Did you know that three of the four Black women pictured, world-class elite athletes, Olympians who won 4x100 Gold Medal at the 2016 Olympics, have since encountered life-threatening situations linked to a pregnancy-related complication caused by high blood pressure? Tragically, just a few weeks ago, one of these athletes, #TorieBowie died due to a similar pregnancy-related high blood pressure complication.
This article aims to channel sadness and grief into proactive steps. If you are a black woman preparing for pregnancy, currently pregnant, or if you’re an ally concerned about the alarmingly high rate of black women who die related to childbirth (maternal mortality), this article is relevant to you. The specific complications are; preeclampsia and eclampsia. These conditions were reportedly linked to the passing of Tori Bowie and caused Tianna Madison and Allyson Felix to have life-threatening medical experiences.
Pregnancy and childbirth bring new challenges, joy, and sometimes tragedy to women of all backgrounds. This article does not diminish or ignore the significance of a woman who endures losing a baby during pregnancy or childbirth. The lives of all mothers and infants matter!
This article responds to the multiple studies that confirm black women encounter distinct obstacles from pre-conception to post-delivery. The disparity in maternal mortality rates is a stark reality. Black women are nearly three times more likely to die during childbirth than other racial groups. This alarming statistic persists regardless of educational or income level.
After bleeding and infections after childbirth, complications tied to high blood pressure round out the top three causes of high maternal mortality rates in Black women. As the Centers for Disease Control (CDC) noted, many causes and proposed solutions exist for the high maternal mortality rates. The CDC suggests that birthing is not colorblind, citing implicit bias (unconscious) by healthcare providers as one factor. https://www.cdc.gov/healthequity/features/maternal-mortality/index.html
That being said, this article focuses on self-help!
This article focuses on self-help! It provides knowledge and skills a Black woman needs to know and can use; how to be ‘seen and heard’ in healthcare settings. I believe self-advocacy is a straightforward way you can #standupforyourhealth. This step-by-step guide can help you or someone you love from becoming a statistic.
As an ER doctor, patient educator, and wellness coach, I find the most fulfillment when referred to as "The Advocacy Coach." During moments of supporting patients in medical crises or providing education, I see the power of self-advocacy conversations in healthcare. These conversations, when necessary, can be life-saving. By understanding your body and utilizing what I call "self-advocacy conversation starters," you can engage in informed and collaborative discussions with your doctor. In pregnancy, these conversations can help ensure the safety and well-being of both mother and baby during pregnancy and delivery. I recommend you read this article from beginning to end. However, if you want to skip the patient education section and go straight to the action steps, go to #TheDoctorTalk section. But I hope you take the time to read and learn about hypertension in pregnancy. Then, you will be armed with evidence-based medical facts, understand the risk of high blood pressure, and recognize the need for self-advocacy. You-along side your partner, family members, doulas, and support team—must be prepared to advocate for yourself during your pregnancy journey to prevent complications due to high blood pressure.
I don’t have the exact medical details of these Olympians. Like you, my knowledge is from media coverage and online posts. But here is a case from my personal ER files.
I was working a Saturday mid-shift in the ER. We received a call on the EMS box. It was reported that a 35-year-old pregnant Black woman was experiencing a sudden onset of severe headache, shortness of breath, blurred vision, and abdominal pain. She suspected she might be having a stroke. Her initial blood pressure reading was 162/89. She was alert and oriented. The paramedics mentioned that they were 14 minutes away from the ER.
Later, we discovered she had come from Jersey to Baltimore for her grandfather's 90th birthday celebration. She was a social worker, 37 weeks pregnant, and had been receiving prenatal care since the tenth week of her pregnancy. The ultrasound performed that day was normal and confirmed her due date. Her obstetrician had approved the two-and-a-half-hour road trip to Baltimore for this special occasion.
As an ER doctor, I was always prepared for the unexpected. Around 10 minutes later, the paramedics called back with an update. They were still at the venue and informed us that the woman had a seizure while they were preparing to transport her. The seizures were severe and persistent, not responding to the usual protocol medicine for seizures in the prehospital setting. Before her pregnancy, there was no history of seizures, head trauma, or known hypertension. However, her blood pressure was 185/94. They followed the protocol, monitoring her airway and heart. I okayed expedited care, priority one transport (lights and sirens), which would get to the ER in 5 minutes.
