Science

Birth can be dismal for Black women. What this hospital is doing to stop that

Published

10 months ago

September 3, 2023

Birth can be dismal for Black women. What this hospital is doing to stop that

Brianna Mckenzie was feverish and shaking in her bed as night drew near at MLK Community Hospital.

The pregnant woman was a week and a half past her due date. She had come to the Willowbrook hospital to be induced a day beforehand and was only halfway to the needed dilation. Her mother, Francine Tomlinson, had grown anxious, knowing that fever could be a sign of an infection.

Nurse Midwife Angela Sojobi, middle, checks on patient Brianna Mckenzie in the labor and delivery unit at MLK Community Hospital in August.

(Francine Orr / Los Angeles Times)

As Tomlinson worried over her daughter, obstetrician Dr. John Pinches III stepped into the room and laid out the decision before Mckenzie, explaining the trade-offs of a cesarean section or continuing with labor. She’d been given antibiotics to quash any infection and Tylenol for her fever, but Tomlinson urged her daughter to consider a C-section.

Her fears and anxiety were underscored by the unsettling statistics surrounding birth in the United States. Black women like Mckenzie have been at much higher risk of dying in pregnancy and childbirth than women of other races in the U.S. — a country where birth is already far more dangerous than in many other wealthy nations.

Two women in nursing scrubs talk with a seated woman as another woman lies in bed.

As Mckenzie weighed her options, Angela Sojobi, the midwife who had been tending to the 23-year-old throughout the day, sought to reassure her mother. “We will not let anything bad happen to her,” Sojobi told Tomlinson, sitting down next to her. “That’s why I’m here, watching her like a hawk.”

Mckenzie decided to continue with her labor. Less than five hours later, she was pushing out her newborn son, surrounded by her mother, her partner and the hospital team. Sojobi coached her through each push, her tone steady and soothing: “What a strong woman. Take a breath. You’re almost done.”

At midnight, Mckenzie pushed once more before Sojobi lifted the wailing infant to his mother’s chest.

“He is so gorgeous!” Sojobi exclaimed. “Look at what you did, Brianna!”

It was a euphoric ending that should be unremarkable: A woman safely bringing a baby into the world. But the way MLK Community Hospital is trying to improve the birthing process for its patients remains far from the norm, and hospital officials fear it could be difficult to sustain.

A digital clock shows 12 o'clock as a woman in bed holds a baby.

Since it opened its doors eight years ago, the South Los Angeles-area hospital has relied on certified nurse midwives like Sojobi — nurses with graduate-level training in pregnancy and childbirth — working together with obstetricians to manage labors. Midwifery proponents point to evidence that such births are associated with fewer C-sections and preterm births. But as of 2021, only about 10% of hospital births in the U.S. were attended by midwives, according to the National Center for Health Statistics.

At MLK, a certified nurse midwife is routinely at the hospital to guide normal labors, collaborating with an obstetrician who is on site to handle patients who are at high risk or face medical complications during their delivery. Hospital officials said they are trying to give South L.A. patients the best of both worlds: the support of a trained and empathetic nurse midwife and the emergency capabilities of an obstetrician if something goes wrong.

A man cuts the umbilical cord of his child as the mother lies in her hospital bed flanked by nurses.

“Most labors start out as a natural process, and a midwife is good at that,” said Dr. Danny Dan, an OB-GYN at MLK. If a birth can proceed without interventions, he said, clinicians can avoid the risk of complications connected to those interventions, which must be weighed against their possible benefits.

“The problem is, when labor turns bad, it turns bad very quickly,” Dan said. In general, “you really don’t need a doctor — until you need a doctor.”

Holly Smith, health policy chair of the California Nurse-Midwives Assn, said that in California, having both midwives and obstetricians working full time has typically been more common at bigger entities such as Kaiser Permanente than at a smaller hospital like MLK, especially one serving a disadvantaged community. MLK officials credit round-the-clock staffing with an OB and midwife with driving its notably low rates of C-sections and episiotomies, measures widely used to gauge the quality of maternal care.

Roughly 14% of its first-time, low-risk births involved a C-section, compared with about 23% of such births statewide, according to statistics gathered by Cal Hospital Compare. Hospital data provided by Sojobi also indicate that most newborns at MLK are in good condition shortly after birth, based on a common metric used to assess newborns.

