News Maternity and Birthing

Panel Recommends Low-Dose Aspirin Regimen for Women at Risk of Preeclampsia

Martha Kempner

A panel of experts now recommends that a baby aspirin each day may be able to prevent up to a quarter of all cases of preeclampsia, a condition that develops in 4 percent of pregnancies and that can be life threatening for both the woman and the developing fetus.

New recommendations suggest that pregnant women at risk for preeclampsia should take a low-dose aspirin every day during their second and third trimester. The recommendations come from the U.S. Preventive Services Task Force and are based on findings suggesting that aspirin can lower the risk of preeclampsia, preterm birth, and low birth weight babies.  

Preeclampsia, which develops in about 4 percent of pregnancies, can be life threatening for both the woman and the fetus. Signs of preeclampsia include high blood pressure, protein in the urine, liver issues, and abnormal blood clotting. The condition causes blood vessels to constrict, which in turn causes high blood pressure and reduces blood flow to a woman’s organs. Women with preeclampsia are at immediate risk of a stroke and organ damage. As the name suggests, preeclampsia can lead to eclampsia, a rare and dangerous condition in which pregnant women have seizures.

Once a women is found to have preeclampsia, the only way to protect her health is to deliver the baby regardless of how far along she is in her pregnancy, which is why the most common outcome for preeclampsia is preterm births and low birth weight babies. Preeclampsia also constricts blood flow to the uterus, which can cause the fetus to grow more slowly than expected, limit the amount of amniotic fluid, or cause the placenta to separate from the uterine wall before delivery (a life-threatening condition for both mother and fetus called placental abruption).

Even after delivery, women who have had preeclampsia have an increased lifetime risk of cardiovascular issues, including high blood pressure and stroke—in fact, a study released in February found that women who’ve had it have twice the risk of stroke and four times the risk of high blood pressure later in life.

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The good news is that research now confirms that a simple aspirin regimen may be able to prevent the condition from developing. A systematic review of research published in the Annals of Internal Medicine found that the low-dose aspirin regimen (81 milligrams per day after the first trimester) reduced the incidence of preeclampsia by 24 percent. Ira M. Bernstein, chair of the department of obstetrics and gynecology at the University of Vermont, put it this way when he spoke to the New York Times: “For every four women who would have gotten pre-eclampsia, one case is prevented. The ability to prevent a quarter of disease is substantial.” The review also found that the aspirin regimen reduced incidences of premature birth by 14 percent and slow fetal growth by 20 percent.

The aspirin regimen was found to be safe; it did not increase the risk of bleeding after delivery, placental abruption, or bleeding inside the newborn’s cranial cavity.

Based on the review, the task force recommends the regimen for anyone at high risk of preeclampsia, which includes women who have already had a pregnancy in which they developed the condition, especially if they delivered preterm; women who are carrying multiple fetuses; and women who already had diabetes or high blood pressure when they got pregnant. It noted that women with other factors considered to be a moderate risk for preeclampsia—including women who are obese, have a family history of preeclampsia, are over 35, or are African American—may want to consider the aspirin regimen and discuss it with their obstetricians.  

Analysis Maternity and Birthing

Pregnant Women Are Being Shackled in Massachusetts—Even Though It’s Been Illegal for Years

Victoria Law

According to a new report, not a single jail or prison facility in the state has written policies that are fully compliant with the law against restraining pregnant women behind bars.

Korianne Gamble was six months pregnant in November 2014 when she arrived at the Bristol County Sheriff’s Office Women’s Center, a jail in North Dartmouth, Massachusetts. Six months prior, the state had passed “An Act to Prevent Shackling and Promote Safe Pregnancies for Female Inmates.”

According to the new law, the jail should have been prohibited from using any type of restraint on Gamble during labor, and using of leg and waist restraints on her during and immediately after her pregnancy. It also guaranteed her minimum standards of pregnancy care and required—as with everyone incarcerated while in their second or third trimesters—that she be transported in the jail’s vehicles with seat belts whenever she was taken to court, medical appointments, or anywhere outside the jail.

But that wasn’t the case for Gamble. Instead, she says, when it came time for her to give birth, she was left to labor in a cell for eight hours before finally being handcuffed, placed in the back of a police cruiser without a seatbelt, and driven to a hospital, where she was shackled to the bed with a leg iron after delivering.