When she arrived, her seizures were ongoing. She was breathing on her own,her blood pressure was 190/102. The baby’s heart rate was acceptable. The diagnosis was apparent eclampsia, a severe complication during late pregnancy and childbirth caused by high blood pressure, which can lead to seizures and death of the mother and baby.
The resuscitation protocol is an ER team effort. Our immediate priorities were protecting her airway and treating the seizures and blood pressure simultaneously, next, getting urine and blood, confirming pregnancy dates, ultrasound, and monitoring her baby. Seizures due to eclampsia require very specific treatment.
Simultaneously I requested that OB be paged. In the ER, our primary goal was to resuscitate and stabilize her before transferring her care to the OB team for a likely C-section. At 37 weeks, the definitive treatment for the mother and baby was to deliver the baby immediately.
By the time the OB team arrived, the seizures had ceased, her blood pressure was under control, and she was feeling very sleepy. The ultrasound confirmed that she was 37 weeks and four days, and the baby had a solid and regular heartbeat. Her husband and mother were still present in the resuscitation bay. The OB doctor discussed the options, risks, and benefits of proceeding with an emergency C-section. Holding his wife's hand, the Dad gave his consent.
They took her to the Labor and Delivery unit, where she successfully delivered a healthy baby girl weighing 6 pounds and 4 ounces via C-section within 60 minutes of arriving at the ER.
Two days later, as she was being wheeled out of the hospital, she passed through the ER and found me. She expressed her gratitude and wanted to thank me and the team personally. She shared that she had experienced visual changes and swelling in her feet a few days prior. She also shared that she had elevated blood pressure during her routine visit at 35 weeks. She had chosen to use a "natural" remedy for high blood pressure, as she did not want to take medications that could harm her unborn child. Curious, she asked if the frightening ordeal could have been prevented. Without judgment and without knowing the specifics of her prenatal care, I advised her to follow up with her OB doctor.
Hypertension and Pregnancy
Pre-Conception: Get Control of Your Blood Pressure
The American Heart Association recently revealed somestartling data: Black women are two times more likely than their white counterparts to have uncontrolled hypertension between the ages of 20 and 50. Having high blood pressure during these years is particularly risky as it
escalates the likelihood of life-threatening complications during pregnancy.Keep tabs on your blood pressure! All Black women should monitor their blood pressure, particularly if they plan to have a baby. Not checking your blood pressure is often the main reason why high blood pressure goes unnoticed. This is something I see often in the ER. Consider a blood pressure monitor if you're brainstorming about what to gift a Black woman for her baby shower. It's not just a gift, it's an investment in her health.
If you have a diagnosis of high blood pressure, schedule a preconception checkup with your healthcare provider and develop a plan to get your blood pressure under control. Remember, a healthy diet and exercise are effective methods to manage blood pressure. Now is the time to revisit your plan for managing stress in your life. You want to begin your pregnancy journey in the healthiest state possible. Maintain a healthy weight, avoid alcohol, smoking (both tobacco and weed), and non-prescription substances. Ideally, this should be done three months before trying to conceive. However, if you have health conditions that could potentially affect pregnancy, it might take longer for your body to be ready for a baby. If you have hypertension going into your pregnancy, you can have a normal pregnancy and deliver a healthy baby. This is called chronic hypertension in pregnancy. But you must collaborate with your doctor and plan.
During Pregnancy: Monitor your Blood Pressure
All women need to monitor their blood pressure during pregnancy. The truth is that one of the changes your body goes through during pregnancy is the production of more blood to support your baby's growth. As a result, your heart works harder, and your blood pressure might increase slightly. But will still be in the normal range. However, a significant increase in blood pressure can lead to complications.
In pregnancy, the numbers you want to aim for are 120/80mm Hg or lower - that's a healthy blood pressure reading. If the numbers drop below 90/60 mm Hg, that's considered too low, which is also known as hypotension. A reading above 140/90 mm Hg during pregnancy is seen as high blood pressure or hypertension.
