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Rising Maternal Mortality Rates Disproportionately Affect Women Of Color

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.
Alyssa Candela, Rosa Salazar
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.

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.

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.

Alyssa Candela and Miguel Espinoza pose for a photo with their son Malachi. 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 very hard decision," Candela said.
Alyssa Candela, Rosa Salazar
Alyssa Candela and Miguel Espinoza pose for a photo with their son Malachi. 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 very hard decision," Candela said.

"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.

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.

"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.

Maternal mortality rate is calculated by dividing the total number of deaths due to pregnancy, childbirth and during postpartum period by the total number of live births. That number is multiplied by 100,000 to determine the rate.
Data collected from Iowa Department of Public Health
2019 Vital Statistics of Iowa
Maternal mortality rate is calculated by dividing the total number of deaths due to pregnancy, childbirth and during postpartum period by the total number of live births. That number is multiplied by 100,000 to determine the rate.

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.

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.

And equal care is not equitable care.
Stephanie Trusty, nurse clinician for the Iowa Department of Public Health

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."

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.

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
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.

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.

En español

Alyssa Candela entraba y salía de la conciencia. Las luces que había sobre ella le quemaban los ojos mientras una multitud de personas se arremolinaba a su alrededor. Estaba muy asustada. Y no sabía qué iba a pasar. Sólo quería que ella y su bebé sobrevivieran.

Estaba en el hospital, sin haberlo planeado. Era el momento de dar a luz a su bebé, pero debido a un grave problema de salud, casi no lograron sobrevivir.

En un vídeo que grabó la primera vez que Candela conoció a su hijo Malachi, su piel, normalmente bronceada, parecía pálida. Le costaba hablar.

Una enfermera ligeramente fuera del encuadre de la cámara le preguntó: “¿Quieres darle un beso?”

Candela respondió con un murmullo arrastrado: “Mmmhmm”.

La madre primeriza de 26 años tuvo un caso tan grave de preeclampsia que ella y su hijo estuvieron a punto de morir en el parto a finales del año pasado. Se enjugó las lágrimas al recordar aquel día.

“No me gusta pensar en ello porque fue aterrador”, sollozó Candela. La madre la abrazó a su lado.

“Sólo recuerdo que estaba tumbada en la cama cuando me llevaron al quirófano y no veía más que luces y mucha gente corriendo de un lado a otro. Y verlos correr tan rápido me hizo pensar que iba a morir. Y pensé que iba a perder a mi bebé”, dijo.

Lo que aumentó su miedo fue que su madre no pudo acompañarla. Debido a las precauciones del COVID-19, el hospital sólo permitía que una persona estuviera con ella. Y ese era el padre del bebé, Miguel Espinoza. Mientras tanto, la mamá de Candela, Rosa Salazar, tuvo que esperar en el estacionamiento.

“Me pareció muy triste. Les gritaba a las enfermeras y les decía que estaba mal. Es su primer bebé, está asustada. Es mi primer hijo que tiene un bebé y estaba asustada”, dijo Salazar. Su voz vaciló y se enjugó las lágrimas.

Salazar se describió a sí misma como “loca, desquiciada” por no poder ayudar a su hija ni a su nieto. Malachi estaba naciendo semanas antes de tiempo. Espinoza la mantuvo al teléfono durante todo el parto.

“Me contaba todo y me decía: ‘Tenemos que ir a una cesárea de emergencia porque podemos perder a los dos por la presión arterial de ella y el ritmo cardíaco de él'”, recuerda Salazar.

El temor de que su hija no sobreviviera al parto no era para nada descabellado, especialmente en Iowa. Candela se enfrenta a un par de factores de riesgo: vive en Muscatine, donde el hospital interrumpió sus servicios de parto y alumbramiento, lo que significa que tuvo que viajar unos 45 minutos en ambulancia hasta Iowa City para recibir atención de parto.

Candela había empezado a mostrar síntomas de la mortal enfermedad un mes antes, pero no le habían dicho que buscara mayor atención en ese momento.

Otro factor de riesgo es que es latina. (Casi el 20% de Muscatine es latino.) Candela nació en Muscatine y Salazar nació en Del Rio, Texas, pero Salazar se crió en parte en México.

La madre y la hija, con 20 años de diferencia, abrazaron a Malachi y se sentaron juntas. Ambas lloraron cuando hablaron del roce de Candela con la muerte.

En Iowa, la tasa de mortalidad materna ha aumentado casi cada década. En 1999, morían unas ocho mujeres por cada 100,000 nacidos vivos. En 2009 la cifra subió a poco más de 10. Y en 2019, era de 16. La tasa específica de mortalidad materna puede tener altibajos dependiendo de cuántos nacimientos vivos hubo en el estado en un año determinado.

En general, el Comité de Revisión de la Mortalidad Materna de Iowa encontró que las latinas tienen casi el doble de probabilidades de morir que las mujeres blancas en el estado. Y las mujeres afroamericanas y asiáticas tienen un riesgo aún mayor. Stephanie Trusty está intentando averiguar por qué.

“Creo que es el racismo sistémico y los determinantes sociales de la salud que sin duda son parte de ella”, dijo Trusty. “Vamos muy mal encaminados”.

En abril, la directora de los Centros para el Control y la Prevención de Enfermedades de EE.UU., la Dra. Rochelle Walensky, declaró que el racismo es una grave amenaza para la salud pública.

