jessamine Flores, Illustration Editor

In New Haven, Black people are seven times more likely than white people to die from pregnancy-related complications. 

The statistic is part of a maternity mortality crisis unfolding statewide. Even though 80 percent of these deaths are preventable, according to the Centers for Disease Control and Prevention, people of color continue to bear the brunt of Connecticut’s dwindling maternity services.

In response to these disparities, S.B. 986 An Act Protecting Maternal Health, introduced by Gov. Ned Lamont in February, seeks to reshape and expand the scope of maternal health care in Connecticut. The bill proposes to license free-standing birth centers for low-risk pregnancies, in addition to implementing nurse home visits for newborn infants and certifying services by doulas — trained professionals who provide emotional and physical support to their clients during childbirth.

The bill was passed out of the Public Health Committee on April 4 and now awaits Senate approval. If signed into law, S.B. 986 could fill in some gaps left by statewide maternity ward closures — which occur overwhelmingly in rural, low-access areas — and offer a more human, intimate birthing experience for expecting mothers.

“This [bill] is just an opportunity to address that issue,” Lucinda Canty, associate professor and director of Health Equity in the Nursing Program at the University of Massachusetts Amherst, said to the News. “We’re a small state, but we still have pockets where people don’t have the resources they need when it comes to healthcare.”

Maternity care in crisis

Maternal morbidity and mortality serve as a bellwether of the general population’s health, said Katherine Campbell, associate professor of obstetrics and medical director of labor and birth at Yale New Haven Hospital.

Yet Campbell has witnessed increasing hemorrhage and hypertension in her obstetrical care patients, much of which occurs in the postpartum period — six to eight weeks after birth. She noted that these complications are compounded by diabetes and obesity, which are also on the rise. 

In Connecticut, the issue is worsened by the shuttering of hospital maternity wards over the past three years. Citing low delivery volumes and high costs, medical center operators have been closing their labor and delivery units in northern Connecticut, including Windham Hospital and Johnson Memorial Hospital in Stafford. 

The closures are part of a larger landscape of consolidation of smaller, often rural hospitals by health system giants such as Yale New-Haven Health System and Hartford Healthcare. 

“[For health systems], maternal health is one of those easier things to cut, because they’re like, ‘Well, it’s just pregnancy. [Patients] can make it to Hartford Hospital, or they can make it to St. Francis.’” Canty said. “They’re not looking at those other pieces that influence and impact women’s lives.” 

Canty — who also serves as a certified nurse-midwife and provides reproductive care at Planned Parenthood of Southern New England — emphasized that “anything can happen” to people in labor during the hour-long drive elsewhere. Aside from the “anxiety and stress” the experience induces, the distance may deter people from seeking prenatal care beforehand.

Nor can people in labor always make it to the nearest hospital in time. When Hartford Healthcare’s Windham Hospital closed its labor and delivery unit in June 2020, rural mother Shantell Jones had to give birth to her son in an ambulance on the side of the road.

The Windham population is 41 percent Latine, with a 25 percent poverty rate compared to the statewide 10 percent poverty rate. 

Campbell explained that the state has adopted some positive measures toward increasing maternity care access. While people enrolled in Medicaid formerly were only covered for six weeks after giving birth, now they are assured health insurance for a full year postpartum. 

This expansion impacts about 40 percent of the maternity population in greater New Haven, according to Campbell. Still, she noted a problem in actually connecting patients to these programs. In underserved areas, individuals may lack awareness about statewide resources which could benefit them. 

“So what is in that area? What’s going to be left for those people who are there, in our rural areas of Connecticut?” Canty asked. “Where are those resources that are going to be right in their community if these things close?”

The historical case for birth centers

Under the first section of the maternal health bill, a licensing category would be created for free-standing birth centers. These facilities would focus on low-risk pregnancies and serve as an alternative to hospital labor and delivery units. Not only would they fill the void left behind by hospital closures, but they would also give pregnant people a choice in the birthing care they receive. 

The bill takes precedent from the Connecticut Childbirth and Women’s Center in Danbury, currently the only standalone birthing center in the state. The center focuses on natural childbirths and is staffed by certified nurse-midwives. 