Two Primary Types of Blood Pressure Problems in Pregnancy
If you have hypertension before your pregnancy, we call this chronic hypertension in pregnancy. If you develop hypertension after pregnancy, this is called gestational hypertension. Both are types of high blood pressure conditions that can occur during pregnancy. Both can lead to complications, but they have distinct differences:
1. Chronic Hypertension: This type of hypertension ispresent before pregnancy or diagnosed before the 20th week of gestation. It can also be determined if high blood pressure persists for over 12 weeks postpartum. It's important to note that chronic hypertension can lead to more severe forms of hypertension disorders during pregnancy, such as superimposed preeclampsia.
2. Gestational Hypertension: High blood pressuredevelops after the 20th week of pregnancy and usually resolves by 12 weeks postpartum. It's known as 'gestational' because it develops specifically during gestation and typically resolves after delivery. This condition is not associated with damage to the kidney or liver. However, women who experience gestational hypertension are at higher risk of developing chronic hypertension later in life.
Again, severely elevated blood pressure may lead to complications for the mother and baby, so careful monitoring and management are
crucial. You and your Obstetrician willset the treatment goal and monitor your blood pressure for both conditions.
Three Primary Complications Tied to High BloodPressure in Pregnancy
1. Hypertensive Emergency
Regarding a medical emergency, according to the American College of Cardiology of Obstetrics and Gynecology, recent guidelines state that any reading persistently above 160/110 is considered a medical emergency due to increased brain injury (stroke) risk. Persistently means two readings 15 minutes apart. This is not to alarm you but to make sure you understand the gravity of the situation. If your blood pressure hits these high levels, immediate treatment is required. Call your OB doctor or go to an emergency room.
2. Preeclampsia
Preeclampsia is diagnosed when this high blood pressure is accompanied by protein in the urine or other related symptoms. (See below) If blood pressure reaches or exceeds 160/110, accompanied by protein in the urine (kidney damage) or other symptoms, the condition is defined as severe preeclampsia. If preeclampsia results in seizures or coma, it is calledeclampsia.
Symptoms of Preeclampsia. Think of these as signals that youmay have preeclampsia.
- New headache severe and persistent
- Swelling in your feet, hands, or face
- Shortness of breath
- Changes in vision: blurred flashes of light
- Abdominal pain
3. Eclampsia
Eclampsia is the onset of seizures or coma with signs orsymptoms of preeclampsia. Usually, eclampsia occurs as a progression from
preeclampsia. It is often difficult to predict whether a patient with preeclampsia will develop eclampsia. AND eclampsia can happen without any previously observed signs or symptoms of preeclampsia. Because of this, self-care and self-monitoring of your blood pressure and close collaboration with your OB is critical to avoid a crisis or a tragedy. These seizures can be quite dangerous for both the mother and the baby. It's one of the reasons why managing preeclampsia effectively is so critical – doing so helps prevent the condition from escalating into eclampsia. Also, eclampsia is the term used for seizures unrelated to a pre-existing brain condition.The mother's risk of death (maternal mortality) in cases of eclampsiais significantly higher for Black women than women of other racial groups.
Specifically, the risk is approximately five times greater for Black women. What’s disturbing is the fact that a substantial 60% of these deaths are preventable. Also, if a black woman survives preeclampsia, you face a 2-fold increased risk of cardiovascular disease after your pregnancy, which can develop within 3 to 5 years after delivery.Post-Partum Preeclampsia
The risk of eclampsia can persist even after the baby is born. Most commonly, it can occur within the first 48 hours postpartum, but there are cases where eclampsia can develop up to six weeks after delivery, during what is known as the postpartum period. This is why close monitoring of blood
pressure and other symptoms is essential in the weeks following childbirth, especially in women who have had preeclampsia during pregnancy.Who is At Risk for Preeclampsia
Black women have a 1.5-2 times higher risk of developing preeclampsia compared to White women.
While Black women have higher rates of chronic hypertension, this is likely just one factor influencing this disparity. While in the general population, only about 3% to 5% of women experience preeclampsia during pregnancy. But for women with chronic hypertension, 17-25% will develop preeclampsia. And women with chronic hypertension develop preeclampsia earlier in pregnancy, before 34 weeks, which places the unborn baby at a greater risk.