According to a new report, Gamble isn’t alone. Advocates have been monitoring pregnancy-related care since the law’s passage. After obtaining and analyzing the policies of the state’s prison and jail system, they found that no facility has policies that are fully compliant with the 2014 law. They issued their findings in a new report, Breaking Promises: Violations of the Massachusetts Pregnancy Standards and Anti-Shackling Lawco-authored by Marianne Bullock of the Prison Birth Project, Lauren Petit of Prisoners’ Legal Services of Massachusetts, and Rachel Roth, a reproductive-justice expert.

In addition to analyzing policies, they spoke with women who were pregnant while in custody and learned that women continue to be handcuffed during labor, restrained to the bed postpartum, and placed in full restraints—including leg irons and waist chains—after giving birth.

“The promise to respect the human rights of pregnant women in prison and jail has been broken,” the report’s authors concluded.

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Medical experts, including the American Congress of Obstetricians and Gynecologists, the American Medical Association and the American College of Nurse-Midwives, have all agreed that shackling during pregnancy is unnecessary, inhumane, and dangerous. Shackling increases the risk of falling and injury to both mother and fetus while also preventing medical staff from assessing and assisting during labor and delivery. In 2014, both the Massachusetts legislature and then-Gov. Deval Patrick (D) agreed, passing the law against it.

“The Massachusetts law is part of a national trend and is one of the most comprehensive in protecting pregnant and postpartum women from the risks of restraints,” said Roth in an interview with Rewire. “However, like most other states, the Massachusetts law doesn’t have any oversight built in. This report clearly shows the need for staff training and enforcement so that women who are incarcerated will be treated the way the legislature intended.”

Gamble learned all of this firsthand. In the month before her arrest, Gamble had undergone a cervical cerclage, in which a doctor temporarily stitches up the cervix to prevent premature labor. She had weekly visits to a gynecologist to monitor the development of her fetus. The cerclage was scheduled to be removed at 37 weeks. But then she was arrested and sent to jail.

Gamble told jail medical staff that hers was a high-risk pregnancy, that she had had a cerclage, and that her first child had been born six weeks prematurely. Still, she says she waited two months before seeing an obstetrician.

As her due date drew closer, the doctor, concerned about the lack of amniotic fluid, scheduled Gamble for an induction on Feb. 19, 2015. But, she says, jail staff cancelled her induction without telling her why.

That same evening, around 5 p.m., Gamble went into labor. Jail staff took her to the medical unit. There, according to Gamble, the jail’s nurses took her blood pressure and did a quick exam, but did not send her to the hospital. “They [the nurses] thought I was ‘acting up’ because my induction was canceled,” she told Rewire.

She was placed in a see-through cell where, as the hours progressed, her labor pains grew worse. “I kept calling to get the [correctional officers] to get the nurse,” Gamble recalled. By the time a nurse came, Gamble was bleeding. “The nurse made me pull down my pants to show her the blood—in front of a male [correctional officer]!” Gamble stated. Still, she says, no one called for an ambulance or made arrangements to drive her to the hospital.

At 1:45 in the morning, over eight hours after she first went into labor, the jail’s captain learned that Gamble was in labor. “[He] must have heard all the commotion, and he called to find out what was going on,” she said. He ordered his staff to call an ambulance and bring her to the hospital.

But instead of calling an ambulance, Gamble says jail staff handcuffed her, placed her in the back of a police cruiser without a seatbelt—in violation of the law—and drove her to Charlton Memorial Hospital. “My body was already starting to push the baby out,” she said. She recalled that the officers driving the car worried that they would have to pull over and she would give birth by the side of the road.

Gamble made it to the hospital, but just barely. Nine minutes after arriving, she gave birth: “I didn’t even make it to Labor and Delivery,” she remembered.

But her ordeal wasn’t over. Gamble’s mother, who had contacted Prisoners’ Legal Services and Prison Birth Project weeks earlier, knew that the law prohibited postpartum restraints. So did Gamble, who had received a packet in jail outlining the law and her rights from Prisoners’ Legal Services. When an officer approached her bed with a leg iron and chain, she told him that, by law, she should not be restrained and asked him to call the jail to confirm. He called, then told her that she was indeed supposed to be shackled. Gamble says she spent the night with her left leg shackled to the bed.

When the female officer working the morning shift arrived, she was outraged. “Why is she shackled to the bed?” Gamble recalled the officer demanding. “Every day in roll call they go over the fact that a pregnant woman is not to be shackled to anything after having a baby.” The officer removed the restraint, allowing Gamble to move around.