Canty explained a recent history of midwifery in marginalized communities, in the 1940s, when segregated hospitals turned away pregnant Black people, these people developed their own communal systems of care. 

“Births were done in a home, where people weren’t trained in our formal institutions, but they were trained through apprenticeships,” Canty said. “It was an environment where women felt safe, and there was a sense of community.”

Canty went on to explain that even while access to hospitals and public health knowledge has grown, the disparity has not budged. Nationwide, Black people are three times more likely to die than white people of pregnancy-related causes — the same differential as in the 1940s.

Naomi Rogers, professor in the history of medicine and of history, also pointed to how people of color have historically received second-rate reproductive care. Even in the 1960s and 1970s in urban hospitals which were free and available for inner city populations, medical students could practice on patients “in the worst possible way,” Rogers said. Unknowing patients were even used for clinical research because, according to Rogers, “it was seen that you didn’t really need to ask anybody’s consent.”

While sweeping reforms have since changed the “horrific nature” of these hospitals, Rogers said, public health persists beyond the hospital building.

“Why do people develop certain kinds of health issues? Because of the houses they live in, the places they live in, the lead in the paint?” Rogers asked.

For both Canty and Rogers, these sustained inequities point toward a need for alternative health centers. 

“I don’t think it’s just the hospital’s fault, but maybe it’s the current structure of care … with medical professionals and the way they treat women,” Rogers said. “Maybe rather than trying to deal with that, you just set up a different environment. You just build a new house.”

At home in the “new house”

At the Labor and Birth Unit of Yale New Haven Hospital, expectant parents are welcomed by walnut-colored wood paneling, plush carpets and soft dim lighting. But Rogers recalled how the cabinets slid back, and out came “the equipment, all the equipment… just you name it.” 

“I’ve never forgotten the sort of total transformation of the birthing space,” Rogers said.

These hyper-medicalized spaces and apparatuses are a growing reason for fear among people, explained Rogers. Birthing centers — without all the “bells and whistles,” as Canty described it — would instead focus on patient-centered care. People would not be attended by doctors and white coat-clad surgeons, but rather certified nurse midwives and doulas, with whom they develop intimate relationships.

Canty also explained that while birthing center staff are trained to screen and respond to medical complications, they aim to make birth feel like a natural process. In that vein, Canty described heightened focus toward helping a patient feel listened to.

“The way that we approach and develop relationships with those we care for helps create an environment where people feel like they’re a part of the team,” Canty said. 

Feeling listened to is not just a matter of emotional satisfaction, emphasized Rogers. When Black people’s symptoms are overlooked and dismissed, the consequences can be life-threatening. 

Rogers alluded to the “Serena Williams problem,” in which the then-pregnant famous tennis player had to fight her nurses and doctors to pay attention to her shortness of breath. While her physicians originally ignored her requests, a CT scan eventually revealed deadly blood clots in her lungs.

Even though Williams’ life was likely saved by this intervention, Rogers stressed that “even wealthy women of color find that hospital staff, nurses and doctors don’t really pay attention to them, when they mention health problems during childbirth.” For other people of color, that power to self-advocate is less present, explained Canty. 

“Women have told me, ‘[my doctors] make me feel like I’m exaggerating, or they don’t listen, or they make me feel like I’m wasting someone’s time,” recalled Canty. 

Thus, Canty pointed to the “holistic environment” of birthing centers. Not only would the physical space be more inviting, but people would have check-ins and regular meetings with their nurse midwives well before the pregnancy, to “feel good and feel welcomed” with their providers.

She also emphasized having a “no-rush” birthing process — rather than hospitals, which may be swamped with patient volumes, birthing centers can afford to wait and take their time with each patient. Canty described her own experience of evaluating the patient, sending them home if necessary, checking in and waiting for the childbirth to occur at a “natural pace.” 

“That’s what I would love to see right away — that someone leaves and says, ‘they listened to me, and I felt my body was respected in this process,’” Canty said. “I want […]  people just to be able to have trust in our healthcare system again. 

Ensuring patient safety

Without the “bells and whistles,” however, some raise concerns about maternal safety as compared to hospitals. 

In its testimony to the Public Health Committee, the Connecticut Hospital Association pushed back on the lack of regulation established around the new centers. 