Other risk factors for preeclampsia, such as obesity,sleep-related breathing disorders, and diabetes, are more commonly found in
Black women.Prevention of Preeclampsia
Low-dose aspirin (also known as baby aspirin) is recommended as a preventative measure for certain women who are at high risk for developing preeclampsia during pregnancy. The U.S. Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG) recommend that pregnant women at high risk for preeclampsia take a daily dose of low-dose aspirin (81 mg) starting at 12 weeks of pregnancy. This is a decision made by your OB doctor and you!
Treatment of Preeclampsia
The definitive treatment for preeclampsia and eclampsia is the delivery of the baby. The delivery timing depends on how far along in your pregnancy you are and the severity of the preeclampsia. If you're at 37 weeks or beyond, your doctor will likely want to deliver the baby as soon as possible.Suppose you're less than 37 weeks pregnant. In that case, the doctor will consider your and your baby's health, your baby's gestational age, and the severity of your preeclampsia to decide when and how the delivery should happen. It's a balance between giving the baby more time to develop in the womb and avoiding further health risks for you.
For severe preeclampsia, your doctor may need to deliver the baby early to prevent serious complications. This could be done by inducing labor or a cesarean section.
While waiting for delivery, your doctor may recommend:
- Bed rest, either at home or in the hospital
- Regular prenatal visits to closely monitor you and your baby
- Medications to lower your blood pressure, if it's dangerously high
- Medications to prevent seizures (magnesium sulfate)
Lastly, it's essential to recognize the long-term risks associated with hypertensive disorders of pregnancy. These conditions can increase the risk of cardiovascular disease later in life, so primary care providers need to be aware of this link. Regular lifelong monitoring of cardiovascular risk factors is necessary for those with a history of hypertensive disorders. Patients should also be educated about lifestyle modifications to reduce this risk. Monitor your blood pressure throughout your pregnancy. understand the numbers, and don't hesitate to voice your concerns to your healthcare provider. It's crucial to your health and the health of your baby. Be proactive, ask questions, and remember, you're a key part of your healthcare team.
Self-Advocacy Truth to Power Conversation Starters: Hypertension in Pregnancy
Here are what I call Self Advocacy Truth to Power Conversation Starters. You can be the BOSS of your Hypertension in Pregnancy. You can adapt to your style. Remember, it's important to keep asking questions until you fully understand your healthcare provider's explanations and advice. You have the right to clear, comprehensible information about your health.
1. Pre-conception Checkup: "What measures can I take to manage my high blood pressure before we plan for a baby? What is the best strategy for me?"
2. Blood Pressure Monitoring: "Can we discuss the proper methods and schedule for blood pressure monitoring during my pregnancy? Could you explain the normal range and when should I contact you?"
3. Understanding Hypertension Types: "Can we discuss the differences between chronic and gestational hypertension and how each could affect my pregnancy?” "Can we discuss the options for medication for treatment during my pregnancy and the side effects?”
4. In Case of Hypertensive Emergency: "If my blood pressure readings is higher than 160/110 mm Hg, and I check it twice over a half an hour, what immediate steps should I take? What is should be my plan of action in such a situation?"
5. Recognizing Preeclampsia: "Could you explain to me the specific symptoms of preeclampsia I need to be aware of? What should be my immediate course of action if I notice any of these symptoms?"
6. Preeclampsia Prevention: "Considering my risk factors, would you recommend the use of low-dose aspirin as a preventative measure against preeclampsia? If so, when should I start?"
7. Postpartum Period: "What steps can I take to monitor my blood pressure and other symptoms in the weeks following childbirth? When should I reach out if there are concerns?"
8. Preeclampsia Treatment: "If preeclampsia occurs, what are the options and potential implications regarding the timing and mode of delivery? What other treatment methods might be necessary?"
9. Long-term Risks: "Given my hypertension during pregnancy, what long-term risks should I be aware of, and how can I mitigate them through lifestyle modifications or other means?"
Please let me know if you have any questions or comments. Happy to respond.
Example of using this conversation approach in a hypothetical scenario.