“We allow the body to do what it does best,” Sojobi said. Medical staff will not hesitate to intervene when needed, she added, but “when we intervene unnecessarily in a normal process, that’s when we end up with problems.”

Midwifery has also been promoted as a way to provide more sensitive and individualized care, an especially urgent concern for Black women. Thirty percent of Black women reported mistreatment during maternity care and 40% reported discrimination, according to a Centers for Disease Control and Prevention analysis of a national survey — rates markedly higher than among white women surveyed.

Listening to women and taking their pain seriously “sounds so basic, but it can literally save people’s lives,” said Jessica Wade, a maternal and infant health manager with the March of Dimes in California.

A nurse wraps a baby in a blanket as another speaks to a woman in the background.

In California, Black mothers have been the most likely to express interest in having a midwife in the future — and the least likely to have worked with one, according to a Commonwealth Fund analysis. Midwives are far more common in many other wealthy countries than the U.S., where midwifery was historically marginalized as birth care shifted to hospitals. One famed obstetrician denounced midwives in 1915 as “a drag on the progress of the science and art of obstetrics.”

Midwifery has regained some ground since then, but many patients remain unable to access such care due to insurance barriers, regulatory restrictions, or a shortage of providers. Cultural acceptance of the role of midwifery is “inconsistent,” said Kim Q. Dau, co-specialty coordinator of the nurse midwifery education program at UC San Francisco School of Nursing, and “it is really hard to keep up with workforce demands” with only two programs educating nurse midwives across the state.

Dr. Neel Shah, a Harvard Medical School visiting scientist focused on maternal health, argued that everyone who is giving birth can benefit from support, monitoring and coaching. Some patients also benefit from medical technology like epidurals, and a minority benefit from surgeons, “which is what obstetricians are.”

In the U.S., “it’s the opposite,” he said, “Everyone gets the surgeon … and the thing we’ve forgotten about is the support.”

A woman in nursing scrubs and a surgical mask.

Sojobi has worked as a midwife in the U.S. and Nigeria, where she was born. There, she said, having a midwife was routine for a normal labor, and for many pregnant patients, “the prayer would be, ‘Dear God, don’t let me see a physician.’ Because when you see the physician, that means something is wrong.”

When Sojobi came to the U.S. as a nurse decades ago, she said, midwives were so uncommon in its hospitals that she did not realize they existed here at all. As a nurse attending births in the 1980s, Sojobi said, she cringed when she observed patients being hustled to the operating room if they hadn’t given birth by a set time.

When she was a patient in labor in the U.S., she said, she was frustrated when a clinician gave her a pain medication she didn’t want without any warning, leaving her dizzy and alarmed. “Her heart was in a good place,” Sojobi said, but she was upset to not be asked what she wanted or even informed what was happening.

At her next birth in the U.S., Sojobi said, her doctor wanted her to undergo a C-section because her labor had been progressing slowly. But Sojobi and her baby were faring well. She told her doctor that she was OK with waiting and asked her to come back in four hours. “By the time she came back, I was ready to push.”

A woman takes a photo of a woman in bed holding a baby as a nurse attends.

Cesarean sections can save lives, but global studies suggest they have become much more common than is necessary. In the U.S., they account for one-third of births rather than the 15% to 19% researchers have found to be optimal in developed countries. Maternal mortality in the U.S. has been going up rather than down in recent decades, researchers have found — and only worsened amid the pandemic, according to national statistics.

Dan, the obstetrician, said what MLK is doing is allowing the normal process of birth to play out with time, with the medical tools and expertise of physicians at hand if anything veers away from what is normal. As Sojobi kept monitoring and checking on Mckenzie progressing in her labor, Pinches was on site at the hospital and ready to step in if needed. Sojobi pointed out to a reporter that the operating room was nearby, through a set of swinging doors down the hall.

It’s a system that closely matches what South L.A. women told researchers they wanted, when MLK commissioned focus groups in the area. Most said they felt safer giving birth in a hospital, with ready access to technology and medication, but also wanted the care of a midwife or birth doula, the research group found.

“To me this is as perfect as it gets,” Dan said one afternoon, gesturing around the labor and delivery unit.

