It’s been 15 months since nearly 20 doctors, midwives, and maternal health experts testified about childbirth in D.C. at a public hearing on maternal mortality.
They described the dire need for a committee to review the deaths of pregnant and new mothers in the District, which is home to an enduring, decades-long maternal mortality crisis. Some told tales of the horrors they’d seen, the extreme illnesses and deaths of women shortly after giving birth, beholding babies who would never meet their mothers. Some spoke at length about health disparities, that in the U.S. black women are three to four times more likely to die from childbirth than white women, a figure that holds true in D.C. They hoped the committee and the reports it would produce could help decrease maternal deaths here.
The District’s maternal mortality rate was 36.1 per 100,000 live births in 2018, while the national rate was 20.7, according to an analysis of data from the Centers for Disease Control and Prevention.
On Thursday at the Wilson Building, more than a dozen women—some of whom spoke at the 2017 hearing—will testify again about D.C.’s need for the committee. But this time, they’ll be speaking as committee nominees, set to be officially confirmed on April 6.
The District will finally have a maternal mortality review committee, joining nearly 30 other jurisdictions in the United States. Ward 6 Councilmember Charles Allen introduced the bill, in October 2017, to form “a multi-disciplinary committee to review all pregnancy-associated deaths occurring during pregnancy, childbirth, or in the year after.” It passed the following June.
Most committee positions are confirmed, but a key seat remains empty: the lived-experience position, reserved for someone who has lost a loved one to maternal mortality. And the committee’s work will not include one of the bill’s original components: the study of morbidity. Definitions of maternal morbidity vary, but at its worst it’s a near miss, when a woman has a life-threatening illness. Allen said that studying morbidity was beyond the office of the chief medical examiner’s current capacity, and so this piece is not in the final bill.
Dr. Connie Bohon, an OB-GYN, will serve on the committee as its American College of Obstetricians and Gynecologists (ACOG) representative. She has been instrumental in the creation of the committee, a process she began working on eight or nine years ago when she and ACOG met to discuss maternal mortality and she was able to get the death statistics for the D.C. region. “I managed to get the numbers and then realized that nothing was being done,” she says. “As a community, we weren’t doing anything.” Unlike D.C., she says, Maryland and Virginia had robust maternal mortality review committees.
The raw maternal death numbers can appear deceptively low. “We could have two maternal deaths in a year, we could have six maternal deaths in a year, and if you look at the raw numbers it seems that’s not very many,” she says. “But we only do 10,000 deliveries a year in D.C., and the way the numbers are reported out is per 100,000 live births. So you take any of our numbers, you have to multiply it by 10. If we have two, it’s 20, and if we have six, it’s 60. The U.S. maternal mortality rate, the goal is to be less than 20. So obviously, if we have a year where we have six, we’re very high.”
Bohon says she and ACOG tried to work with the Department of Health to start a review committee but was told the department didn’t have the time or capability. She persisted, and a few years ago, after turnover in the department, D.C. Chief Medical Examiner Dr. Roger Mitchell Jr. agreed to take on the committee.
As it is currently constructed, the committee is diverse and equipped to discuss the many shapes the issue takes—racial, social, economic. Mitchell said at the December public hearing that 75 percent of the maternal deaths D.C. recorded between 2014 and 2016 were black women. “We have a lot of cultural barriers that we’re not really discussing,” Ebony Marcelle told City Paper last year, speaking about black maternal health. Marcelle is the director of midwifery at Community of Hope’s Family Health and Birth Center, which primarily serves black women from wards 7 and 8, and will be a member of the review committee.
Councilmember Allen says he expects additional people to be nominated to serve on the committee, which he hopes will result in even greater geographic representation and racial diversity.
The committee must dig into the lives of mothers who have died, looking at hospital charts and patient health histories, figuring out what kind of environments the patients lived in, how difficult it was for them to get to their providers, and what could’ve been done differently to prevent death.
But what about the morbidity cases?
The OB-GYN community has not yet accepted a universally agreed upon definition of maternal morbidity, Bohon explains. Some say morbidity is when any woman who is pregnant gets admitted to an intensive care unit, others say it’s when a pregnant woman has a transfusion of four or more units of blood. In the committee print, morbidity was defined as when a woman receives four or more units of blood products or is admitted to an intensive care unit while pregnant or within one year of giving birth.