According to advocates, it’s not unusual for staff at the same jail to have different understandings of the law. For Gamble, that meant that when the shift changed, so did her ability to move. When the morning shift was over, she says, the next officer once again shackled Gamble’s leg to the bed. “I was so tired, I just went along with it,” Gamble recounted.

Two days after she had given birth, it was time for Gamble to return to the jail. Despite Massachusetts’ prohibition on leg and waist restraints for women postpartum, Gamble says she was fully shackled. That meant handcuffs around her wrists, leg irons around her ankles, a chain around her waist,g and a black box that pulled her handcuffs tightly to the waist chain. That was how she endured the 20-minute drive back to the jail.

Gamble’s jail records do not discuss restraints. According to Petit, who reviewed the records, that’s not unusual. “Because correctional officers don’t see it as out of the ordinary to [shackle], they do not record it,” she explained. “It’s not so much a misapplication of the extraordinary circumstances requirement as failure to apply it at all, whether because they don’t know or they intentionally ignore it.”

While Bristol County Sheriff’s Office Women’s Center’s policies ban shackling during labor, they currently do not prohibit restraints during postpartum recovery in the hospital or on the drive back to the jail. They also do not ban leg and waist restraints during pregnancy. Jonathan Darling, the public information officer for the Bristol County Sheriff’s Office, told Rewire that the jail is currently reviewing and updating policies to reflect the 2014 law. Meanwhile, administrators provide updates and new information about policy and law changes at its daily roll call. For staff not present during roll call, the jail makes these updates, including hospital details, available on its east post. (Roll call announcements are not available to the public.)

“Part of the problem is the difference in interpretation between us and the jurisdictions, particularly in postpartum coverage,” explained Petit to Rewire. Massachusetts has 14 county jails, but only four (and the state prison at Framingham) hold women awaiting trial. As Breaking Promises noted: “Whether or not counties incarcerate women in their jails, every county sheriff is, at minimum, responsible for driving women who were arrested in their county to court and medical appointments. Because of this responsibility, they are all required to have a written policy that spells out how employees should comply with the 2014 law’s restrictions on the use of restraints.”

Four jurisdictions, including the state Department of Correction, have policies that expressly prohibit leg and waist restraints during the postpartum period, but limit that postpartum period to the time before a woman is taken from the hospital back to the jail or prison, rather than the medical standard of six weeks following birth. Jails in 11 other counties, however, have written policies that violate the prohibition on leg and waist shackles during pregnancy, and the postpartum prohibition on restraints when being driven back to the jail or prison.

Even institutions with policies that correctly reflected the law in this regard sometimes failed to follow them: Advocates found that in some counties, women reported being restrained to the bed after giving birth in conflict with the jail’s own policies.

“When the nurse left, the officer stood up and said that since I was not confirmed to be in ‘active labor,’ she would need to restrain me and that she was sorry, but those were the rules,” one woman reported, even though the law prohibits restraining women in any stage of labor.

But shackling pregnant women during and after labor is only one part of the law that falls short. The law requires that pregnant women be provided with regular prenatal and postpartum medical care, including periodic monitoring and evaluation; a diet with the nutrients necessary to maintain a healthy pregnancy; written information about prenatal nutrition; appropriate clothing; and a postpartum screening for depression. Long waits before transporting women in labor to the hospital are another recurring complaint. So are routinely being given meals without fruits and vegetables, not receiving a postpartum obstetrician visit, and waiting long stretches for postpartum care.

That was also the case with Gamble. It was the middle of the night one week after her son’s birth when Gamble felt as if a rock was coming through her brain. That was all she remembered. One hour later, she woke to find herself back at the hospital, this time in the Critical Care Unit, where staff told her she had suffered a seizure. She later learned that her cellmate, a certified nursing assistant, immediately got help when Gamble’s seizure began. (The cell doors at the jail are not locked.)

Hospital staff told her that she had preeclampsia, a pregnancy complication characterized by high blood pressure. Postpartum preeclampsia is rare, but can occur when a woman has high blood pressure and excess protein in her urine soon after childbirth. She was prescribed medications for preeclampsia; she never had another seizure, but continued to suffer multiple headaches each day.

Dr. Carolyn Sufrin is an assistant professor of gynecology and obstetrics at Johns Hopkins Medicine. She has also provided pregnancy-related care for women at the San Francisco County Jail. “Preeclampsia is a leading cause of maternal mortality,” she told Rewire. Delayed preeclampsia, or postpartum preeclampsia, which develops within one to two weeks after labor and delivery, is a very rare condition. The patient suffering seizures as a result of the postpartum preeclampsia is even more rare.

