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Philadelphia resident Carolyn Santamauro vividly remembers lying in bed at a Philadelphia hospital as she recovered from an emergency cesarean section, and finding out doctors had started her newborn on a morphine drip without telling her or her husband.
Santamauro was blunt about her response that day. “I lost my sh-t,” she said. “I didn’t know for 24 hours.”
Morphine is used to wean a baby off opioids when a mother has been using during pregnancy. But Santamauro was not a drug user.
She did take Kratom, derived from a tree in Southeast Asia and sold legally in Philadelphia, usually as a green powder people mix into tea. Although it has opioid-like properties, it is not an opioid. Santamauro uses it to alleviate the constant pain caused by her Ehlers-Danlos Syndrome, and after doing some research, she and husband Christopher Moraff decided it made sense for her to continue taking it during pregnancy.
At some point after an emergency c-section to avoid preeclampsia during a difficult birth, someone on the care team drew Santamauro’s blood for a drug test while she was barely conscious.
As soon as baby Olivia Rose was lifted from her mother’s womb, the hospital started her on morphine.
“A doctor told me they were shocked when my [drug] test came back negative,” Santamauro said. “They said that they thought we were lying.” Even after speaking to her and Moraff about the situation, she said the hospital did not take Olivia Rose off the drip; she was on it for three days. “They gave opioids to an opioid-negative baby.”
The modern hospital birthing process doesn’t usually involve a mistake this serious, but for many parents, it can feel very unfriendly — and even traumatic.
At least part of the blame falls on health insurance restrictions, according to Maureen Sullivan Gonzales. An assistant professor at Drexel’s College of Nursing and Health, she previously worked as a labor and delivery nurse practitioner at a city hospital she declined to name for legal reasons.
After a person gives birth, Gonzales said, the focus shifts to the baby because of fear of lawsuits, and to hurrying everyone home as soon as possible because of the costs. For the parents who may be worried or confused, there’s no built-in protocol for counseling.
“If the baby is healthy and you’re healthy, but it was a [hard] birth — do you get mental health support? Probably not,” Gonzales said.
Psychological support for parents is critical, she said, because the trauma can have a ripple effect. Traumatic births can lead to postpartum depression or post traumatic stress disorder in the mother and the partner. People who have had a traumatic birth experience are less likely to have more biological children, according to several studies.
The trauma can be caused by something seemingly small, like hospital staff ignoring parents, or by much more serious issues like a stillbirth, noted Joanna Parga-Belinkie, an attending neonatologist at the Children’s Hospital of Philadelphia and the Hospital of the University of Pennsylvania.
A baby may be sent to the newborn intensive care unit (NICU) for low birth weight, low blood sugar, or other reasons — and complications can be especially traumatic if issues weren’t diagnosed in advance.
Complications are much more common for people of color
Birth complications are 63% more common for mothers in majority Black communities and 32% higher in majority Hispanic communities when compared to majority white communities, according to a May 2021 Blue Cross Blue Shield Association study.
Deaths are also more common. Black women giving birth are more than twice as likely to lose their babies than white women, according to a 2018 New York Times investigation.
In Philadelphia, where two-thirds of the population is not white, there are roughly 8 infant mortalities per 1,000 live births. That’s one of the highest rates in Pennsylvania, per state data from 2015 to 2019, and on par with rates in Louisiana or Alabama.
“It’s unacceptable with the resources we have at our fingertips,” said Meg Snead, acting secretary of the Pennsylvania Department of Human Services, whose background includes work in healthcare policy.
Saleemah McNeil, a birth trauma expert who founded the Oshun Family Center, soon to move to North Philadelphia, noted that “racism manifests itself in hospitals from the top to the bottom.”
During her own traumatic birth experience, which required McNeil to stay in the hospital for nine days because her blood pressure wouldn’t stabilize, “I felt like they were doing things to me, versus being collaborative and discussing things that needed to be done,” she said.
The mission of McNeil’s organization is “to provide racially concordant care to members of the Black community that are struggling to cope with life transitions — especially those impacted by postpartum mood changes, birth, and racial trauma.”
If doctors could sit down with Black patients and treat those individuals as a people, that would help the Black community gain trust in the medical system, McNeil said. She also described how many Black women have told her about doctors or nurses looking for rings on fingers — in other words, assuming that most are single mothers.
“It is the providers’ duty to make sure they have a streamline of resources that can help people thrive in the ‘fourth’ trimester — to point people to the best resources to help Black birthing people,” McNeil said. “It just takes that one person to listen and be attentive to really shift the birthing experience.
The fact that Black women are six times more likely to die in childbirth than white women “doesn’t have anything to do with education or money,” said Fran Ayalasomayajula, a doctor who has worked for the World Health Organization and the CDC.
Ayalasomayajula is the founder of Reach, a nonprofit global social impact organization that leads “Save Moms,” a national maternal mortality and morbidity prevention campaign in support of expectant mothers in underserved communities.
Though there are many health care workers like her who dedicate themselves to making the system more equitable, she said, shortages of care sometimes occur in cities like Philadelphia because of “professionals not wanting to practice in areas where the need is… They don’t want to treat and care in areas where the circumstances are challenging.”
Counseling doesn’t exist, and doulas aren’t covered by Medicaid
Lisa M. of Bala Cynwyd, who asked that her last name be withheld to protect her privacy, recalled that during the birth of her first child, “the delivery room was like a war zone. There was blood everywhere.”
