Access to high-quality healthcare is absolutely necessary for perinatal health. On Nov. 8, about 40 people came together to learn about the “fourth trimester of pregnancy.” Organized by postdoctoral fellow Marie McCausland, “The Fourth Trimester: Surviving and Thriving After Baby” addressed maternal mortality, postpartum health, public policy, self-advocacy and the work-life balance.

McCausland welcomed attendees and introduced herself as a survivor of postpartum preeclampsia—a pregnancy complication often characterized by high blood pressure which, left untreated, may be fatal—and shared the story of her son’s birth on Mother’s Day of 2017.

On the day her labor was induced, McCausland read an NPR and ProPublica investigative report which found the U.S. to have the worst rates of maternal death in the developed world, with mortality rates continuing to rise. “I want to be able to advocate for myself if this happens [to me],” McCausland recalled thinking on that day.

The importance of self-advocacy in healthcare proved to be a recurring theme throughout the symposium. McCausland continued, “Four days after I had my son, I started to feel a bit off. I went to go lie down, and I had this overwhelming feeling that if I go to sleep, I won’t wake up.”

Upon presentation to the emergency department (ED), the physician dismissed her, saying she did not have preeclampsia. Remembering Lauren Bloomstein, a mother described in the NPR article who died due to complications of postpartum preeclampsia, McCausland knew she needed to listen to her body and fight for care. “At one point, my blood pressure peaked at 200/115 mm of mercury [where normal postpartum is about 120/80 mm Hg] and I asked my husband to take a picture of me with my son because I thought this is it, this is all he is going to have left of me.”

McCausland showed the audience the photo of her laying in the hospital bed, trying to smile and hide her fear with visibly swollen ankles. After making countless phone calls, her husband finally contacted the on-call obstetrician-gynecologist (OB/GYN) who confirmed what they both already knew: she had preeclampsia. McCausland was lucky enough to be transferred and receive treatment before it was too late.

Her traumatic experience inspired her to share her story and become an advocate, in hopes of counteracting the current trend of maternal mortality in Cleveland and the U.S. Collaborating with University Hospitals (UH), she encouraged them to retrain ED staff, require an on-call obstetrician for any woman up to six weeks postpartum and give all new mothers a post-birth factsheet with worrisome signs and symptoms; all three of which have since been implemented.

Dr. Maria Shaker, an OB/GYN with UH, followed McCausland to further discuss the reality of maternal mortality in the U.S. “An American mother in 1990 had a better chance of surviving childbirth than her own daughter has today,” with the overwhelming majority of complications being preventable, she explained.

Shaker encouraged everyone to contact members of Congress and emphasize the need for inherent change as a society. “We need love,” she said.

Shaker also suggested women get and stay healthy before, during and after pregnancy, as pre-existing health conditions can complicate childbirth. Perhaps most importantly, she asserted to women, is to “speak up for yourself and make sure you have someone else who will fight for your health when you are in labor.”

McCausland, like Shaker, also emphasized the need to contact Congress members. There are currently bills in Congress, Preventing Maternal Deaths Act of 2017 and Maternal Health Accountability Act of 2017, which will assist states in establishing maternal mortality review boards. “One of the problems with fixing maternal mortality is that we don’t even count all the deaths, so how can we fix a problem we don’t even have data to understand,” she said, encouraging people to support the bill.

McCausland compared a pregnant mother to a disposable candy wrapper. “It feels as if we are monitored incredibly well while pregnant, not to monitor our health, but to make sure that we keep the baby alive.” She qualified this claim with the statistic that 80 percent of preeclampsia deaths occur postpartum.

The reality of maternal mortality in the U.S. is concerning for all women, and even more so for women of color. Da’Na Langford, a certified nurse midwife with UH, stressed that black women are three to four times more likely to die giving birth than white women. Langford emphasized that some people will always be at a disadvantage.

“Health disparities are often linked to social, economic and environmental status,” Langford said, “with racism being the root cause [of such disadvantages].” She discussed how racism acts as a stressor, compromising black women’s overall health and wellbeing—exemplified by their higher maternal mortality rate. Her advice was to “be good human beings.”

The fourth trimester is often minimized when discussing pregnancy expectations and realities with women. Natalie Cowan, a staff member in the School of Graduate Studies and an attendee of the event, commented, “People don’t really shine light on all the struggles that a woman has to go through during those nine months [and beyond]. I believe it’s brushed under the rug. I think some individuals look at women as though it was your decision to get pregnant, this is just what you have to deal with.”

All of the speakers at the symposium emphasized that lack of care and death are not just things women have to deal with when they are pregnant.

The event also tried to raise awareness in support of postnatal care for women. Department of Biophysics graduate student, prospective OB/GYN and symposium attendee, Tonia Rhone, said, “In the healthcare field, a lot is focused on prenatal care and getting to the birth but then after, there is not a lot of patient advocacy and support surrounding the mother. Our mindset in the hospital is focusing on [mothers] while they’re there, but then after it is ‘you’re on your own.’”

The Cleveland Regional Perinatal Network (CRPN) works to ensure mothers do not feel alone, overwhelmed or helpless after childbirth, particularly regarding mental health. Licensed social worker and Project Director for CRPN Avril Albaugh, spoke of their efforts to help mothers struggling with mental health. The organization, among other things, launched the Perinatal Depression Project to develop screening tools, training and data systems to refer women suffering from perinatal depression to the appropriate provider and resources.

The event illuminated severe and worrisome problems, while providing relief strategies for any mothers, or those soon-to-be. Ann Blackman, a Masters of public health and social administration graduate student in the audience, emphasized that “what happens [after the third trimester] is a really important piece that is sometimes forgotten.”

“The Fourth Trimester” instilled a sense of urgency in addressing issues related to maternal mortality and postnatal care in the greater Cleveland area and the U.S. To ignore these, risks perpetuating the current circumstances in which two women—someone’s mother, daughter, sister, friend—die daily from preventable complications of childbirth.