Trusty es enfermera clínica del Departamento de Salud Pública de Iowa. Enumeró otros “determinantes sociales” como la depresión, la ubicación geográfica, el acceso a los alimentos y la educación e incluso el WiFi.

“Creo que nos queda trabajo por hacer en ese ámbito para entender los factores que contribuyen a la mala salud, desde aquellas cosas que no son médicas”, dijo Trusty. Dijo que la Universidad de Iowa añadirá una vía rural al programa de residencia en obstetricia y “reforzará” otros recursos para las madres de Iowa.

Trusty también forma parte del equipo que prepara la revisión estatal de la mortalidad materna. Por ley, están obligados a revisar cualquier muerte de una mujer durante su embarazo hasta un año después del parto.

El equipo de Trusty, en colaboración con la Universidad de Iowa, se encuentra a mitad de camino de su subsidio de cinco años para mejorar los resultados de la salud materna en el estado. Es uno de los nueve estados que han recibido estos fondos. Según el Colegio Americano de Obstetras y Ginecólogos, Iowa es el estado con menos obstetras per cápita del país. Trusty dijo que ella y otros expertos en atención de salud están preocupados por el número de hospitales que cierran sus servicios de obstetricia.

Empezó a centrarse en el tema después de que su propia familia sufriera una muerte cuando ella tenía cinco años. Aunque su madre no murió durante el parto, su hermano pequeño no sobrevivió más de un día.

“Empecé a interesarme por la medicina y por trabajar para prevenir el dolor, la pena y el dolor que mi familia experimentó con la muerte de mi hermano”, dijo Trusty.

Dijo que la mayoría de las veces, la muerte materna es evitable, pero a veces los prejuicios pueden influir. Subrayó que no es culpa de la madre.

“Tenemos esta cultura con nuestros profesionales de la salud de: ‘Bueno, somos buenos en Iowa. Tratamos a todo el mundo por igual. No soy racista. No discrimino a nadie'”, explicó Trusty. “Así que no entienden el sesgo implícito que a veces tienen en la atención. Y una atención igual no es una atención equitativa”.

Trusty utilizó un ejemplo. Si una mujer blanca nacida en Iowa tiene una hora con un médico, puede tener menos preguntas y menos preocupaciones que una mujer que no habla inglés con fluidez y es de otro país. Así que una hora supone una atención diferente para las mujeres, aunque sea el mismo tiempo.

Candela dijo que sentía este sesgo implícito. Su amiga, que es blanca, también tuvo preeclampsia pero no tuvo las mismas experiencias. Candela describió su embarazo como todo lo contrario a como lo había planeado.

Quería un parto natural, pero le quitaron esa decisión. Dijo que ni siquiera tuvo tiempo de pensar en su confusión, y sintió que nadie podía responder a sus preguntas.

“No sé, sentí que no me prestaron atención, especialmente por lo que pasé allí. Siento que mi situación era muy seria, pero no pensé que se tomara tan en serio”, dijo Candela. “Al principio quería un segundo para pensar o respirar y me dijeron que no había tiempo para nada”.

Dijo que el personal necesitó varias veces para administrar correctamente la epidural. Como es la mayor de cuatro hermanos y contó con la ayuda de Salazar durante todo el embarazo, Candela dijo que se sentía muy preparada antes de dar a luz de urgencia. Cuando la gente no pudo responder a sus preguntas, la autodenominada nueva madre tímida se sintió aún más perdida.

Hay algunas organizaciones externas que trabajan en Iowa para solucionar estos problemas. Pero algunas no tienen suficientes recursos para atender a todo el estado, especialmente a las zonas rurales y a las mujeres que no dominan el inglés.

“Está el impacto del racismo sistémico y las disparidades de salud que persisten. Y eso, ya sabes, no es exclusivo de Iowa. Es un problema nacional”, dijo Jordan Wildermuth.

Wildermuth es el director de asuntos gubernamentales de la Oficina Nacional de Servicios de la Asociación de Enfermeras y Familias (NFP, por sus siglas en inglés). Esta organización asocia a las enfermeras tituladas con las madres para abordar y combatir las disparidades sanitarias. Pero el NFP sólo atiende a seis condados de Iowa: Pottawattamie, Montgomery, Polk, Jackson, Clinton y Scott. Y cuando está al límite de su capacidad, no tiene recursos para ayudar a nadie más.

Se calcula que el 15% de las madres del programa NFP de Iowa se identifican como latinas, aunque éstas sólo representan algo más del 6% de la población del estado.

Wildermuth coincidió con Trusty en que existen prejuicios implícitos en la atención a la salud materna. Por eso el NFP trabaja con las madres, para que aprendan a abogar por sí mismas y por su propia salud. Esto, dijo Wildermuth, es una forma de empoderar a las madres para que puedan identificar mejor cómo les afectan las disparidades del sistema.

En cuanto a Candela, dice que quiere tener otro hijo en algún momento, pero no está segura de si seguirá con el mismo equipo de cuidado de salud.

Aunque sólo pesó un kilo al nacer y pasó sus primeras semanas en la unidad de cuidados intensivos neonatales, Malachi está ahora feliz y sano. Candela dice que es un bebé tranquilo y que incluso duerme toda la noche. Salazar dice que le encanta llegar a casa del trabajo todos los días para verlo.

La traducción de Hola Iowa.

Kassidy was a reporter based in Des Moines