“But it’s very costly to have this model.”

A woman looks down at a baby she's holding.

Employing midwives around the clock at MLK costs more than $700,000 annually, in addition to the costs of staffing the unit with other clinicians. The hospital has been under financial strain for years as it tries to survive on reimbursements under Medicaid, which covers the bulk of its patients and pays less than commercial insurers. California recently granted it a $14-million no-interest loan under a program for hospitals in financial distress; MLK officials said they were grateful for the loan, but that it would not plug its annual losses.

Dr. Elaine Batchlor, chief executive of MLK Community Healthcare, estimated that the hospital loses more than $2 million annually on its labor and delivery unit. Across the country, many hospitals have been cutting labor and delivery units entirely in the face of financial pressures. In California, the number of hospitals with birthing services fell by a fifth between 2019 and 2020, according to a March of Dimes analysis — and more have closed their maternity units in the years since.

Labor and delivery units need a lot of staff, which means they typically lose money unless a hospital is delivering thousands of babies annually, Shah said. In areas where more patients rely on Medicaid than commercial insurance, the financial strain is worse. And industry groups say labor costs have risen as hospitals continue to grapple with short staffing after the eruption of the pandemic.

A woman attends to a baby in a hospital bassinet.

Such closures have hit rural areas especially hard, creating “maternity care deserts” in more than a third of U.S. counties, the March of Dimes found. But urban and suburban areas have also lost birthing units, including in Los Angeles County. In the South Bay, Memorial Hospital of Gardena closed its maternity services three years ago. East of Los Angeles in Montebello, Beverly Hospital announced this spring that it would be halting maternity services and filed for bankruptcy protection.

And in Inglewood, Centinela Hospital Medical Center is closing its unit in October, citing declining births. The decision was announced before the hospital was dealt a $75,000 state fine for faulty practices that led to the death of a woman admitted to its labor and delivery unit.

The state did not name the patient, but the date and details of the death matched those of April Valentine, a 31-year-old Black woman who died at Centinela in January. Another mother, a Black woman named Bridgette Burks, died in March at California Hospital Medical Center in the aftermath of a C-section, leaving behind five children and a devastated husband. Again, the state did not name the patient, but investigators found the hospital failed to address signs of a hemorrhage before a birthing patient died that day.

And in July, a federal agency confirmed Cedars-Sinai Medical Center is facing a federal civil rights investigation over how it treats Black women who give birth there, years after the death of Kira Dixon Johnson, whose husband told Congress that he was “smitten with her zest for life.”

Black women in the U.S. were more than 2½ times as likely to die in pregnancy and its aftermath than white women in 2021, national data show. Such disparities exist even for wealthy Black mothers, who are about as likely to die of pregnancy-related causes as the poorest white mothers, according to an analysis of California deaths published in the National Bureau of Economic Research. And Black babies are also at a higher risk of death than white infants.

A mother holds her baby as the father looks on.

Sojobi said in the South L.A. area, what stands out to her is the fear among her patients, who are mostly Latina and Black. “Women looking at me and saying, ‘Please don’t let anything happen to me.’” At MLK, “from the second the patient walks in the door, they’re shown respect. They’re listened to.”

“We don’t just dictate what’s going to happen to them,” she said.

A United Nations analysis found that Black women are “disadvantaged before, during and after pregnancy” and faulted structural racism and sexism for alarming levels of Black maternal mortality across the Americas. Researchers have increasingly focused on the toll of racism within the healthcare system and the kind of care that Black women receive before, during and after childbirth, as well as the physical effects of chronic stress endured by Black women in the U.S.

Racism “is so deeply embedded in the system that it is not surprising that we have these outcomes,” said Janette Robinson Flint, executive director of Black Women for Wellness, an organization that engages in education and advocacy for the health of Black women and girls. “What is surprising is that we continue to tolerate it.”

The bulk of pregnancy-related deaths in the U.S. are preventable, researchers have found. Across California, more than two dozen people have died since January of complications of pregnancy, childbirth or its aftermath, according to state data from death certificates. California has had lower rates of such deaths than other states, but “I don’t think California can rest on its laurels,” Robinson Flint said. “Why would we accept that it’s OK that women have died giving birth this year?”

