Rising Maternal Mortality Rates Disproportionately Affect Women Of Color

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Alyssa Candela, left, poses for a photo with boyfriend Miguel Espinoza and their newborn son Malachi in December, 2020. He was born one day before Candela's birthday. Candela had such a severe case of preeclampsia, both she and Malachi almost didn't survive the birth.
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By Kassidy Arena, Iowa Public Radio

Alyssa Candela drifted in and out of consciousness. The lights above her burned her eyes as a rush of people shuffled around her. She was so scared. And she didn’t know what was going to happen. She just wanted her and her baby to live.

She was in the hospital, unplanned. It was time to deliver her baby, but due to a serious health condition, they almost didn’t survive.

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In a video that recorded the first time Candela met her son Malachi, her normally tan skin looked pale. She struggled to speak.

A female nurse slightly out of the camera’s frame asked her: “You wanna give him a kiss?”

Candela replied with a slurred mumble: “Mmmhmm.”

The 26-year-old first-time mom had such a severe case of preeclampsia that she and her son almost died in childbirth at the end of last year. She wiped away tears as she recalled the day.

“I don’t like to think about it because it was scary,” Candela sobbed. Her mom held her closer to her side.

“I just remember laying on the bed when they took me to surgery and seeing nothing but lights and so many people running around. And seeing them run around so fast made me think I was gonna die. And I thought I was going to lose my baby,” she said.

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What added to her fear was that her mom couldn’t come with her. Due to COVID-19 precautions, the hospital only allowed one person to be with her. And that was the baby’s dad Miguel Espinoza. Meanwhile, Candela’s mom Rosa Salazar had to wait in the parking lot.

Alyssa Candela and Miguel Espinoza pose for a photo with their son Malachi who is just about six months old now. Espinoza was the only person allowed with Candela during the delivery. “With COVID it only had to be one person. And that was hard. It was a very hard decision,” Candela said.

“I thought that was really sad. I was yelling at the nurses and I’m like it’s just wrong. It’s her first baby, she’s scared. My first kid having a baby and I was scared,” Salazar said. Her voice wavered and she wiped her own tears away.

Salazar described herself as being “insane, crazy” because she couldn’t help her daughter or her grandson. Malachi was being born weeks too early. Espinoza kept her on the phone throughout the delivery.

“And he was telling me everything and he’s like, ‘We got to go to emergency C-section because we could lose both of them because of her blood pressure and his heart rate,'” Salazar recalled.

The fear that her daughter would not survive giving birth was not far-fetched at all, especially in Iowa. Candela faces a couple of risk factors: she lives in Muscatine, where the hospital paused its labor and delivery services, meaning she had to ride about 45 minutes in an ambulance to Iowa City for maternal care.

Candela had started exhibiting symptoms of the deadly condition a month prior, but she hadn’t been told to seek further care at that time.

Another risk factor is that she’s Latina. (Almost 20 percent of Muscatine is Latino.) Candela was born in Muscatine and Salazar was born in Del Rio, Texas, but Salazar was partly raised in Mexico.

The mother and daughter, 20 years apart, held Malachi and sat close together. Both cried when they talked about Candela’s brush with death.

In Iowa, the rate of maternal death has risen almost every decade. In 1999, about eight women died for every 100-thousand live births. In 2009 the number rose to a little more than 10. And by 2019, it was 16. The specific rate of maternal mortality can ebb and flow depending on how many live births there were in the state in a given year.

Overall, Iowa’s Maternal Mortality Review Committee found Latinas are almost twice as likely to die as white women in the state. And Black and Asian women are at an even higher risk. Stephanie Trusty is trying to figure out why.

“I do think it is systemic racism and social determinants of health that certainly are part of it,” Trusty said. “We’re going very much in the wrong direction.”

In April, the director for the U.S. Centers for Disease Control and Prevention Dr. Rochelle Walensky declared racism a serious public health threat.

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Trusty is a nurse clinician for the Iowa Department of Public Health. She listed other “social determinants” like depression, geographic location, access to food and education and even WiFi.

