Maternal Health

My journey to an affirming birth experience was anything but a straight line. It began back in 2007, before concepts like supportive birth teams for mothers-to-be and birthing autonomy were widespread in the maternal healthcare world. I became pregnant with my first child when normal and healthy pregnancies were still routinely pathologized and medicalized.

Fifteen years ago, there was still a dearth of alternative birthing options for anyone wanting to labor and deliver outside of the conventional paradigm of laying on one’s back, legs up in stirrups. The only other option was having surgical birth. There certainly wasn’t any open public discourse around saving placentas for use in treating the symptoms of postpartum depression! The word doula was still an unfamiliar term to the majority of birthing folks, and midwifery was a dirty word in most hospitals.

At the time of my first pregnancy in Atlanta, Georgia, the only approved midwifery practice was nurse midwifery, and there was only one such practice in the metro Atlanta area. Unfortunately, that practice, and the corresponding hospital it worked out of, was over 20 miles away from where I lived, but I was determined and stubborn.

I was set on realizing a low-intervention birth. It just so happened that the hospital serviced by this nurse midwifery group also offered water birth. It was not a decision that took long for me to come to. The option of having a home birth was not open to me because of cost. I had to rely on using health insurance to pay for my maternal care. Thankfully, the midwifery practice in North Fulton accepted a health insurance plan I qualified for.

The path to an affirming birth experience was not an easy one. Long drives to prenatal appointments, switching insurance carriers, locating a birth education class and subsequently getting back and forth, and finally, finding and booking the services of an experienced and caring doula all posed challenges along the path to procuring an empowering and affirming birth experience.

I went on to have three more children. The birth of each taught me something different about motherhood and myself. Each time, I set to the task of diving into the tedious work of researching birthing options. Every two years or so, it became easier to find the maternal healthcare team that was both close and convenient to me, and also supported my desired pregnancy journey and birth plan.

Today, more health insurance companies are waking up to the advantages of covering the cost of doulas, home births, and birthing centers, realizing it makes good economic sense to do so. In short, these supportive services often lower the amounts of high cost medical interventions that drive routine hospital births to costs upwards of $20,000!

The opportunity to have a doula covered by insurance was unheard of 15 years ago. I was fortunate that even before this was the case, my state Medicaid plan covered the cost of my prenatal care at the hands of a nurse midwifery practice, and it covered the cost of the birthing tub I elected to use while I labored in the hospital.

There are a plethora of resources directing birthing people to a variety of low- intervention, low-medicalized birthing options. More and more hospitals nationwide are
accommodating low-intervention birth plans. The health care world is beginning to catch up to the demands of birthing professionals, helpers, and birthing people.
What has not fully caught up with the plethora of birthing options is awareness.

Maternal health education and advocacy is not being accessed by the general population of birthing people. Most still do not have a concept of the obstetric violence that occurs in hospitals, nor do they know both the short and long-term benefits of a low-intervention, de-medicalized birth. In addition, the importance of having a birth support team for healthy birth outcomes and postpartum experiences still goes largely unrecognized.

As doulas start becoming covered by health insurance, this gap in birthing empowerment will begin to close even more than it has from a decade ago. I am optimistic,
thanks to the efforts of organizations like the Black Coalition for Safe Motherhood, that we will reclaim empowerment, autonomy, and fulfillment in the average birth experience. With the strides that have been made so far, I am confident that day is right around the corner.

-Rabiah Lewis, MPH

This Obstetrician Recommends Midwifery Care:
But Why are Midwives in Short Supply?

By Leslie Farrington, MD, Cofounder of Black Coalition for Safe Motherhood

In 2014 I learned about the worsening maternal mortality statistics in the US, and the racial disparities in maternal health, which could not be explained away by socioeconomic or medical risk factors. I decided a community-based solution was necessary because, as an African American Obstetrician, I had no expectation that my fellow Obstetricians would soon recognize how racism permeated our specialty and impacted the lives of birthing people, especially Black women.

Black Coalition for Safe Motherhood promotes the ACTT Curriculum for Black health care consumers to advocate for their rights to safe respectful medical services. ACTT stands for self-affirming and potentially lifesaving steps to take in the office, clinic, hospital, and especially on Labor & Delivery:

• Ask questions until you understand the answers.
• Claim Your space – Physical and Mental.
• Trust Your Body
• Tell Your story

If Black birthing people were cared for by Black Midwives and other birth workers like doulas, who listen to and support them, research shows they would have better outcomes and less traumatic experiences of care. And there would be little need to ACTT. But culturally congruent care is hard to find because of the lack of Black Midwives. And many women mistakenly believe that obstetrical care is safer than midwifery care.

Recently I learned how Obstetricians virtually eliminated the centuries old practice of Traditional Midwifery in North America and medicalized birth. The result has manifested over the last several decades in the rising c-section rates and, to an unknown extent, worsening maternal health statistics in the US, especially for Black and Indigenous birthing people. Most Obstetricians are not aware of the history of the specialty, and they do not see the obvious effects on the business of birthing. Even if they were aware, hospitals are too invested in the status quo to adopt the midwifery model of care. The fact that racism outside of obstetrics plays a large part in the Black Maternal Health Crisis does not diminish the impact of obstetric dominance and medicalization of birth.