When Mckenzie moved to Los Angeles and began looking for a hospital to deliver her baby, she knew she wanted a facility that wouldn’t put her in the position of having to choose between herself and the baby, she said. She toured several hospitals before deciding on MLK, noting its low rates of cesarean sections.

“I wanted a safe delivery. I wanted staff members who listened to me. … And that’s what they were about.” She was reassured that Sojobi was checking on her constantly, and praised another nurse, Monica Waite, as being “like a mom.”

A woman holding her baby is wheeled through a hospital in a wheelchair.

“They really treated me like I belonged,” Mckenzie said. “For Black women, it’s rare to find that.”

Before her son was born, Mckenzie told nurses that she hadn’t picked a name. But shortly after her partner Wayne Morgan cut the umbilical cord, the name sprang readily to her lips: Javen Lucas. Javen, for her brother who had gone missing in Jamaica, where her family is from. Lucas, which means “bringer of light.”

She had long since chosen the name, but wanted to surprise her mother. Her family had lost a boy, “and then God blessed me with another boy,” McKenzie said. “The entire family was in a place of darkness due to my brother being missing.”

“And I do feel like his name — and him — kind of brightened up everything.”

It was just after midnight at MLK Community Hospital. Morgan was leaning over Mckenzie, speaking softly to his son. Tomlinson gazed at the sight of her first grandchild cradled in the arms of her daughter. Sojobi kidded with the new grandmother that she had grown new gray hairs.

“You have done a good job,” Tomlinson told Sojobi with relief.

A woman in a wheelchair and another holding a baby.

Sojobi later reflected that in other circumstances, Mckenzie might have quickly undergone a C-section after her mother grew concerned. Fear of litigation can weigh on those decisions by doctors, researchers have found. But Sojobi said what made the difference at MLK was time: Time to talk with Tomlinson about her fears and reassure her. Time to shift Mckenzie into different positions to help the baby turn and descend, even with the constraints of an epidural.

“This is what we live for,” Sojobi said, beaming over the red frames of her eyeglasses.

Science

Live poultry markets may be source of bird flu virus in San Francisco wastewater

Published

22 hours ago

July 4, 2024

Press Room

Live poultry markets may be source of bird flu virus in San Francisco wastewater

Federal officials suspect that live bird markets in San Francisco may be the source of bird flu virus in area wastewater samples.

Days after health monitors reported the discovery of suspected avian flu viral particles in wastewater treatment plants, federal officials announced that they were looking at poultry markets near the treatment facilities.

Last month, San Francisco Public Health Department officials reported that state investigators had detected H5N1 — the avian flu subtype making its way through U.S. cattle, domestic poultry and wild birds — in two chickens at a live market in May. They also noted they had discovered the virus in city wastewater samples collected during that period.

Two new “hits” of the virus were recorded from wastewater samples collected June 18 and June 26 by WastewaterSCAN, an infectious-disease monitoring network run by researchers at Stanford, Emory University and Verily, Alphabet Inc.’s life sciences organization.

Nirav Shah, principal deputy director of the U.S. Centers for Disease Control and Prevention, said that although the source of the virus in those samples has not been determined, live poultry markets were a potential culprit.

Hits of the virus were also discovered in wastewater samples from the Bay Area cities of Palo Alto and Richmond. It is unclear if those cities host live bird markets, stores where customers can take a live bird home or have it processed on-site for food.

Steve Lyle, a spokesman for the state’s Department of Food and Agriculture, said live bird markets undergo regular testing for avian influenza.

He said that aside from the May 9detection in San Francisco, there have been no “other positives in Live Bird Markets throughout the state during this present outbreak of highly-pathogenic avian flu.”

San Francisco’s health department referred all questions to the state.

Even if the state or city had missed a few infected birds, John Korslund, a retired U.S. Department of Agriculture veterinarian epidemiologist, seemed incredulous that a few birds could cause a positive hit in the city’s wastewater.

“Unless you’ve got huge amounts of infected birds — in which case you ought to have some dead birds, too — it’d take a lot of bird poop” to become detectable in a city’s wastewater system, he said.

“But the question still remains: Has anyone done sequencing?” he said. “It makes me want to tear my hair out.”

