Vital signs: Checking in on DC’s maternal health care crisis
Nandi Barton faced many closed doors during and after her pregnancy. Her experience was stressful from beginning to end. “I was alone and depressed,” she siad.
During her pregnancy, Nandi gained over 100 pounds, which led to breathing problems. She was placed on bedrest for several weeks. At one point, she tried going to the Virginia Williams Family Resource Center in Northeast, which provides emergency shelter. They told her that her mother couldn’t put her out without 30 days’ notice, and then they sent her back. Her mother’s home provided shelter, she said, but wasn’t a “place for me to rest, heal or eat healthy. I had to pay for my grandma to come to DC just so I could have some help, but she was helping my other family members. So it was stressful because she was supposed to only be there for me.”
Her problems didn’t let up postpartum. Nandi, 28, delivered her baby girl in June but some complications led to the baby being placed in a neonatal intensive care unit, which meant a lot of going back and forth from her hospital room to the nursery. “I had a midwife during labor and a doula. They both were great. But after they left, I was all alone. No one was there to advocate for me. It was just me,” she said. She developed blood clots and was in pain. It took five months, Nandi said, for her to truly heal from her pregnancy.
Today, Nandi and her baby are doing well. She has an apartment in Ward 8 and an internship. “I couldn’t have made it this far without God and the people God placed in my life, the clothes from Capitol Hill Pregnancy Center, and the help from DC Primary Care Association. I really can’t stress that enough.”
The spotlight on maternal health in America — and in the District — has grown in intensity over the last few years. There has been increased scrutiny about the care available to expectant mothers, especially in black communities where health care can be deficient. In late October The Atlantic, Bloomberg Philanthropies and The Aspen Institute hosted their annual City Lab Summit on the Southwest waterfront, with maternal health among the event’s topics. This traveling think tank brought together experts, policymakers and thought leaders from cities around the world to converse about common issues and solutions that affect urban settings.
DC Mayor Muriel Bowser and March of Dimes president and CEO Stacey Stewart were panelists at a discussion about maternal health. “In our city, access to health insurance is not the issue,” Bowser said. “Over 95% of Washingtonians have insurance. We wanted to know what it’s going to take for all of our citizens to manage the best health care possible. And when they do have concerns, are they heard? Are they listened to?”
The mayor made several points about the maternal mortality problem and possible solutions, as well as social determinants that continue to plague some DC mothers. So what is being done to lower maternal mortality rates and increase the availability of supportive services? And how are socioeconomic issues that women like Nandi face being addressed?
Diving into mortality rates
The Joint Commission, the country’s top healthcare accrediting organization, raised the alarm back in 2010 regarding the national uptick in maternal mortality rates. The group noted that as of 2006, the national maternal mortality rate was on the rise at 13.3 deaths per 100,000 live births — far above the 1990 rate of 8.2 per 100,000. In its alert, the commission warned of contributing factors such as hemorrhage, hypertension and pre-existing chronic conditions.
This trend, however, has not yet been reversed either nationally or locally. The five-year maternal mortality rate in the District from 2012 through 2016 was 27.3 deaths per 100,000 live births, which, according to DC Department of Health senior deputy director Dr. Anjali Talwalkar, is statistically similar to the national rate of 21.2 per 100,000 live births. Talwalkar explained that 13 maternal deaths occurred in the District over those five years.
Two years ago, the DC Council passed the Maternal Mortality Review Committee Establishment Act of 2018, which required the city to assemble a panel of local experts and residents experienced in maternal care to examine the causes of maternal deaths, identify trends and recommend methods for preventing maternal deaths.
Dr. Roger Mitchell, DC’s chief medical examiner, played an active role in developing the legislation and was appointed by the mayor to lead the committee. The panel has met four times since forming in April 2019.
“The committee really wants to understand what are the issues surrounding pregnancy in the District, and then find where the system can be improved to ensure a better outcome for our mothers,” Mitchell said.
Mitchell explained that the committee investigates each maternal death case and then, based on the results of the investigation, provides a series of recommendations for health care providers and support personnel.
DC Council members have proposed several bills in recent months to combat the rise in maternal mortality rates. In June, Ward 6 Council member Charles Allen introduced the Maternal Health Care Improvement and Expansion Act of 2019 with suppport from 11 colleagues. The bill — among several discussed at a Dec. 18 public hearing — proposes to expand maternal health services covered by insurance, such as increased postpartum visits and transportation stipends to get to the doctor. The bill also calls for a maternal health and wellness center to consolidate multiple services into one location. Finally, the bill mandates implicit bias training as part of continuing education requirements for medical professionals.
In September, Bowser asked Charles Allen to introduce the Investigating Maternal Mortalities Emergency Amendment Act of 2019. The legislation, which passed in October and expires on Jan. 21, requires mandatory reporting of all maternal deaths occurring in the District so that the Office of the Chief Medical Examiner can investigate and determine the cause. A temporary version became law Jan. 10 and will remain in effect for 225 days; the permanent legislation has not yet had a public hearing.
The role of social determinants
According to the DC Department of Health, black DC residents continuously face an uphill battle for equitable health care and an infrastructure that supports wellness. This carries into maternal health care as well. The March of Dimes’ Stewart stated at the City Lab Summit that implicit bias has been an issue in the obstetrics field for a long time. “We have systemic challenges and racial inequity going back decades, and some people are just waking up to this fact, but some of us have been living this a long, long time,” she said.
