MARY LOUISE KELLY, HOST:
We're going to hear the story of a woman who died earlier this year a few weeks after giving birth. Her name was Shalon Irving. She was in her mid-30s. She was black. NPR's Renee Montagne and ProPublica's Nina Martin learned about her at the beginning of an investigation into the high rate of maternal deaths here in the U.S.
KELLY MCEVERS, HOST:
Within that alarming rate is an even more troubling one. Black women are three times more likely to die than white women. Sometimes it's an issue of poverty, lack of prenatal care or not having access to the best hospitals. Racism also plays a role. Experts say prolonged exposure to bias is so stressful; it can make the difference between life and death. Here's Renee.
RENEE MONTAGNE, BYLINE: It is an especially cruel irony that Shalon Irving was focusing on the exact issue of how racism figures into health. Armed with a Ph.D., she was rising through the ranks of the Centers for Disease Control and Prevention, where she researched the many ways the body can be negatively impacted by its surroundings.
By any measure, Shalon had accomplished a lot - highly educated and well-paid. She owned her own home and had access to the finest health care. Yet none of that protected her from becoming part of a shockingly high rate of black maternal mortality.
WANDA IRVING: Soleil, can you say hi? Hi.
MONTAGNE: On a recent afternoon, we joined Shalon's mother, Wanda Irving, in her home outside of Atlanta. She was surrounded by photos and mementos and caring for the baby Shalon left behind when she died from complications of childbirth.
IRVING: Here's a picture of her and Soleil with the same outfits. That was taken the day she collapsed, the morning of the day she collapsed. Soleil is French for sun. She just lights up a room when she smiles. She's the only reason I have for getting out of bed every morning.
(SOUNDBITE OF BABY COOING)
MICHAEL LU: The fact that in 2017 America a black woman is still three to four times as likely to die in pregnancy and childbirth and that they are twice as likely to suffer a life-threatening complication - I think that's a national disgrace.
MONTAGNE: Dr. Michael Lu spent years as head of the Maternal and Child Health Bureau. That's the main federal funder of programs for mothers and infants. He and others have done studies showing that an important cause of poor outcomes in childbirth for all black women is prolonged exposure to the indignities and dangers of discrimination.
LU: We're talking about African-American doctors and lawyers and business executives, and they still have higher maternal mortality rate than white women who were high school drop-outs. It's the experience of having to work harder than anybody else just to get equal pay and equal respect. It's being followed around when you're shopping at a nice store or being stopped by the police when you're driving in the nice neighborhood. Those types of experiences create the kind of chronic stress that continue to gun the engine which over time create the wear and tear on your body's systems.
MONTAGNE: There is a word researchers use for this accelerated deterioration of the body. It's called weathering. And some studies suggest it can be measured at the level of chromosomes. One study looking at the chromosomal markers for aging found that middle-aged African-American women on average appear seven and a half years older than their white counterparts. The lead author was a pioneer in the study of weathering - Arline Geronimus of the University of Michigan School of Public Health.
ARLINE GERONIMUS: Long-term exposure to cascades of stress hormones causes a lot of different health vulnerabilities, and it increases your susceptibility to infection but also the early onset of chronic diseases, in particular hypertension, diabetes, morbid obesity.
MONTAGNE: Weathering and chromosomal indications of aging can occur in anyone. One study, for example, showed similar weathering in white mothers caring for autistic children. The core problem is lifelong unrelenting stress. And for African-American women, pregnancy becomes an even more dangerous time.
LU: Pregnancy is a big stressor on the body. And a healthy body can adjust and adapt to it, but a body that's worn out will have a much harder time and therefore putting the woman at greater risk.
MONTAGNE: Photos of Shalon Irving show a vibrant woman river rafting with friends, posing in a silky evening gown. At 36, Shalon would be categorized as high-risk. But added to that, a black woman who is, say, 35 can be biologically closer to 45, a far greater risk for giving birth. And beneath Shalon's broad smile and healthy glow lurked many of the same issues that beset less-privileged black women. Shalon had already lost both of her siblings - a baby brother in a car accident. And then her beloved older brother, Sam, died slowly from MS. As a primary caregiver, Shalon fretted over what she saw as sub-par treatment being offered to Sam because he was black and on Medicaid.
Then last year, Shalon got news she had long hoped for. She was pregnant but soon found herself single when her relationship with the baby's father fell apart. These traumatic life events do add to the risk of pregnancy. Along with Shalon's history of surgery for uterine fibroids, which meant she would have to have a caesarean. She was overweight and taking medication to control a blood clotting disease. Still, her mother says, Shalon managed to overcome all these risk factors through to the very end of her pregnancy.
IRVING: It was a great birth. It was just a beautiful time. So the problem didn't come in until after the birth, and she didn't have an after-birth plan.