“The mortality numbers, if you multiply those by 100, many people would say that’s the morbidity,” Bohon says. “If we can get those morbidity statistics down, that’s going to really help prolong the lives of these women and help them avoid crisis. If we can decrease the morbidity, we definitely will decrease the mortality.”
She says that the creation of the committee had to move forward, even as the bill lost the morbidity study component, so it could eventually work toward expanding to include morbidity.
The maternal morbidity that Bloomingdale resident Dorie Nolt experienced has changed her life. The 39-year-old gave birth to her son Hugo in May of 2017 at Sibley Memorial Hospital. Her water broke two weeks early. She labored for two days before doctors told her it was time for a cesarean section. She says she had multiple doctors, and it always felt like there was someone new in the room. “My epidural never really worked very well, so I could feel everything. It was terrible.” (City Paper published a recent cover story featuring women who had similar experiences across the city.)
Following a successful C-section, she and her new baby were eventually released from the hospital. But after 30 hours at home, Nolt felt strange in the night. She says she called her doctor and was told to come into the office in the morning. The next morning, she began vomiting, blacking out, and feeling significant pain. She was eventually taken to the emergency room.
She says there was a hole in her uterus stitches, and because of that, everything in her uterus was leaking into her abdominal cavity, which was then filled with E. coli. She spent Mother’s Day, her first as a mother, in a hospital operating room. “They ended up having to split open my stomach and drain out all the infection,” she says. She was in the hospital for two and a half weeks, missing moments in her newborn’s life, too sick to hold him for long.
Nolt says doctors failed her: “I don’t feel like they listened to me at the beginning when I called and told them I wasn’t feeling well.”
(A spokesperson for Sibley says, “as the hospital that delivers the most babies in D.C., we strive to provide the best care possible for mothers and their babies during this very special time of their lives,” and “we listen to all patient concerns in order to address and resolve concerns as well as improve the quality of our care.” The hospital has a formal process for responding to concerns through its Patient Relations Department.)
Nolt now works from home in education communications consulting, still coping with her agonizing birth experience and the stress that followed her trauma. “There’s not a day that goes by that I don’t think about the hospital stay.”
She took classes, she had a doula, she had good health care, and her birth still went sideways. It’s no wonder then, she says, that “black women, low income women, and women in rural parts of the country are dying.” Nolt wants action to save these mothers and the mothers who have survived birth trauma. “There are women walking around who have been through hell,” she says.
At a panel on maternal health this February, Nolt stood up and told her story as a diverse room full of women thanked her for sharing it. A staffer at Councilmember Allen’s office was present at the panel, and approached Nolt about possibly serving as a lived-experience committee member. But she says the mayor’s office told her that she didn’t fit the description in the legislation because she hadn’t lost a loved one to maternal mortality.
“It’s hard to find someone,” says Dr. Bohon. “We’ve been trying forever. It’s just so painful to discuss it and every time you sit on that committee and hear the discussion, you feel it again.”
Bohon anticipates that the meetings will commence in May at the latest. If the lived-experience role is not filled by then, it will remain open.
Bohon says the group will begin with older cases, reviewing contemporary cases when available, as is typical for such committees. She expects meetings to be quarterly and closed to the public—at least in terms of case review. Its findings and recommendations will be released to the public in annual reports.
“We were certainly ready to go in October of last year, that didn’t happen, obviously,” says Allen. “We did send a letter to encourage the nominations to come down.” He believes the upcoming hearing will put the issue on the front burner and jumpstart the committee so its experts can “begin to go at the loss of life with the degree of urgency it really needs—really try to focus on the disparity in maternal mortality outcomes, make concrete recommendations on where we should be investing our money and what laws should be changed.”
Though it has come later than those involved would have liked, Bohon says the bottom line is that the committee is here. “We finally got success,” she says. “I’m just glad we’re there.”
She hopes the city pays more attention to pregnant women, whose health impacts entire communities. One of the signs of an unhealthy city, she says, is a high maternal mortality rate.