In this situation, a pregnant 32-year-old black woman, Jillian, has been on bed rest for pre-eclampsia for two weeks. She is now 35 weeks and encounters a severe health crisis. Despite enduring two weeks of bed rest, she was hospitalized yesterday because her feet were swelling and her blood pressure was creeping up. The doctor is now rounding at her bedside. Ty, her partner, is at her side. She tells him she has belly pain and a headache. The nurses charted her blood pressure 160/90 overnight in the hospital. She has been reading and talking to her cousin, a nurse. Jill believes her condition is progressing to eclampsia. Meanwhile, her obstetrician on call, who isn't her usual doctor, wants to continue with a 'watch and wait' approach. However, Jillian and Ty, feel they need to discuss the potential risks and benefits of proceeding with delivery based on her research and current health guidelines.
Jillian: "Doctor, thank you for your time. I understand you're suggesting we continue to 'watch and wait'. However, given my research and the severe symptoms I'm experiencing, I'm growing increasingly concerned. Can we talk more about my symptoms?"
Doctor: " I understand your concerns, but pre-eclampsia doesn't always progress rapidly. At this moment, we believe the baby isn't ready for delivery and could benefit from a little more time."
Ty: "We understand that Doctor, but we're also worried about my wife's health. Her blood pressure is significantly high, and these new symptoms like abdominal pain, she said her vision was blurry and she has a headache. I'm sure you understand our fear, especially considering the statistics around Black women and childbirth complications."
Jillian: "That's right. I know I'm not a doctor, but I've tried to educate myself about pre-eclampsia and eclampsia. From what I understand, these symptoms could indicate that my pre-eclampsia is progressing. I'm also worried about the risks of developing eclampsia. Can we discuss the benefits and risks of possibly delivering the baby sooner?"
Doctor: "You're right to advocate for your health, and it's important that you're educated about your condition. Let's discuss your concerns in more detail. As you know, early delivery does carry its own risks..."
Jillian: "I understand that early delivery carries its risks, but the development of these symptoms makes me think that the risks of waiting might be greater. What are the specific risks for our baby if we were to deliver now at almost 37 weeks?"
Doctor: "A delivery at 35 1/2 weeks could mean that the baby might have immature lungs and could need help breathing for a while. Additionally, babies born this early may face difficulties feeding and maintaining their body temperature. However, most babies born at this gestation do well with proper neonatal care."
Ty: "And what about the risks if we wait and my wife's condition worsens? How would that affect both her and the baby?"
Doctor: "The concern here is that pre-eclampsia can indeed progress into eclampsia, which is a very severe condition that includes seizures and could lead to coma or even death. This is a risk to both the mother and the baby. On the baby's part, pre-eclampsia can lead to poor growth, premature birth, and placental abruption."
Jillian: "Doctor, considering the possibility of my pre-eclampsia escalating to eclampsia and the risks associated, don't you think it might be safer for us to consider a delivery plan now?"
Doctor: "You've clearly done your research and thought this through. It is absolutely crucial to consider all possibilities. Given your symptoms and the risks you're willing to take, we should reconsider the options.
Ty: “I want to sign the consent. Let's go. My wife feels bad, you need to do this now.”
Doctor: " I have to go see the patient in the room down the hall; you think about it more, I will be back.”
When the doctor prepares to leave the room to handle his other patients briefly, she begins to have a seizure, and her blood pressure monitor shows dangerously high readings. Her husband is understandably distraught. The doctor turns around quickly outlines an immediate action plan to address the escalating emergency, focused on saving both the mother and the baby.
The nurse begins to preparing to take her to the suite for a C-section.
Doctor: "Mr. Smith, I understand you're very scared right now, but we're going to do everything possible to ensure your wife's and your baby's safety. Your wife's condition has escalated into eclampsia. This is an emergency, and we need to act fast."
Ty: "That is what we were trying to avoid. What's going to happen? I will pray for you, Doctor; you better make this right!"
Doctor: "I hear you. I’m sorry we waited. Right now, we will treat your wife to stop her seizures and stabilize her blood pressure. I'll have the nurses administer magnesium sulfate to stop the seizures. This is the most effective medication for preventing further seizures in eclampsia. They'll also give her medication to lower her blood pressure quickly, probably labetalol or hydralazine. She's in a critical situation, but these medications can help stabilize her."