He said genetic sequencing would help health officials determine the origin of viral particles — whether they came from dairy milk, or from wild birds. Some epidemiologists have voiced concerns about the spread of H5N1 among dairy cows, because the animals could act as a vessel in which bird and human viruses could interact.

However, Alexandria Boehm, professor of civil and environmental engineering at Stanford University and principal investigator and program director for WastewaterSCAN, said her organization is not yet “able to reliably sequence H5 influenza in wastewater. We are working on it, but the methods are not good enough for prime time yet.”

A review of businesses around San Francisco’s southeast wastewater treatment facility indicates a dairy processing plant as well as a warehouse store for a “member-supported community of people that feed raw or cooked fresh food diets to their pets.”

Science

Be grateful for what you have. It may help you live longer

Published

1 day ago

July 3, 2024

Press Room

Be grateful for what you have. It may help you live longer

Death may be inevitable, but that hasn’t stopped health researchers from looking for ways to put it off as long as possible. Their newest candidate is something that’s free, painless, doesn’t taste bad and won’t force you to break a sweat: Gratitude.

A new study of nearly 50,000 older women found that the stronger their feelings of gratitude, the lower their chances of dying over the next three years.

The results are sure to be appreciated by those who are naturally inclined toward giving thanks. Those who aren’t may be grateful to learn that with practice, they might be able to enhance their feelings of gratitude and reap the longevity benefits as well.

“It’s an exciting study,” said Joel Wong, a professor of counseling psychology at the University of Indiana who researches gratitude interventions and practices and wasn’t involved in the new work.

Mounting evidence has linked gratitude with a host of benefits for mental and physical health. People who score higher on measures of gratitude have been found to have better biomarkers for cardiovascular function, immune system inflammation and cholesterol. They are more likely to take their medications, get regular exercise, have healthy sleep habits and follow a balanced diet.

Gratitude is also associated with a lower risk of depression, better social support and having a greater purpose in life, all of which are linked with longevity.

However, this is the first time researchers have directly linked gratitude to a lower risk of earlier death, Wong and others said.

“It’s not surprising, but it’s always good to see empirical research supporting the idea that gratitude is not only good for your mental health but also for living a longer life,” Wong said.

Study leader Ying Chen, an empirical research scientist with the Human Flourishing Program at Harvard University, said she was amazed by the dearth of studies on gratitude and mortality. So she and her colleagues turned to data from the Nurses Health Study, which has been tracking the health and habits of thousands of American women since 1976.

In 2016, those efforts included a test to measure the nurses’ feelings of gratitude. The women were asked to use a seven-point scale to indicate the degree to which they agreed or disagreed with six statements, including “I have so much in life to be thankful for” and “If I had to list everything I felt grateful for, it would be a very long list.”

A total of 49,275 women responded, and the researchers divided them into three roughly equal groups based on their gratitude scores. Compared with the women with the lowest scores, those with the highest scores tended to be younger, more likely to have a spouse or partner, more involved in social and religious groups, and in generally better health, among other differences.

The average age of nurses who answered the gratitude questions was 79, and by the end of 2019, 4,068 of them had died. After accounting for a variety of factors such as the median household income in their census tract, their retirement status, and their involvement in a religious community, Chen and her colleagues found that the nurses with the most gratitude were 29% less likely to have died than the nurses with the least gratitude.

Then they dug deeper by controlling for a range of health issues, including a history of heart disease, stroke, cancer and diabetes. The risk of death for the most grateful women was still 27% lower than for their least grateful counterparts.

When the researchers considered the effects of smoking, drinking, exercise, body mass index and diet quality, the risk of death for the nurses with the most gratitude remained lower, by 21%.

Finally, Chen and her colleagues added in measures of cognitive function, mental health and psychological well-being. Even after accounting for those variables, the mortality risk was 9% lower for nurses with the highest gratitude scores.

The findings were published Wednesday in JAMA Psychiatry.

Although the study shows a clear link between gratitude and longevity, it doesn’t prove that one caused the other. While it’s plausible that gratitude helps people live longer, it’s also possible that being in good health inspires people to feel grateful, or that both are influenced by a third factor that wasn’t accounted for in the study data.

Sonja Lyubomirsky, an experimental social psychologist at UC Riverside who studies gratitude and was not involved in the study, said she suspects all three things are at work.

