Black Maternal Health Week was celebrated in April 2023 from the 11th to the 17th.

Our article, with commentary from our Registered Midwife Allie Campbell, offers some insight into the shocking and eye-opening statistics on Black maternal health, raising awareness of the issues Black women still face in the maternity system. We share some resources for Black women from organisations such as Five X More who offer the ‘six steps’ guide, including steps they can take to help improve their care. This article also stresses the importance of healthcare professionals continuing to join in on the conversation of Black maternal health and working together to offer a better healthcare system for all, regardless of race.

Eye-opening statistics

Our Registered Midwife at Integra Healthcare, Allie Campbell offered some insight into the disparities that still exist in the maternity system for Black women, in her video here.

Some statistics shared by her included research that Black women in the UK are 3.7 times more likely to die in childbirth and postpartum (Source: MBRACE, 2022). The CDC also notes, in the US in 2021, Black women were 2.6 times more likely to die.

Kaiser Family Foundation, also states:

“Research has documented that social and economic factors, racism, and chronic stress contribute to poor maternal and infant health outcomes, including higher rates of perinatal depression and preterm birth among African American women and higher rates of mortality among Black infants.”

With these horrifying and eye-opening statistics, it is vital that we, as healthcare professionals, continue to join in raising awareness of this important cause and work together for ways to create positive change in the maternity system.

‘The Six Steps’

The purpose of Black Maternal Health Week is not only to raise awareness but amplify the voice of Black women.

Allie also shared very insightful information from Five X More, where it advises Black women on the six steps to navigate the maternity system and ways they can help improve their care.

The six steps are as follows:

• Speak Up
• Trust Your Gut
• Seek a Second Opinion
• Document
• Find an Advocate
• Do your Research!

Starting the Conversation

Race should not define the health that a woman receives within the healthcare system. Problems can only be resolved if they are brought to light. The statistics above highlighted this past Black Maternal Awareness Week sheds light that there is a problem that is not adequately spoken about because it has been such a taboo topic for a long time.

At Integra Healthcare, we join Allie and the many others encouraging education and greater awareness on black maternal health. It is the sharing of these issues and inequalities that helps start the conversation that turns into taking action to help ensure black maternal health needs will continue to be addressed, ensuring that black women will be advocated for in regard to getting the proper healthcare she and her child need to be healthy, just as much as pregnant women of any other race. As Allie states:

“…it is our job as healthcare professionals to change those statistics and challenge the institutional racism that is still quite clearly evident.”

Important resources on Black Maternal Health:

• https://www.fivexmore.com/As
  
• https://globalblackmaternalhealth.org/about/
  
• https://birthequity.org/

Vaginal delivery is the most well-known and familiar way to give birth. Babies are primarily born in the head-down position. The baby moves down into the birth canal when the mother starts pushing on her contractions. A lot of the time, vaginal birth is the safest birthing method for both the mother and baby. But there can indeed be risks for some women that vaginal birth is unsafe. Assistance may be needed to deliver the baby vaginally, or a caesarean section may have to be done. So, what are the choices available to women in the Cayman Islands regarding their birthing plan? We break this down with some insight from Dr. Marinova, Paediatrician and Neonatologist of Integra Healthcare.

Normal Vaginal Delivery

Standard vaginal delivery is when a woman goes into labour after 37 weeks gestation with the presence and assistance of a birthing team. This is without any intervention, which is how most babies are born. In modern times regarding neonatal care and obstetrics, risks have been identified that can lead to an outcome that isn’t good for both the mother and baby. This is why pregnancies are so closely monitored. Because observations are so frequent, healthcare professionals can intervene if labour needs to be induced due to complications. Labour is no walk in the park; for this reason, women may opt for an epidural to help reduce or remove the pain of contractions. An epidural helps reduce the stress levels of a woman’s hormones and can improve the birthing experience for the mother. A downside to the epidural is that it may make it seem difficult for the mother to push effectively. In this case, an assisted delivery is more than likely needed.

Assisted Delivery

An assisted delivery is when the mother needs help delivering the baby, especially if the baby is becoming distressed. Assisted delivery included using forceps or the vacuum to get the baby out faster due to slow progression while pushing. Dr Marinova says, “Around 30 to 50% of women having an epidural have an assisted vaginal delivery Having an epidural does not increase the risk of an emergency caesarean.”.

