Kellman, who’s on track to become the one of the first fully-licensed African American professional midwives in Missouri’s history in 2019. Kellman founded the Jamaa Birth Village, a support group in Ferguson.

Raised in Ferguson from the age of five, Kellman was pregnant by age 13 and in an abusive relationship. By age 17, Kellman was pregnant again, with no support and in yet another abusive relationship. So she saved up for an abortion.

Just days before the scheduled procedure, Kellman says she was contacted by the Ferguson police department about some past due traffic tickets. To avoid jail, she used her abortion money.

“I tried to kill myself multiple times after I had my second son,” Kellman explains. “I spiraled so far down, I just didn’t see any reason to keep going.” Three books helped save her life: “Sacred Pampering Principles: An African American Woman’s Guide to Self-Care and Inner Renewal,” a book about yoga, and another about spiritual midwifery.

“I went on a path of self-discovery starting in 2007. I realized I deserved to be treated with respect. I needed to treat myself with respect. It really laid the foundation for my midwifery training.” Kellman even traveled to Ghana to study traditional midwifery and birth support.

Kellman founded Jamaa in October of 2015, and began her formal midwifery apprenticeship in January of 2016, offering pregnancy support from her home at the same time.

That training also helped her realize how far too many women in North St. Louis are often completely isolated and lacking information, guidance and support as they consider getting pregnant, during those nine months and after birth.

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Midwife-in-traing Brittany “Tru” Kellman and Midwife Corina Hossle, do a prenatal check-up with April Turner, her partner, Antione Patterson, Sr., and their two children, Quinn Jones, 4, and Zakari Patterson, 1, in one of the birthing rooms at Embrace Midwifery and Birth Center in Richmond, Virginia. April was 31 weeks pregnant, and didn't receive any prenatal care until she was 28 weeks pregnant. Kellman is founder of the Jamaa Birth Village perinatal support center in Ferguson, Missouri. Her training helped her become one of the first fully-licensed Certified Practicing Midwives of color in the state of Missouri.

Which is ironic, many birth equity advocates say, considering the role African American women have played in America’s reproductive health history. Throughout the slavery era and into the early 20th century, African American “granny midwives,” were unofficially charged with overseeing the majority of births in many southern and rural settings, for black and white women alike. Only the advent of modern medical organizations and policies that outlawed non-hospital based deliveries fueled the demise of home deliveries—and with it the reverence for granny midwives.

But in the 21st century, African American women are once again taking the lead in the effort to ensure equitable access to care and support for women of color. In September of 2018, Washington DC Mayor Muriel Bowser convened a Maternal and Infant Health summit featuring African American female mayors of Flint Michigan, Gary Indiana, Baltimore, Maryland and Hartford, Connecticut. An audience of nearly 1,500 gleaned information about the latest research, policies and community health initiatives aimed at supporting better maternal and reproductive health for black women.

And in August of 2018, Bowser signed an agreement with George Washington University Hospital that would create a state of the art hospital and trauma center--and a full-fledged maternity ward—in Ward 8, one of the poorest, mostly minority areas of Washington, DC. Construction is slated to begin in 2020, with a goal of opening in 2023.

“Big city mayors recognize this problem, and we are acting on what we know works to solve it,” Bowser says. “Too often, any maternal death in our communities is outsized, in terms of the impact it has on families. Mayors are being forced to extend our reach to do things we used to rely on the federal government to provide. With this issue, we have to call on the knowledge, and the voices and the energy of our communities to save lives. We can’t wait for the next study or report.”

In this interview for ABC Live's 'Reporter's Notebook' series, National Geographic editor-in-chief Susan Goldberg and photographer Lynsey Addario discuss the making and importance of this story.