"Sixteen years ago, I almost died giving birth," Ebonie Karma Tudor said, recalling the birth of her son. "It was just a really traumatic experience."

It was 2007. Tudor, a Black woman, was 24 years old. During the delivery, she needed two blood transfusions and couldn't see her son immediately after giving birth to him, she said.

Experiences like Tudor's are not uncommon, research suggests.

But while labor and delivery are thought to be the most dangerous time in pregnancy, studies show it's after mother and baby come home when most deaths occur, according to the US Centers for Disease Control and Prevention.

Among pregnancy-related deaths, 53% happened within one week after childbirth to one year postpartum. The same study lists cardiac and coronary conditions as the primary underlying cause of pregnancy-related deaths among non-Hispanic Black individuals.

Wealth also does not make much of a difference for Black families. The wealthier a mother is, the more likely they are to survive the first year after childbirth -- unless she's a Black woman, a January study published by the National Bureau of Economic Research found.

The study included infants born to first-time mothers in California from 2007 to 2016.

Tudor's experience inspired her to become a doula -- a trained birth worker that provides physical, educational and emotional support for their clients before, during and after childbirth. To some Black mothers, that kind of advocacy could mean life or death.

The recent death of Olympian Frentorish "Tori" Bowie has once again raised questions about Black maternal health care in the United States.

The track and field athlete died from "complications of childbirth" in early May, according to an autopsy report. The 32-year-old, three-time Olympic medalist, who was found dead in bed, was estimated to be 8 months pregnant. There was evidence she had been "undergoing labor," an autopsy report released by the Orange County, Florida, Medical Examiner's Office states.

Her manner of death was ruled natural, and the report found there had been "possible complications," including "respiratory distress and eclampsia."

Eclampsia is an especially severe pregnancy-related complication and can happen when a mother's blood pressure gets too high.

Black maternal death rates rising

The overall rate of pregnant women dying of delivery-related causes in the hospital appears to have declined significantly -- by more than 50% -- across the United States in recent years, a new study suggests.

That decline, seen among more than 11 million hospital patients, came over a 13-year period from 2008 through 2021, according to the national study, published Thursday in the medical journal JAMA Network Open. But the decrease represents only in-hospital maternal deaths, not the nation's overall maternal mortality rate, which has been on the rise.

The new study "seems to contradict the data at the national level where maternal mortality is increasing, because most of the women don't die in the hospital during childbirth; they die after they left the hospital after childbirth," said Dr. Jean Guglielminotti, an assistant professor at Columbia University Medical Center who was not involved in the new study but has conducted research on severe maternal morbidity.

And Black maternal death rates have been steadily rising in the United States for decades. Black mothers are nearly three times as likely to die from pregnancy-related complications as White women with 69.9 deaths per 100,000 live births in 2021, according to the CDC. The rate among White women was 26.6 per 100,000. Multiple factors contribute to the racial disparities seen in the data, including underlying chronic conditions, structural racism and implicit bias, the CDC found.

Black babies are more likely to die than any other racial or ethnic group, the agency found. They are also far more likely to be born prematurely, setting them up for health issues that could follow through their lives.

"The important thing for me is the advocacy. That's what was missing in my birthing story," Tudor said. "I didn't know that I could say, 'no.' I didn't know that I could switch providers. I didn't know that I had all these different options."

Tudor recalled a comment from a doctor when she was pregnant who told her, "You're a strong girl, you know this isn't anything for you, you can deal with it."

After her traumatic birth experience, Tudor became a certified doula in New York City, she said.

Studies have shown treatment of pain in Black patients has been influenced by racial bias. A 2019 study by the American Journal of Emergency Medicine showed Black patients were 40% less likely to be prescribed medication for acute pain. A separate study in 2016 showed racial bias in pain assessment by medical trainees and beliefs that Black and White patients had biological differences like the misconception that Black patients had thicker skin than their White counterparts.

When working with Black birthing people as a doula, Tudor said, those kind of comments aren't as common.

"I do notice that once a doula walks in the room, that it's less likely to happen."

Tudor was trained by a group called Mama Glow. Based in Brooklyn, Mama Glow is a global maternal health and education platform. It has trained more than 2,500 doulas worldwide, it says. Its two-day Doula Expo is a gathering of birth workers and families prioritizing education, connection and community.

'Coachella for birth workers'

Mama Glow's founder, Latham Thomas, likes to call the expo "Coachella for birth workers."

This year's expo took place in New York at Hudson Yards. The space was transformed into a festival-like event featuring keynote conversations, live entertainment, a children's play space and infant feeding lounge. Amid the fun, the expo tackles serious health care issues.

"Black women are telling us that they don't feel seen, they don't feel heard; that they feel dismissed, ignored and feel undervalued by our health care system," Thomas said. "We have people who feel afraid to give birth, that something will happen to them."

Mama Glow aims to raise awareness about the high death rate of Black mothers and find ways to bring it down.

"It's really scary, I think, for people to sit with the statistical information, we know what it is. We know it's alarming, we know that it's unsettling and yet we still have to make improvements. We still have to build towards a future where birth is safe," Thomas said.

One of those efforts is an initiative called "Love Delivered."

Mama Glow and beauty company Carol's Daughter teamed up to combat high Black maternal mortality rates with the initiative, which provides training to doulas and expands access to doula services by providing grants to Black families.

Cost is one of the major obstacles to hiring doulas. Kiyoko Ray was pregnant with her seventh child when she decided to hire doula Zania Mathis. Cost was a major factor in her decision.

"I felt like I couldn't afford (a doula), but I wanted it so bad," Ray said.

Mathis has been working with Ray since early in her pregnancy. Based just outside Atlanta, Mathis says most of her clients live in Georgia -- a state with one of the highest rates of maternal mortality in the United States, according to the CDC. Georgia ranks sixth in the nation.

Mathis' own pregnancies have not been without complications.

She is 6 months pregnant with her fourth child -- a girl. She's the mother of twin boys, 7, and a 5-year-old daughter. Both of her previous pregnancies were difficult. Mathis' younger twin was in the Neonatal Intensive Care Unit (NICU) for 2 days after his birth; she also experienced pelvic floor damage.

'We're told we don't need a doula'

"In the Black community, we're told we don't need a doula. It is looked at something as far as luxury goes. Look at the numbers, look at the data. We need doulas more than any other race," Mathis said.

Research suggests having a doula can be beneficial during childbirth and the postpartum period for both mother and baby. One study published in 2013 by The Journal of Perinatal Education, found expectant mothers who had doulas were four times less likely to have a low-birth-weight baby, two times less likely to experience a birth complication, and significantly more likely to initiate breastfeeding compared to those without doula support.

Mathis said she has also seen a lot of close calls in her four years of doula work.

"I've seen a mom code. I've seen mom's contractions completely stop," Mathis said. "I've seen a mom completely neglected in active labor, having to wait in the (hospital) waiting room."

Mathis knows that cost can be a barrier to access when it comes to hiring a doula. She says she will sometimes make exceptions for clients who need her care by offering payment plans or exchanging services because she believes the care she offers is essential -- especially for Black mothers.

Ray, a hairdresser, partially paid for Mathis' services by styling her hair. "She's more than a doula," Ray said. "She became my therapist. She became a friend."