The benefits of Midwifery are not well known in this country because 90% of births are attended by Obstetricians. In European nations most births are supported by midwives – with much lower rates of poor outcomes and at half the cost of US maternity care. Even though it is well known in the public health sector that Midwives Save Lives, we do not see hospitals rushing to reduce the profitable high intervention business of Obstetrics.

Public health experts, Black, Brown, and Indigenous reproductive justice scholars, activists, and birth workers, all can see that the emperor has no clothes on, but doctors and hospitals still see themselves as fully dressed. This is not surprising. After all, the statue of the “Father of Gynecology” J. Marian Sims was only recently removed from its Central Park location because his craft was developed on the bodies of enslaved women. Now the American College of Obstetricians and Gynecologists and the American Medical Association acknowledge their racist origins, policies, research, education, and mistreatment of non-white patients, and have developed strategic plans to increase equity, diversity, and inclusion, and eliminate racism in medicine.

But that’s not the same as recognizing that Obstetricians put Traditional Midwives (especially Black Midwives) out of business by slandering them and virtually outlawing them in the early 1900’s. By denigrating midwifery care, pathologizing the natural process of birth, and instilling fear of complications and pain, doctors persuaded women to give birth at the hospital under their care. By touting the benefits of anesthesia, forceps delivery, episiotomy, and promoting in-hospital birth, doctors and hospitals were able to capitalize on the new specialty.

Interventions of increasing risk and complexity, and their routine use – without proof of benefits for the 80% of birthing people who are low risk – have caused harm not just because of their invasive nature, but because the birthing person is subjected to various forms of persuasion and coercion (without informed consent) to do what doctors believe is best for them and their babies. Many of the practices employed on Labor & Delivery interfere with the natural process of birth. When patients ask to avoid those interventions (which often make life easier for the staff or more money for the hospital) they are told they are not allowed to do what they want for their labor and birth. In a 2019 survey of women who gave birth in US hospitals 28% reported mistreatment. Black people report discrimination in about one third of their medical encounters.

Hospitals and doctors are comfortable placing blame on patients for poor outcomes and avoid transparency about those outcomes. It may take decades for Obstetricians to embrace the midwifery model of care, collaborate with midwives, support out of hospital birthing options, and listen mindfully to all the people they serve. That is why it is up to the consumers of maternity services and birth justice advocates, like Black Mamas Matter Alliance, to light the way forward. In the meantime, while pushing for improvement, there is the option to ACTT.

[/et_pb_text][/et_pb_column]
[/et_pb_row]
[/et_pb_section]

Reclaim the Joy, Hope and Spirituality of Birth – Grow the Black Birth Workforce

The April 2021 Love Letter to Black birthing people provides a list of valuable suggestions for improving birthing experiences and outcomes. In rural and poor areas, because of shortages of Black midwives and doctors, it can be challenging to find a culturally congruent (Black) doctor or midwife and depends on transportation and insurance coverage. In addition, the medical industrial complex puts production pressure on providers, which often limits the time even the most compassionate clinician can spend listening mindfully to their patients. Despite these obstacles, and the recognition that racism and capitalism dominate healthcare, the Black birth workforce knows how the Black community can come together and reclaim the joy, hope and spirituality of birth.

Doulas, Midwives, Nurses, Lactation Support and Group Prenatal Care      
Access to doula support, group prenatal care, childbirth education, and the midwifery model of care all need to be scaled up in Black communities. Research shows these solutions positively impact maternal and infant health. While we await slow change in the provision of maternity services and the elimination of racism in medicine: the Black community can SOS, “Save Our Selves” – as Home Birth Midwife Nubia Martin recommends. Nubia raises funds to cover the costs of home births for families who prefer autonomy or want to avoid hospital birth. Doula Trainings like that of Midwife Shafia Monroe and Midwife Jennie Joseph’s new School of Midwifery also show how Black women are leading the charge.

Holistic Community Support  
In NYC, Doula collectives like Ancient Song Doula Services and Bronx Rebirth and Progress, give out diapers and food and offer free or low-cost doula support to birthing families. Black women led community-based prenatal care and birthing centers are growing in number, albeit slowly due to scarce funding. The Birth Center Equity Fund seeks to address this obstacle.

Digital Resources and Vetting Maternity Services
Digital platformed initiatives, developed by Black women, include the Irth App with Yelp like reviews of maternity services, the Believe Her peer support app, and the Health In Her Hue App which connects to culturally competent providers. These can help steer consumers away from poor performing health care services and provide important mental health support.

Asserting Rights for Person Centered Care
Black Coalition for Safe Motherhood (where I am a principal) promotes its ACTT Curriculum in Black communities nationwide. ACTT is an acronym for the powerful and self-affirming steps mothers and their supporters (advocates) can take to engage with providers. Knowing about patients’ rights to self-determination and respectful care, and practicing ways to assert those rights, helps ACTT participants navigate maternity services with confidence.

