The death of Sha-Asia Washington on July 3rd, 2020, has sparked outrage in Brooklyn and attention from the entire country regarding the safety, or lack thereof of black women during childbirth.
As a practicing OBGYN and as a black woman, I feel the need to address this particular case and examine not only the possible causes of death, since one has yet to be reported, but how ANY expectant mother can protect herself as much as humanly possible.
According to 2018 CDC statistics,
… of the 658 women who died of maternal causes in 2018, black women fared the worst, dying 2½ times more often than white women (37.1 vs 14.7 deaths per 100,000 live births)…https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr69_01-508.pdf
While this was actually a slight improvement from the 42.8 per 100,000 Black women who died according to reported data between 2007 and 2016, this stark contrast is still disturbing. It can spark fear in any Black expecting mother.
I think it is important to revisit the top causes of maternal death. This list is from an article I wrote in The Gyneco-(b)Logic last year:
According the Center for Disease Control, and looking at the years 2011-2014, the most common causes of death were as follows:
- Cardiovascular diseases (heart disease), 15.2%.
- Non-cardiovascular diseases (like diabetes), 14.7%.
- Infection or sepsis, 12.8%.
- Hemorrhage (excessive blood loss), 11.5%.
- Cardiomyopathy (heart malfunction), 10.3%.
- Thrombotic pulmonary embolism (blood clot), 9.1%.
- Cerebrovascular accidents (aka stroke), 7.4%.
- Hypertensive disorders of pregnancy, 6.8%.
- Amniotic fluid embolism (it’s like a clot), 5.5%.
- Anesthesia complications, 0.3%.
We don’t know what Sha-Asia died from at this time. The most that I could find as a cause of death was “Child Birth,” which is NOT a cause of death. I did find a report about the scenario that preceded her death and speculated from it. This is from TheCITY.NYC:
In an interview with Rolling Stone, Juwan Lopez and Williams said that Washington was admitted to Woodhull on July 2nd for a routine stress test. The hospital kept her for observation because she was several days past her due date and her blood pressure was unusually high, they said. Doctors asked Washington if she wanted an epidural and she agreed after some hesitation, Williams told the magazine.
Washington went into cardiac arrest, prompting doctors to perform an emergency C-section. Her daughter, Khloe, was healthy.
Now, the following statements are COMPLETELY speculative. I have no knowledge of the details of Sha-Asia’s medical care. Still, I am going to speculate what could have happened in an effort to deduce how her death could have been prevented.
Sha-Asia’s Possibly Story
If Sha-Asia was admitted on July 2nd because of blood pressure elevation, the diagnosis of preeclampsia should have been suspected. That is the life-threatening medical condition that I had when I was pregnant and that Beyonce had during her delivery. Any pregnant person with a blood pressure of 140/90 at least 4 hours apart needs to be evaluated for preeclampsia. A person can look completely normal and feel completely normal (present) and yet have preeclampsia.
Even without preeclampsia, elevated blood pressures in pregnancy, known as gestational hypertension, carries a significant risk of leading to stroke in pregnancy. Blood pressures need to be closely monitored and sometimes treated with medication. They don’t always need to be treated because, depending on the level, your provider may not want to bring the blood pressure too low. After all, that could compromise blood flow to the baby. It is a delicate balance.
Advice #1: Watch Your Blood Pressure
Keep track of your blood pressure in your prenatal appointments and in the hospital. If you notice that it is elevated, inquire about whether or not further evaluation can be done. Some people with severe preeclampsia will also have headaches, vision changes, or upper abdominal pain that won’t go away. People with high blood pressure diagnosed before 20 weeks of pregnancy, people with gestational diabetes, and Black women are at increased risk of developing preeclampsia.
Consider bringing a notebook to prenatal visits. Ask questions if you see values higher than 140/90, either number during labor. Find out what blood pressure numbers would warrant treatment in your particular case and watch for those.
Gestational hypertension and preeclampsia can be managed in labor. Still, the cure for both is delivery, especially at term when the baby is old enough. Let’s get back to Sha-Asia’s possibly story.
Sha-Asia’s Possible Story Continued…
If Sha’Asia was offered an epidural, I could speculate that a few things were happening. 1) She was likely being induced, possibly because of suspected gestational hypertension or preeclampsia, and 2) She was probably not progressing normally in labor.
I believe that she was being induced because the reports that I read said that she was admitted after fetal testing because of her high blood pressure, not because of labor. However, labor would be the only reason for her to need an epidural. Therefore she must have been being induced.
I think that she may not have been progressing in labor because, at least in my practice, the only time that I recommend that a person gets an epidural if they don’t request it themselves is if their labor is stalling and we need to add interventions that are not tolerated well.