“I think we have some work to do in that arena of understanding the contributors to poor health, from those things that are not medical,” Trusty said. She said the University of Iowa will be adding a rural track to the OB residency program and “beefing up” other resources for mothers in Iowa.

Trusty is also part of the team that prepares the state maternal mortality review. By law, they are required to review any death of a woman during her pregnancy through one year postpartum.

Trusty’s team, in partnership with the University of Iowa, is about halfway through its five-year grant to improve maternal health outcomes in the state. It is one of nine states to have received these funds. According to the American College of Obstetricians and Gynecologists, Iowa has the fewest obstetricians per capita in the country. Trusty said she and other health care experts are concerned about the number of hospitals closing their OB services.

She began focusing on the topic after her own family experienced a death when she was five years old. Although her mother did not die during childbirth, her infant brother did not survive longer than a day.

“I became interested in medicine and working to prevent the pain, that grief and pain that my family experienced with the death of my brother,” Trusty said.

She said the majority of the time, maternal death is preventable, but sometimes bias may play a role. She emphasized it’s not the mother’s fault.

“We have this culture with our healthcare professionals of: ‘Well, we’re Iowa nice. We treat everybody the same. I’m not racist. I don’t discriminate against anyone,'” Trusty explained. “So it’s them not understanding the implicit bias that they sometimes have in care. And equal care is not equitable care.”

Trusty used an example. If one Iowa-born white woman has an hour with a doctor, she may have fewer questions and fewer concerns than a woman who doesn’t speak English fluently and is from another country. So one hour amounts to different care for the women, even though it’s the same amount of time.

Candela said she felt this implicit bias. Her friend, who is white, also had preeclampsia but didn’t have the same experiences. Candela described her pregnancy as the exact opposite of how she planned it.

She had wanted a natural birth, but that decision was taken away from her. She said she didn’t even have time to think in her confusion, and felt like no one could answer her questions.

“I don’t know I just felt like they didn’t pay attention to me especially for what I went through there. I just feel like my situation was very serious, but I didn’t think it was taken that serious,” Candela said. “I wanted just a second to like think about it or breathe at first and they said there was no time for anything.”

Malachi Angel Candela Espinoza is just about six months old now. He was alert throughout the entire interview as his grandma, Rosa Salazar, held him.
Kassidy Arena/Zoom

She said it took a few times for the staff to properly administer the epidural. Since she’s the oldest of four, and had extensive help from Salazar throughout her entire pregnancy, Candela said she had felt very prepared before going into emergency childbirth. When people couldn’t answer her questions, the self-described shy new mother felt even more at a loss.

There are a few outside organizations working in Iowa to address these problems. But some don’t have enough resources to serve the entire state, especially rural areas and women who aren’t fluent in English.

“There’s the impact of systemic racism and health disparities that persist. And that’s, you know, that’s not unique to Iowa. That’s a nationwide issue,” Jordan Wildermuth said.

He’s the senior government affairs manager for the Nurse-Family Partnership National Service Office (NFP). It partners registered nurses with mothers to address and combat health disparities. But NFP only serves six counties in Iowa: Pottawattamie, Montgomery, Polk, Jackson, Clinton and Scott. And when it’s at capacity, it doesn’t have the resources to help anyone else.

An estimated 15 percent of mothers in Iowa’s NFP program identify as Latina, although Latinos only make up a little more than six percent of the state’s population.

Wildermuth agreed with Trusty that there are implicit biases within maternal health care. That’s why NFP works with mothers, so they can learn how to advocate for themselves and for their own health. This, Wildermuth said, is one way to empower mothers so they can better identify how disparities in the system affect them.

As for Candela, she said she wants another child at some point, but she’s not sure if she’ll stick with the same healthcare team.

Although he was only three pounds at birth and spent his first few weeks in the neonatal intensive care unit, Malachi is now happy and healthy. Candela said he is an easy baby, and even sleeps through the night. Salazar said she loves to come home from work every day to see him.

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