Ty: "And what about our baby?"
Doctor: "At 35 weeks, your baby is nearly full-term, and the chances for a successful outcome are high. Once we stabilize your wife, we will need to deliver the baby as quickly as possible, most likely via cesarean section. This is to protect both your wife and your baby. A team of neonatologists will be on hand to immediately care for your baby once delivered."
Ty: "What can I do right now?"
Doctor: "The most important thing you can do is stay calm and be there for your wife. It's a stressful time, I understand. But she needs your strength. We'll keep you updated every step of the way, and we'll make sure you understand what's happening. I promise you we're doing everything in our power for your wife and your baby."
Ty: "Please, save them, doctor."
Doctor: "We're on it, Mr. Smith. We'll do everything we can. Now I need to get going and help your wife."
Less than 20 minutes later, a 5-pound baby girl was born, with APGAR scores were initially 5, then repeated were 9. Jillian was sedated, but all appeared well, and Ty was on his way to see his new baby girl in the neonatal ICU.
(Apgar scores are a standard method used to quickly assess the overall health and well-being of newborn babies immediately after birth. They evaluate five key factors: heart rate, respiration, muscle tone, reflex irritability, and skin color. Apgar scores range from 0 to 10, with higher scores indicating better health and adaptation to the outside world. Apgar scores provide a snapshot assessment and are not the sole indicator of a baby's long-term health.)
1. What self-advocacy skills did Ty and Jillian demonstrate during their conversation with the doctor?
2. What could Ty and Jillian have done differently to strengthen their self-advocacy efforts?
3. Considering Jillian's condition and symptoms, what factors may have decreased the likelihood of her survival if they had not advocated for immediate action?
4. How did Jillian's research and knowledge about her condition contribute to her self-advocacy?
5. What risks did the doctor mention when discussing the potential benefits and drawbacks of early delivery?
6. What risks did Ty highlight when expressing his concerns about waiting and his wife's deteriorating condition?
7. What do you think about how the doctor responds to Ty and Jillian's concerns about the potential risks and benefits of proceeding with delivery? What about the doctor’s response to Ty after she started seizing?
8. Reflecting on the entire scenario, what lessons can be learned about the importance of self-advocacy in healthcare?
My deepest condolences go out to the family, friends, and the global track and field community who knew her or were touched by Tori Bowie. My thoughts and prayers are with you.
To readers of this post:
It is important to establish clear communication with your healthcare provider to ensure the best outcome for you and your baby. Proactively create and discuss your birthing plan, with a focus on minimizing preventable health complications. Remember that your doctor is not your adversary; they are your partner in this journey. Listen, ask questions, and continue the conversations to understand your pregnancy journey. Consider the use of Doulas. these are trained and certified support for women from conception through postpartum. Doulas are not trained medical professionals. They work alongside your doctor or midwife. Data shows that can make a positive difference during pregnancy and delivery, particularly for Black women. You can make a positive impact as an advocate for yourself, your family, and your community.
To my Physician Colleagues:
As medical professionals, we all took the Hippocratic Oath upon graduating from medical school. This pledge, steeped in a promise to do no harm and to apply our knowledge for the benefit of our patients, serves as our unifying creed. As a medical community, we embody diversity – a rich tapestry of different races, ethnicities, and cultural backgrounds. This diversity strengthens our ability to understand and meet the needs of the varied populations we serve. As physician-scientists, we must recognize that the disparities cited in this article are undeniable and reflect the reality of many patients. Like any other we use in our practice, this data should guide our care and actions. I encourage all of you to consider how we can apply this information to make a tangible difference, not only in addressing this particular condition but also in rectifying other health disparities affecting Black women's and their families’ lives. Let's leverage our shared commitment to healing to create a more equitable healthcare landscape. Let's strive to listen, learn, and adapt our practices so that every patient feels seen, heard, and valued. As we address the disparities impacting Black women and their families, let us remember our shared oath and strive to truly live its principles, shaping a future where every patient receives equitable, compassionate care.
No parts are to be copied, reproduced, or used without written permission.
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- New headache severe and persistent