Postpartum preeclampsia not only needs to be treated immediately, Sufrin said, but follow-up care within a week at most is urgent. If no follow-up is provided, the patient risks having uncontrolled high blood pressure, stroke, and heart failure. Another risk, though much rarer, is the development of abnormal kidney functions.

While Sufrin has never had to treat postpartum preeclampsia in a jail setting, she stated that “the protocol if someone needs obstetrical follow-up, is to give them that follow-up. Follow through. Have continuity with the hospital. Follow their instructions.”

But that didn’t happen for Gamble, who was scheduled for a two-week follow-up visit. She says she was not brought to that appointment. It was only two months later that she finally saw a doctor, shortly before she was paroled.

As they gathered stories like Gamble’s and information for their report, advocates with the Prison Birth Project and Prisoners’ Legal Services of Massachusetts met with Rep. Kay Khan (D-Newton), to bring her attention to the lack of compliance by both county jails and the state prison system. In June 2015, Khan introduced An Act to Ensure Compliance With the Anti-Shackling Law for Pregnant Incarcerated Women (Bill H 3679) to address the concerns raised by both organizations.

The act defines the postpartum period in which a woman cannot be restrained as six weeks. It also requires annual staff trainings about the law and that, if restraints are used, that the jail or prison administration report it to the Secretary of Public Safety and Security within 48 hours. To monitor compliance, the act also includes the requirement that an annual report about all use of restraints be made to the legislature; the report will be public record. Like other statutes and bills across the country, the act does not have specific penalties for noncompliance.

In December 2015, Gamble’s son was 9 months old and Gamble had been out of jail for several months. Nonetheless, both Gamble and her mother drove to Boston to testify at a Public Safety Committee hearing, urging them to pass the bill. “I am angered, appalled, and saddened that they shackled her,” Gamble’s mother told legislators. “What my daughter faced is cruel and unusual punishment. It endangered my daughter’s life, as well as her baby.”

Since then, both the Public Safety Committee and Health Care Financing Committee approved the bill. It is now before the House Committee for Bills in the Third Reading, which means it is now at the stage where it can be taken up by the House for a vote.

Though she has left the jail behind, Gamble wants to ensure that the law is followed. “Because of the pain I went through, I don’t ever want anyone to go through what I did,” she explained to Rewire. “Even though you’re in jail and you’re being punished, you still have rights. You’re a human being.”

Commentary Maternity and Birthing

What My First Pregnancy Taught Me About Birth Justice

Ruth Jeannoel

The medical community needs to do more to support women of color, particularly Black women, who must confront a number of hurdles in order to have a vaginal birth after cesarean.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

After discovering I was pregnant for a second time, I had concerns that my previous cesarean section would keep me from having a vaginal birth. But what I learned after speaking with medical professionals and reading up on vaginal birth after cesarean (VBAC) is that it is possible, with the appropriate resources. I also came to realize that the medical community needs to do more to support women of color, particularly Black women, who must confront a number of hurdles in order to have a VBAC.

All across the country there has been an injection of #BlackLivesMatter in our decades-long Black liberation movement, and reproductive justice, including birth justice, is a critical part of those efforts. Birth justice includes making sure Black moms have full control of their own health and birth process through proper childbirth education and community resources.

It was around 9:30 p.m. on October 22, 2008, when I began to have contractions and I went to the hospital. I was about 32 weeks into my first pregnancy, which was well before my “safe period” of 37 weeks, which in 2008 was described as the stage when the fetus has fully developed. (The “safe period” has since changed to 39 weeks.) Within six hours of labor I developed preeclampsia, which is a pregnancy condition affecting as many as 8 percent of all pregnancies and can be deadly for Black women.

At about 10:30 p.m., the doctors explained I would need an emergency cesarean or else I could lose the little one I had been carrying.

I was scared: At the age of 21, I had to have major surgery.

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The nurses quickly changed my gown, gave me an epidural, and moved me from my hospital room to surgery. I kept thinking about how I didn’t want any of this, because I wanted to give birth naturally and without any pain relief medication, but it sounded so urgent. It sounded like I needed to really have a cesarean for both my safety and the health of my baby. And so on October 22 at 11:59 p.m. I had a c-section.