MONTAGNE: In fact a few new mothers do. Obstetrician Elizabeth Howell is known for her work on racial disparities as a professor at Mount Sinai's Icahn School of Medicine in New York.
ELIZABETH HOWELL: We've had a longstanding history in this country of just sort of sending moms out. You know, they've done the big thing. They've delivered the baby, and now they'll heal. They'll be fine. And you know, that's actually not true, right?
MONTAGNE: In fact the CDC finds that more than half of America's maternal deaths occur postpartum. Fully a third of those happen at least a week or more after giving birth. Monica McLemore is a nursing professor at the University of California, San Francisco, now leading a major effort to reduce premature births among black women. Her research involves scores of focus groups with black mothers.
MONICA MCLEMORE: And so one of the things that has been very striking from the focus groups that I've conducted is that people feel disrespected during their care. They talk about not being believed. They talk about reporting signs and symptoms of deterioration and not having any real action that occurs.
MONTAGNE: Numerous studies do support the existence of implicit bias in the treatment of black patients. And in a survey recently released by NPR, the Robert Wood Johnson Foundation and Harvard's Chan School of Public Health, one-third of black women said they had been discriminated against because of their race when going to a doctor or health clinic. One in 5 avoided going to a doctor or seeking health care out of concern that they would be racially discriminated against. Monica McLemore has found that anticipation of bias can also disrupt key communication between a mother and her provider.
MCLEMORE: One of the patients who was talking through her birth story was going on and on and on about how she has no game face. And she says people who know me know that I have very emotional reactions. And as a black woman, I've learned to curtail that because I don't want to appear to be angry all of the time.
But one of the things that was really difficult during her birthing experience was she was working so hard to not appear to be angry or to not appear to be in pain that every time she spoke to the nurses and requested pain medicines, they didn't believe her. And so she really was trying to suppress what her natural facial expressions and responses were because she didn't want people to be buying into stereotypes about black women and particularly whether or not we're angry.
MONTAGNE: Among the more than 200 stories ProPublica and NPR collected about black mothers, inadequate care after birth was a constant theme. When we review Shalon Irving's medical records, we discovered a cascade of complications after birth. Within days, the wound from her caesarean became badly infected. It was treated, but a week later, she had to be seen again. The wound wasn't healing well and so painful she couldn't sleep.
Reflecting Shalon's mounting distress, her medical records quote her. It just doesn't feel right. Her legs were swelling until one became bigger than the other, and she was gaining weight, not losing. When a visiting nurse noticed Shalon's blood pressure suddenly spiking, she made another appointment.
IRVING: And she went in. It was just sort of, oh, that's to be expected. You just had a baby. Don't worry about it.
MONTAGNE: She was tested for a blood clot - it was negative - and given a new prescription - pills for high blood pressure. But when Wanda looks back now, all she sees is a series of missed opportunities to save Shalon.
IRVING: Because there is something wrong with this lady. Why not check it out instead of just sending her home? She's got swollen limb. She's not feeling well. She's got high blood pressure. Why wouldn't you put that person in the hospital? She thought they were not paying attention. She did indicate that, yeah, they never listen to us.
MONTAGNE: That night after her fourth visit in the three weeks since she'd given birth, Shalon collapsed.
IRVING: She just, you know, reached up one arm as if she was trying to grab something, and she just made a - I don't know - a gargling kind of sound like she was trying to say something and passed out.
MONTAGNE: Paramedics found her without a pulse and not breathing. She never regained consciousness. An autopsy later concluded Shalon Irving died from complications of hypertension. We can't know if Shalon would have survived had she been white. But hers is a story that does fit into the larger picture described by researcher Arline Geronimus of why black mothers too often die after giving birth.
GERONIMUS: Weathering itself just leads to a greater health vulnerability. So you could think of it as, we'll patch up this problem, and we'll patch up that problem. But overall you're in a weakened physiological state. And so all sorts of different manifestations in your health can show up and some very quickly.
MONTAGNE: In the 11 months since Shalon has been gone, Wanda's sorrow has never abated.
IRVING: I never really cry in front of Soleil.
MONTAGNE: Except once recently when she received a book put together by Shalon's friends and colleagues at the CDC called "Letters To Soleil," telling her how great her mother was.
IRVING: I was trying to read a couple of the letters to Soleil, and I just totally lost it. And she just looked at me like - this puzzled look and cocked her head a couple of times. And then she just put her head on my chest and started patting me like I do for her when she's crying. And it was just the sweetest thing. She's just an amazing little girl. She understands so much.
MONTAGNE: Wanda Irving is in her 60s now, raising the daughter her own daughter had so longed for. And Soleil - she will have her first birthday on January 3. Renee Montagne, NPR News.
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