Planned Caesarean

For some women, a planned C-section is the safest birthing option. This could be for several reasons; for example, the mother could be very unwell, or the baby is not turning their head down. Dr. Marinova says, “It’s not clear what percentage of planned caesarean section is acceptable and safe for the population. But it’s probably around 10 to 15% with a further 15 to 20% of women needing an emergency caesarean.” There are both pros and cons to having a c-section though many have the misconception that it is safer than a vaginal birth. Women must remember that when all is said and done, like any operation, a c-section carries risks. After c-sections, the risk of placenta praevia is increased. It increases the risk of a blood transfusion and an emergency hysterectomy during delivery. But bear in mind that this is an uncommon but severe risk. C-sections are only recommended if an obstetrician recommends this.

Delivery Choices After Previous Caesarean Section

If a woman has a c-section with her previous birth, it may be safe for her to have a vaginal delivery with later pregnancies. Dr Marinova explains: “There is a consensus between the Royal College in the UK and the American College of Obstetrics and Gynaecology that vaginal birth after caesarean section (VBAC) is safe for the majority of women.” Out of approximately 75% of women who attempt to have a VBAC, have a successful vaginal delivery. This rises to around 90% if the woman has had previous vaginal deliveries. If pregnancy is uncomplicated for both the mother and the baby, the best time to have a repeat c-section is after 39 weeks. It is important to remember that childbirth is safe by whichever method is used, especially here in the Cayman Islands. Your obstetrician is the best person to discuss the pros and cons of birth. They will be able to best advice specific to your circumstances. Integra has two highly trained OBGYNs, Dr Lisa Joels and Dr Madhavi Manoharan with a combined 50+ years of experience between them. Get in touch today and book your appointment at Integra with our obstetrics team here.

High-risk pregnancies: An overview

There are a small proportion of pregnancies that carry a greater risk and complications that can negatively impact the health of the mother, baby or both. These are classified as ‘high-risk pregnancies’. We use the term ‘high-risk’, because specialist care is needed during the pregnancy to ensure optimal health and safety for both the mother and baby. The majority of high-risk pregnancies and births do go without complication. However, it is important to note that this is because of the cautious approaches put in place to help ensure that any risks are addressed. It also means ensuring that you have a contingency plan put in place by specialists, which include OBGYNs but also by a qualified maternal-fetal medicine specialist where closer monitoring and management are required.

Risk-factors for a high-risk pregnancy

Some women will know from the start that they are likely to be higher risk due to the presence of certain risk factors (see below), which helps them make sensible choices about whether they might need a dedicated high-risk pregnancy service. However, for some, risk is not apparent at the start and so understanding what a high-risk pregnancy is and what to do if issues emerge is part of ensuring yours and your baby’s safety. The following list of risk factors is not designed to be fully comprehensive but certainly covers the main ones.

Existing health conditions:

• High blood pressure
• Polycystic ovary syndrome (PCOS)
• Diabetes
• Kidney disease
• Autoimmune disease
• Thyroid disease
• Obesity
• Certain infections e.g. Zika
• Women living with health problems like high blood pressure, anaemia, blood problems like thalassemia and sickle cell disease or trait, asthma epilepsy, diabetes, heart or blood disorders, obesity, autoimmune disease like lupus or rheumatoid arthritis, kidney disease, thyroid disease, or chronic infections like HIV, Hepatitis B or C are at higher risk. Some sexually transmitted infections and mental health concerns like depression can also pose a risk to pregnancy.

Life Decisions and Lifestyle:

• Age of the mother: Women who are younger than the age of 17 and older than the age of 35 are more likely to experience pregnancy complications than women between the ages of 17 and 35. Women who are over 40 years of age also have a higher risk of experiencing miscarriage and delivering a baby with genetic disorders. In Cayman, we have our fair share (or more) of pregnancies in women over 35 years of age.
• Alcohol use
• Tobacco use
• Drug use

Conditions of Pregnancy:

• Multiple gestation
• Gestational diabetes: Gestational diabetes is another complication that develops during pregnancy, usually resolving after the delivery of the baby. If you have developed Gestational diabetes, your Maternal-Fetal Medicine Specialist will follow your baby’s growth and well-being, and manage your health with nutrition counseling, glucose monitoring and, possibly, medications.
• Pre-eclampsia: Pre-eclampsia is a condition unique to pregnancy where you have high blood pressure in conjunction with protein in your urine and edema (swelling of the skin). In some women with pre-eclampsia, liver or platelet abnormalities are present. Referral to a Maternal-Fetal Medicine Specialist may be important, depending on the severity of your disease or if you are preterm. The treatment of pre-eclampsia is delivery of the baby, so this is a condition that requires very close monitoring to balance maternal complications against the risks of delivering your baby early.
• Eclampsia
• Previous preterm birth: Past preterm births may also predict future early deliveries, and so coordination with a neonatologist may be important.
• Placental complications: Placenta previa is a condition in which the placenta covers the cervix. The condition can cause bleeding, especially if a woman has contractions. If the placenta still covers the cervix close to delivery, your doctor will schedule a cesarean section to reduce bleeding risks to the mother and baby.
• Fetal problems: These can be seen on ultrasound. Approximately 2% to 3% of all babies have a minor or major structural problem in development. Sometimes there may be a family history of fetal problems, but other times these problems are completely unexpected. If you are under the care of a Maternal-Fetal Medicine Specialist, they will monitor and test for these problems and discuss them with you, advising on the implications and care options.
• Birth defects or genetic conditions: Previous issues with miscarriage and/or a complicated genetic family history are also risk factors for a high-risk pregnancy.

Role of Maternal-Fetal Medicine Specialist

As mentioned above, after the circumstances of a high-risk pregnancy are reviewed and there are risk factors or concerns, you will likely be referred to a Specialist in Maternal-Fetal Medicine. In certain cases, pregnancy women with existing health conditions or genetic risks may even be referred to Specialist in Maternal-Fetal Medicine before pregnancy. This type of doctor has received special training in how to care for women with a high-risk pregnancy. It is a higher training than normal obstetric training and carries formal accreditation in modern health systems, as well as experience of working in high-risk specialist centres.

In addition, the Maternal-Fetal Medicine Specialist has extensive training in assessment and treatment of fetal problems. In this case, the Maternal-Fetal Medicine Specialist will coordinate your care, as well as your baby’s care during pregnancy, with other doctors, nurses, and other healthcare professionals, and at delivery with the help of a Neonatal care team to ensure the best possible outcome for both you and your baby. The goal is to improve the outcome of the patient’s current pregnancy, as well as lower her risks for complications in future pregnancies. Safe care typically involves a multidisciplinary approach and seamless coordination.

Are there preventative measures?

Many recommend a preconception appointment with your health care provider or OBGYN to ensure you are as healthy as you can be before you become pregnant, even if you have no existing health conditions. OBGYNs and Maternal-Fetal Medicine Specialist may recommend the following to help reduce risk of certain conditions:

• Getting at least 400 micrograms of folic acid daily, starting before and continuing through pregnancy, occasionally you may be advised to take bigger doses like 5 mg of folic acid.
• Getting recommended immunizations
• Eating a healthy balanced diet and maintaining proper weight
• Getting regular physical activity, unless advised otherwise by your doctor
• Eating a healthy balanced diet and maintaining proper weight
• Avoiding smoking, alcohol, and drugs (except for medications approved by your doctor)
• Taking only the over the counter and prescription medicines that your doctor or midwife has OK’d for you
• Seeing your doctor regularly
• Working with them to manage problems such as diabetes, depression, high blood pressure, or infection

There is a possibility to have normal pregnancy initially and develop conditions that then classify your pregnancy as high-risk. Each antenatal visit is in effect a repeat assessment of risk factors, aiming to identifying any new risk factors that may have arisen since the last visit, coming up with an effective management plan for the condition and providing guidance on preventative measures to ensure everything runs smoothly.

Integra Healthcare’s High-Risk Pregnancy Service

The Integra Obstetric-Neonatal team collectively represents decades of consultant-level, tertiary experience in managing both high risk pregnancies and the fetal or newborn complications that can arise. It is quite simple unique on Island:

• Only combined Obstetric-Neonatal team, allowing a true, seamless, multidisciplinary approach
• Only team with both obstetric and neonatal accredited and experienced tertiary consultants
• Detailed fetal anomaly scans conducted by a highly experience sonographer and independently reported
• All key obstetric and neonatal team members live within 5 minutes of Cayman Islands Hospital in George Town
• 24/7 access to the team for concerns or urgent care issues

In the meantime, if you have would like more information or have any concerns, we’d be delighted to help:

Based on our combined experience of literally thousands of high-risk pregnancies, here and in the UK, our approach is comprehensive, designed to assess all risk factors, proactive and multidisciplinary. We’d be delighted to talk through that approach in detail, without charge, so that you can understand just why it is unique, as well as meet the team members who might be involved.

Click here for more information.