C-section rates are declining in the United States, but Black women continue to have them more frequently than their white counterparts. According to 2014 data from the Centers for Disease Control and Prevention, the cesarean delivery rate “declined for non-Hispanic white women for the fifth consecutive year, down 2% from 32.0% in 2013 to 31.4% in 2014 and 4% from the 2009 peak. Rates declined 1% for both non-Hispanic black (from 35.8% to 35.6%) and Hispanic women (32.3% to 31.9%). For the second year in a row, non-Hispanic white women had the lowest cesarean delivery rate; non-Hispanic black women continued to have the highest rate.”

Throughout my pregnancy I saw a midwife at a birth center, who ultimately was not with me when I developed preeclampsia and had to go under the knife. I felt disempowered because everything happened so fast and it seemed as if all of the decisions were made for me.

After the surgery, my family and close friends were glad that the baby and I were both safe. But beneath their concern for our safety I could see there was an underlying stigma around having a cesarean birth. Even though the c-section was not planned, I would get looked down on as if I wasn’t “woman enough” because I didn’t have a vaginal birth. I felt ashamed and didn’t know how to share my birth story because in a way I had lost decision-making control over it. I was unprepared to deal with the stigma that was attached with having a c-section.

A couple years after having my first child, I began to have a different understanding of what reproductive justice is and began to reflect more on what it would look like in my own life. SisterSong Women of Color Reproductive Justice Collective describes reproductive justice as, “the human right to have children, not have children, and parent the children we have in safe and healthy environments.”

During that period between my two pregnancies, after having more conversations with other mothers and hearing different birth stories, I began to understand that what I was attempting to deal with wasn’t about vaginal birth vs. cesarean birth; it was about women having the bodily autonomy to make their own decisions. I told myself that if I ever got pregnant again, I would make sure that I had all the necessary information to ultimately decide how my birth went: I would do everything in my power to have a vaginal birth. For example, had I known in advance that I may be susceptible to preeclampsia, I would have looked into methods to lower the risks of complications.

While telling everyone who asked (or didn’t) that I would have a vaginal birth, I ran into several myths. The main one was that you can’t have a vaginal birth after c-section. It just didn’t make sense to me because I knew that birthing was a natural process, meaning that I needed to trust my body and know that every pregnancy was different and that my body could handle a vaginal birth.

At that point I had a lot more questions than answers.

I began reading and asking my OB-GYN about vaginal births and she described the risks and benefits of having a VBAC and emphasized that it was very possible. And she, of course, was right.

As research from the National Institutes of Health explains, “VBAC is a reasonable and safe choice for the majority of women with prior cesarean.” The American College of Obstetricians & Gynecologists (ACOG) agrees, adding that “most” women with one prior cesarean and “some” women with two prior cesareans are candidates for VBAC.

The main problem a woman seeking to have a VBAC might encounter, I found during my research, was a potential uterine rupture. However, a report published in the Obstetrics & Gynecology medical journal found:

Despite increased rates of VBAC attempt and VBAC failure among black women as compared with other racial groups, black women are significantly less likely to experience a uterine rupture. It is unclear whether this discrepancy in magnitudes of risks and benefits across race associated with VBAC trials is attributable to selection bias or inherent racial differences.

My research helped me to better understand that the risks associated with a VBAC weren’t as high as I thought.

When I found out that I was pregnant five years later, I moved forward with my plan to have a VBAC. By that time I had moved to another state, and VBACs were not as common or accessible in Florida as they were in Massachusetts.

I quickly learned that not every OB-GYN I encountered performs VBACs. In South Florida, I had only three doctors to choose from. With help from my doula, I was able to find the right one and a hospital where VBAC was an option.

Unfortunately, in Black communities, not everyone may have access to doctors who do VBAC. Because of the higher risk of uterine rupture, many hospitals, especially in low-income communities of color, are not able to make this accommodation. Also, I found that doctors often do not promote VBACs; therefore, many women who may want to have one may not know that such an option exists.

In 2014, at 37 weeks, I was able to have a successful VBAC and give birth to my second born. I was proud of myself that I was able to have a vaginal birth under my own terms in a hospital room with an amazing team of doctors.

It’s important to dispel the myth that you can’t have a vaginal birth after a previous c-section. Doctors and the medical community have a responsibility to make sure that all women have the appropriate information to make an informed decision over their body. It will always be a woman’s right to choose how she wants to have her child, and where she wants to have her child if her local hospital doesn’t offer the services she requires.