“Before any birthing center is approved, clinical thresholds and protocols, mandatory clinical guidelines, stakeholder review, public oversight and transparency must be in place – and accomplished in a way that would meet typical standards of administrative procedure,” Connecticut Hospital Association wrote in its testimony. 

Connecticut Hospital Association also included a list of questions about what guidelines birthing centers would be subject to, citing safety standards, HIPAA guidelines, statewide Certificates of Need and data collection by the Department of Public Health.

Canty views extensive oversight as something that would detract from these centers’ mission. She acknowledged that guidelines were necessary to protect people’s safety. Still, she emphasized her hope that state and hospital intervention will help people feel “safe” and supported, rather than scrutinized by rules and regulations. 

“Talk to women, and look at their experiences of care,” Canty said. “There are women who are terrified. We have to make sure [the state] is not putting that medical model that we’re trying to run from because it’s causing harm.”

Rogers bolstered Canty’s perspective, emphasizing that a patient’s emotional wellness is often mirrored by their physical health. 

A patient feeling that “they’re in a safe place, that people are listening to them,” as Rogers puts it, can already lower their risk of complications. Hypertension, for example, commonly poses risk during pregnancy and is caused by high stress. For an individual about to give birth, in an unfamiliar environment, that may be enough to drive up their blood pressure. 

“The health of the patient is profoundly caught up with their mental state,” Rogers reiterated. “One of the reasons that alternative health center birthing centers are seen as likely to work is that they will create an environment that will help a woman feel cared for.”

Even so, Campbell cautioned that there are a multitude of pregnancy-related complications that can arise suddenly, some of which can be fatal if not properly attended to. Hypertension is sometimes unavoidable, as is postpartum hemorrhage, which arises in 7 to 9 percent of the patients she attends. Campbell also pointed toward necessary interventions for shoulder dystocia, in which the baby’s shoulder becomes stuck during childbirth, and Cesarean sections. 

“There does have to be some regulated system to make sure that all the unpredictable nature of obstetrics is there, ready and able to support that patient if they were to need it,” Campbell said. “For a freestanding birth center, that’s going to be a hospital that’s prepared to receive a complex obstetrical patient who no longer can safely remain at the freestanding birth center.”

Campbell also spoke to the cruciality of care in the postpartum period, during which pregnancy-related complications often strike. 

According to Campbell, existing Yale New Haven Health programs already draw upon the hospital’s extensive resources to support patients after childbirth, such as a blood pressuring monitoring program and Family Centered Neonatal Opioid Withdrawal Syndrome Program, which assists opioid-dependent pregnancy patients. Programs also offer personalized consultants and lactation classes.

“A lot of effort has been put into these infrastructures at hospitals across the state,” Campbell explained, in reference to YNHH’s resources. “My recommendation would be to listen to patients’ needs, and let’s see how we can use our existing resources and infrastructure to meet those needs. Could we lean on our existing infrastructure and expand?”

Ultimately, Campbell expressed overwhelming support for the birth centers for low-risk pregnancies, but explained that existing hospital systems can — and should — help patients when unforeseen health issues occur. 

“How can we collaborate and work together?” Campbell asked. 

Toward community health

S.B. 986 is scheduled to go before the Senate. In the meantime, Campbell, Canty and Rogers hope that, if signed into law, the bill will establish birth centers as long-standing fixtures in communities statewide.

Canty reiterated that she hopes centers would not just exist when “a woman pops in to give birth,” but rather as integrated forms of community healthcare. They could provide routine people’s health checks as well as postpartum care. 

They could also serve as easier points of access — a person seeking care would only have to check-in at the center in her town, rather than setting up an appointment at a distant hospital location.

“That’s a wonderful vision of better healthcare,” Rogers explained. “Because if they are seen by the community and used by the community, as a welcoming place, women would be more likely to go to be checked out to have critical prenatal visits.”

From their experience with patient care, Campbell and Canty spoke to the importance of medicine which broaches the “human side of care,” particularly in reproductive health. 

“Every woman deserves a beautiful birth,” Canty said. “I think any birthing person that delivers should have access to quality care should feel safe, from beginning to end.”

The United States is 55th in the world for the World Health Organization’s maternal mortality rate rankings.