Because she has a phobia about needles, Lisa said she made a deal with her obstetrician at Pennsylvania Hospital that they would try to avoid a c-section. But she was a week late and wasn’t dialating. After an entire day of pushing, she remembers doctors sternly warning her, “You can’t sleep.'”
Then one obstetrician got on top of her, pushing down hard on her stomach, while the other obstetrician, one foot propped for support on the delivery table, vacuumed Luke out into the world.
Lisa had a vaginal tear requiring 60 stitches, inside and out. Yet she received no counseling in the hospital. “They probably felt like this was kind of normal, but I felt like it was not normal at all,” she said. “I was so traumatized.”
Baby Luke ended up healthy, but it took Lisa and her husband Ronald years to get past the experience. They waited longer than they originally planned before having their second child.
“The experience of having a history of not being listened to — it’s definitely cumulative,” said Maureen Campion, a national birth trauma expert based in the Twin Cities. “On top of everything else — the transition to being a parent — is also the risk of being treated disrespectfully.”
Most hospitals aren’t doing anything in terms of mental health care after traumatic births, Campion said. “In terms of checking in on the experience of the woman, it’s very much a model of ‘Get you out as soon as possible.’ … There’s a lot of CYA [cover your ass].”
She said one of the changes that could help is for providers to be more trauma-informed. “A lot of women come in with prior traumas,” Campion added. “All those things get triggered when you’re giving birth.”
Hospitals could easily improve care for families who have experienced a traumatic birth in a very basic way, she said. “If you have some compassion, if you say, ‘This was an important event in your life. How are you doing? How are you feeling?'”
Some couples are scared away from ever having another biological child after experiencing trauma at the hospital. That’s what happened to Rhode Island’s Victoria Picinich and Chris Revill. Picinich had to have an emergency c-section after developing preeclampsia, and then started hemorrhaging blood.
“It looked like a scene from ‘Psycho,'” Revill said about walking into the empty room, after his wife had been taken to a second hospital for another surgery. It didn’t stop the bleeding, and Picinich was taken to a third hospital for yet another procedure.
During this time, Revill didn’t know what was going on. He was at the original hospital, with no place to sleep, wondering whether his wife was alive or dead. The hospital did not offer counseling or any kind of mental health intervention, he said. The most Revill remembered being offered was a card for free food in the cafeteria.
Luckily, the couple had hired a doula. The doula stayed at the hospital with Revill, advocating for him and his wife and finally getting him word that Picinich had survived.
First popularized in U.S. culture during the 1960s natural birth movement, a doula is “a trained professional who provides continuous physical, emotional and informational support to a mother before, during and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible,” per doula-certifying organization DONA International.
In a recent series of recommendations by the American College of Obstetricians and Gynecologists, the organization stated that “evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor.”
Medicaid only covers the cost of doulas in a few states — not including Pennsylvania — although there’s a growing movement to expand coverage. After her experience, Picinich tirelessly lobbied the Rhode Island legislature to pass a bill requiring Medicaid and private insurance to cover doula services in hospitals, which was just this summer implemented as law.
Pa. has fewer OBGYNs, but ‘we cannot lose sight of the mom’
The American College of Obstetricians and Gynecologists recently updated its guidelines to recommend more postpartum care for women and families.
It recommends OBGYNs “strive to universally implement a trauma-informed approach across all levels of their practice with close attention to avoiding stigmatization and prioritizing resilience,” and build a “trauma-informed workforce by training clinicians and staff on how to be trauma-informed.”
But in Pennsylvania, as the cost of malpractice insurance rose sharply over the past two decades, many obstetricians left the state or resorted to gynecological-only practices — so those still practicing have less time for each patient. An ongoing nursing shortage means less hand-holding at the bedside.
And seemingly minor miscommunications can spiral into situations that have the potential to derail entire childhoods.
Even after being removed from the unnecessary morphine drip, Olivia Rose spent three weeks in the Newborn Intensive Care Unit, held there as nurses “scoring” the infant’s symptoms didn’t see enough improvement, said Santamauro, the mother whose Kratom use had led to the misdiagnosis of potential opioid withdrawal.
Santamauro said she visited the NICU every day. When she was there, Olivia Rose scored well. When she was away, Olivia Rose scored worse.
“I spent 14 hours there, and she didn’t cry once in those 14 hours,” Santamauro said, crying herself as she recalled that particular day. “When I went to have dinner, she scored negative!”
At some point, the Philadelphia Department of Human Services became involved.
“The day DHS showed up, I thought I was going to have a heart attack,” Santamauro said.
A DHS case manager questioned whether Santamauro and Moraff had the proper baby equipment to take Olivia Rose home. Santamauro said her mother’s apartment, where they were staying while their baby was in the NICU, looked like “Babies R Us.” At a second appointment, the case manager apologized, she said.
At the state level, Snead, Pa.’s acting DHS secretary, is actively working to make sure this kind of misunderstanding doesn’t happen, and that parents also get counseling.
While the infant’s health is obviously of critical importance, the mother’s experience is a “defining moment and can affect outcomes into the future,” Snead said. “From the moment the baby is born, we cannot lose sight of the mom. That is the most critically important thing. It is particularly important if it’s a single mother.”
In general, Snead said, there needs to be a much bigger focus on behavioral health supports rather than just physical support for the mother. “It is really critically important that we’re expanding trauma-informed care on both the prenatal and the postnatal sides.”
Although Olivia Rose is now nine months old and thriving, Santamauro and Moraff haven’t fully recovered from the trauma they experienced in the hospital.
Said Santamauro: “I just wish I had someone to advocate for me.”