Said differently, if a person is contracting and not dilating and I need to add more assistance to help their cervix dilate further, that will also hurt more. Also, if I offer to break a person’s bag of water to help labor to progress, that often leads to stronger contractions that hurt more. Someone who is having difficulty tolerating labor at its present level will likely benefit from pain relief if I have to level up their labor intensity.
Advice #2: If your doctor offers an intervention, ask why.
Understanding the reason for proposed interventions may help you better understand and decide whether or not you want to take that advice. When you ask why, be sure to include that you are interested in understanding. Humans are humans. Many professionals of various careers are more likely to respond positively to a request for clarification than a perceived challenge of their knowledge or expertise.
Feel free to also ask what the alternative is. In medical training, we are trained to offer risks, benefits, and alternatives. A healthcare provider should be able to explain those upon request for any intervention proposed.
Sha-Asia’s Possible Story Part 3…
The third part of the story from the article above states, “Washington went into cardiac arrest, prompting doctors to perform an emergency C-section.” Considering epidurals account for less than 1 percent of deaths, I do not think that the epidural was the cause of her death.
Cardiac arrest during labor is likely to be due to one of three causes, heart disease, a blood clot causing a pulmonary embolism (which is what Serena Williams had), or an amniotic fluid embolism, which behaves like a blood clot.
Heart disease, like the heart defects that can cause young athletes to die suddenly, can also affect people in labor in the same way. Blood clots are significantly more likely to form during pregnancy and labor. Black women, people with a genetic predisposition, pregnant women, and those who are obese are significantly more likely to develop a blood clot. This can be small enough to be caught and treated with blood thinners, or they can be big enough to cut off oxygen to your body and cause you to die practically immediately. Preeclampsia also increases this risk.
Amniotic fluid embolism is one of those rare but very random and spontaneous things that can also lead to sudden death if severe.
Considering my speculation that Sha-Asia had preeclampsia, she may have also been on IV Magnesium, which is one medication given to treat this condition. Magnesium can be life-saving if appropriately used but threatening if not monitored properly. If a person’s blood Magnesium level is too high, it can lead to depressed reflexes, sedation, and cardiac arrest. If levels are too low, a person is at risk for Eclampsia, which is manifested as seizures that can lead to coma, brain and organ damage and death.
Magnesium levels can be monitored by blood levels or physical exams- checking alertness, reflexes, etc. The IV containing Magnesium has to be correctly labeled and monitored to ensure that it is not confused with other fluid infusions and isn’t stopped or given in large quantities by mistake.
Advice #3: Know what you are receiving through the IV.
Intravenous (IV) fluids can also be life-sustaining during labor since maternal hemorrhage (excessive rapid blood loss) is among the more common causes of death and damage during delivery. If your labor also necessitates antibiotics, say because of Group B Strep colonization or infection, or other types of infections that can occur in labor, you should be informed. If you also need Pitocin, you should be aware of that too.
If you develop preeclampsia and need IV Magnesium, know where it is, as in where it is hooked up. Ask how your levels will be monitored. Keep notes of any information you are told so that you can be aware of things that are happening properly and when questions may need to be raised.
We know that having a healthcare advocate or caregiver can improve outcomes for the elderly and people undergoing surgery. I propose that the same MUST be valid for pregnancy. If the expectant mother can’t be her own advocate, a family member or friend can keep notes and ask questions even as the joys of welcoming a new baby into this world are unfolding.
Preeclampsia is cured by delivery, but that doesn’t mean it’s over. Blood pressure abnormalities and the risk of Eclamptic seizures can occur even as far as 6 weeks or more after delivery. If you have access to a blood pressure monitor at home, continue to check your blood pressure periodically in those first few days and weeks to ensure that it is normal and contact your healthcare provider immediately if it’s not.
What is the take-home?
Prayerfully, a healthy, happy baby and mother are the primary take-homes.
As for this article, while I wait for more information about Sha-Asia’s story to surface, I want to see each maternal death investigated. Not just for wrong-doing either. I want them all investigated to determine the exact cause of death and the events leading up to identify if anything could have been done differently.
I also want all healthcare providers to receive formal, vetted implicit bias training. We HAVE to examine the role of systemic racism in not-only access to quality care, but in the manner care is dispensed to different people from different backgrounds, even if blatant racist practices do not appear to be in place.
Obesity, hypertension, diabetes, and lifestyle choices like smoking also contribute to the risks of having babies. We cannot ignore those. Regular exercise, access to healthy dietary choices, and regular prenatal care are ESSENTIAL.
I’ll tell you what I WON’T accept…
I will NOT accept the cause of death as “Child Birth.” The delivery of a baby is not what is killing these ladies. Complications surround that delivery, even up to a year post-delivery, are what are to blame. Prevention and reduction of these outcomes have to come from all sides, even the expectant mothers.