There are 39 facilities in the District that provide prenatal care but their locations show a glaring slant. Ward 2, for example, has 12 facilities, whereas wards 7 and 8 each have four. Ward 4 has only two and Ward 6 has only one.
Dr. Jalan Washington Burton — a Ward 7 resident, pediatrician and founder of Healthy Home Pediatrics, a home-care medical practice — worked briefly in the Children’s National Hospital community pediatric department and as the attending pediatrician who worked with high-risk deliveries in the newborn nursery of the obstetrics department before going into private practice. She stressed the need to reevaluate the quality of care provided to expectant mothers in wards 7 and 8.
“I think we need to look at the quality of services we offer,” Burton said in an interview. “We should be offering the same quality of services that we offer in Northwest. It’s not the same.”
Burton remembers interacting with pregnant women when she worked with the now-shuttered OB/GYN department at United Medical Center, the city-owned hospital in Ward 8 that serves an area with the District’s highest poverty rates. She assisted pregnant women who tested positive for marijuana and crack cocaine. She also remembers how stressed the mothers were, as well as the lack of resources available to help them. “I had never seen a lot of the things I saw there. It was an eye-opening experience,” she said. “But it shows that the people east of the river were underserved.”
Bowser has hosted two maternal health summits: in September 2018 and September 2019. Washington-Burton, who attended the first one, said she isn’t sure how helpful they were. “My friends and I were texting at the summit and we were like, ‘I wonder how many OB/GYN salaries we can pay with the money they used to buy these swag bags. I wonder how many community health worker salaries we can pay for with this lunch that we are getting for free. Or how many women’s rents we can pay in a high-quality apartment instead of leaving them in these apartments that are old with roaches and rats and mice.’”
The 2017 closures of United Medical Center’s obstetrics ward in Southeast and Providence Hospital’s maternal and infant care services in Northeast caused a shift in maternal care in the District. Prior to closing, United Medical Center had been losing business when residents living nearby chose to deliver their babies in hospitals across town. Prior to the closure, UMC had made several serious mistakes in its maternity ward; one led to a newborn contracting HIV from its mother, and another led to the death of a pregnant woman who had trouble breathing. The hospital’s overall ratings have been poor for years.
Providence Hospital also suffered from poor ratings prior to closing its obstetrics ward. Patient volume had been declining for several years as residents chose to go elsewhere to receive health care. The Ward 5 hospital subsequently closed in April 2019 despite strong resistance from workers, residents and DC Council members; Providence reopened as an urgent care center three months later.
Putting solutions into place
The DC Primary Care Association (DCPCA), a nonprofit health advocacy organization, has been following the health care in the District since 1996. With funding from the Institute for Healthcare Improvement, a Boston-based nonprofit focused on improving the quality of health care, DCPCA created a maternal health equity lab in 2018. The lab brings together people who know the maternal health system best — those who provide care, and women who have recently experienced it — to co-design strategies to address issues surrounding maternal and perinatal health. The DC Department of Health is working with the equity lab to inform future health policy.
There are three design teams that are looking at respectful care, postpartum support, and awareness of and access to high-quality medical services, explains Patricia Quinn, director of policy and external affairs at DCPCA. “All three of those things came out of [the group’s September 2018] report about women, their experiences, what they knew about how they felt about the care, and what was missing for them in that care,” Quinn said. “It’s been a really exciting project.”
Policy solutions are in the works to help ease the burden of finding trained professionals to help care for expectant mothers. In June, every DC Council member signed on to introduce the Perinatal Health Worker Training Access Act of 2019. The bill, which drew mostly supportive testimony at a public hearing on Dec. 18, would “require the Department of Health to distribute grant funds to promote a perinatal health worker training program for residents in Wards 5, 7, and 8 in the health field.” The services these workers could provide include pre- and post-natal visits with mothers; labor and postpartum support; and referrals to social services such as housing assistance.
“Perinatal health workers serve as liaisons between their clients and the health system,” at-large Council member Robert White said in an interview with The DC Line. “They make sure clients receive culturally appropriate care from the healthcare system and that health care providers listen and respond to women respectfully — something many black patients don’t experience when interacting with the health care providers,” said White, whose office drafted the bill.
He added that the birth of his own children gave him perspective on the perils of delivering babies in the District.
“Standing in the hospital room with my wife as she delivered our children, I could not help but worry about the alarming infant and maternal mortality rate,” White said. “My very own wife’s life was at risk just by giving birth in the District as a black woman.”
The Maternal Mortality Review Committee has one opening for a community member impacted by maternal mortality. The committee meets every other month on the fourth Tuesday of the month. The next meeting is scheduled for Jan. 28 from 10 a.m. to noon. Anyone interested in serving is invited to call Jenna Beebe-Aryee, the supervisory program manager of the Fatality Review Unit at the Office of the Chief Medical Examiner, at 202-689-9081.
This post has been updated to streamline the opening paragraphs and to clarify details about Dr. Jalan Washington Burton’s work at United Medical Center, to update the status of the Investigating Maternal Mortalities Temporary Amendment Act of 2019, and to include information on the Maternal Health Care Improvement and Expansion Act of 2019.
Comments are closed.