Another limitation is that all of the study participants were older women, and 97% of them were white. Whether the findings would extend to a more diverse population is unknown, Wong said, “but drawing on theory and research, I don’t see a reason why it wouldn’t.”

There can be downsides to gratitude, the Harvard team noted: If it’s tied to feelings of indebtedness, it can undermine one’s sense of autonomy or accentuate a hierarchical relationship. Lyubomirsky added that it can make people feel like they’re a burden to others, which is particularly dangerous for someone with depression who is feeling suicidal.

But in most cases, gratitude is an emotion worth cultivating, Lyubomirsky said. Clinical trials have shown that gratitude can be enhanced through simple interventions, such as keeping a gratitude journal or writing a thank-you letter and delivering it by hand.

“Gratitude is a skill that you can build,” she said.

And like diet and exercise, it appears to be a modifiable risk factor for better health.

Lyubomirsky has found that teenagers who were randomly assigned to compose letters of gratitude to their parents, teachers or coaches took it upon themselves to eat more fruits and vegetables and cut back on junk food and fast food — a behavior not shared by classmates in a control group. Perhaps after reflecting on the time, money and other resources invested in them, the teens were inspired to protect that investment, she said.

More research will be needed to see whether interventions like these can extend people’s lives, but Chen is optimistic.

“As the evidence accumulates, we’ll have a better understanding of how to effectively enhance gratitude and whether it can meaningfully improve people’s long-term health and well-being,” she said.

Science

Drug can amplify naloxone's effect and reduce opioid withdrawals, study shows

Published

1 day ago

July 3, 2024

Press Room

Drug can amplify naloxone's effect and reduce opioid withdrawals, study shows

Naloxone has long been hailed as a life-saving drug in the face of the opioid epidemic. But its capacity to save someone from an overdose can be limited by the potency of the opioid — a person revived by naloxone can still overdose once it wears off.

Stanford researchers have found a companion drug that can enhance naloxone’s effect — and reduce withdrawal symptoms. Their research on mice, led by Stanford University postdoctoral scholar Evan O’Brien, was published today in Nature.

Typically, overdose deaths occur when opioids bind to the part of the brain that controls breathing, slowing it to a stop. Naloxone reverses overdoses by kicking opioids off pain receptors and allowing normal breathing to resume.

However, it is only able to occupy pain receptors for 30 to 90 minutes. For more potent opioids, such as fentanyl, that may not be long enough.

To determine how the naloxone companion drug, which researchers are calling compound 368, might boost naloxone’s effectiveness, researchers conducted an experiment on pain tolerance in mice, said Jay McLaughlin, a professor of pharmacology at the University of Florida. How quickly would mice pull their tails out of hot water, depending on which combination of opioids and treatments they were given?

Mice that were injected with only morphine did not respond to the hot water — given their dulled pain receptors. Mice given morphine and naloxone pulled their tails out within seconds. No surprises yet.

When the dosage of naloxone was reduced and compound 368 was added, the compound was found to amplify naloxone’s effects, as if a regular dose was used. When used on its own, the compound had no effect, indicating that it is only helpful in increasing the potency of naloxone.

What researchers did not expect, however, was that the compound reduced withdrawal symptoms.

McLaughlin said withdrawal is one reason that people who have become physically dependent on opioids may avoid naloxone.

“Opioid withdrawal will not kill you, but I have talked to a number of people who have gone through it, and they have all said the same thing: … ‘I wished I was dead,’” McLaughlin said. “It has a massive range of nasty, horrible effects.”

The idea that the compound could amplify naloxone’s effect at a lower dosage, while limiting withdrawal symptoms, indicates that it may be a “new therapeutic approach” to overdose response, McLaughlin said.

The research team said their next step is to tweak the compound and dosage so that the effects of naloxone last long enough to reverse overdoses of more potent drugs.

Though the compound is not yet ready for human trials, the researchers chose to release their findings in the hope that their peers can double check and improve upon their work, said Susruta Majumdar, another senior author and a professor of anesthesiology at the Washington University School of Medicine in St. Louis.

“We may not be able to get that drug into the clinic, but somebody else may,” Majumdar said. He added: “Let them win the race.”