• Ask Questions until You Understand the Answers
• Claim Your Space – Physical and Mental
• Trust Your Body
• Tell Your Story

In Black communities across the nation, churches, women’s groups, sororities, nurses, doctors, midwives, and doulas are mobilizing to protect and empower birthing families. They are continuing the African tradition of Ubuntu – in recognition of our shared humanity – knowing that it takes a village for Black families to thrive with hope and joy.

 

 

OV is Mistreatment or Disrespect by medical personnel during Labor or Birth

The Giving Voice to Mothers Study 2700 US Women Surveyed

One in 6 (17%) US women surveyed reported mistreatment giving birth.  About 27% of women of color with lower socio-economic status report mistreatment including “…loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help.”

“Black women, Hispanic women, Asian, and Indigenous women were twice as likely as White women to report that a health care provider ignored them, refused their request for help, or failed to respond to requests for help in a reasonable amount of time”

OV ranges from verbal disrespect to physical assault. All are traumatic for birthing people and may result in short term and long term mental and physical health impacts on the mother/infant dyad.

Joking about pain and loss of autonomy and dignity

Paternalism – you are Allowed or Not Allowed, ignoring a birth plan

Dismiss or Ignore patient reports of pain or other symptoms

Microaggressions and Disrespect

Coercion – giving biased (not evidence based) information, threats of harm, calling Child Protective Services and threatening legal kidnapping

Procedures done without consent – vaginal exam, breaking bag of waters, episiotomies

Physical restraint and forced procedures = Assault and Battery!

Disrespect, Degradation, Assault when Giving Birth can cause PTSD and PPMD and can impact infant health.

Why is OV happening?

History of Obstetrics: founded in Sexism, Racism, Capitalism, Patriarchy, the pathologizing of Birth, and the virtual eradication of traditional African American Midwifery

Medical Training Pecking Order and Culture of Disrespect

“Disrespectful behavior threatens organizational culture and patient safety in multiple ways. A sense of privilege and status can lead physicians to treat nurses with disrespect, creating a barrier to the open communication and feedback that are essential for safe care. A sense of autonomy can underlie resistance to following safe practices, resulting in patient harm. Absence of respect undermines the teamwork needed to improve practice. Dismissive treatment of patients impairs communication and their engagement as partners in safe care.”

Doctor/Patient Power Differential and Ignorance of Human (Maternal) Rights

What Can Be Done to Avoid/Prevent OV?

Vet Maternity Services Early – learn about their policies and names of those in charge

Culturally Congruent Care, Midwifery, Community Birth (outside Hospital)

Learn about Pregnancy and Birth so you know what you need, value, prefer

Know Your Rights and Practice ACTTing

Bring a Doula, or well-informed partner, get names/titles of staff, post patients Bill of rights of the Hospital or the State

Create and post one page Birth Plan several copies.

Give and Expect Respect and Empathy – if not – Switch Nurse/Doctor

If OV does happen – Lawsuit rarely helps

Get Support, write complaint to CEO etc, Patient Advisory Council of the Hospital, Reviews – including on the Irth App. News Media or Social Media – Videotape or audiorecord.

My grandmother, Edith Farrington, died of a pregnancy related complication at Queens General Hospital in New York City almost 100 years ago. Last week I learned on Facebook about the loss of a mother, one month postpartum, at that same hospital. Nowadays when a young person dies and leaves behind a toddler and newborn baby, the entire community is grieving, gathering support for the family, and holding demonstrations in front of the hospital. In the case of Denise Williams, they are protesting because no answers are forthcoming as to what led to her death. The social media videos of Denise’s aunt and sister and mother mourning her loss are heartbreaking.

In the several years since the rising rates of pregnancy related deaths and complications in the United States were exposed, there have been many news reports about how Black mothers are 3 times more likely to die than their white counterparts.  Now doctors and midwives are hearing Black women say, “I am afraid I’m going to die”. Birth Justice activists want to stop the media capitalizing on shocking racial disparities in maternal health, calling the recent surge in stories highlighting Black women’s deaths “trauma porn”. But even without mainstream media coverage, each tragedy ripples through the deceased mother’s community.

Media attention has added fear to the mistrust many Black people already feel towards medical providers. In April 2021, leaders in the Birth Justice movement pushed back against the stressful narratives Black birthing people hear – with factual information and love in their message:

“Our actual risk of dying from a pregnancy-related cause, as a Black woman, is 0.0417% (41.7 Black maternal deaths per 100,000 live births) — to put that in perspective, our risk of dying is higher walking down the street or driving a car.  Based on past and present injustices, we have every right to be scared, but make no mistake:  that fear comes at a cost and Black birthing people are the ones paying the bill!”

Indeed, the risk of death or near-death complications is very low.  However, the actual numbers – 700 maternal deaths and 50,000 severe complications  per year – represent a problem which is worsening.  The good news is over 60% of the deaths are preventable.  Major legislation to address the issue, the Momnibus, has been sitting in Congress for over a year. Given the lack of political will to make the necessary changes, and the denial of racism in medical care, it is not surprising that it might be a challenge to convince Black birthing people that their birth experience can be a joyful, powerful, and even spiritually uplifting experience.  Especially considering that deaths of Black mothers are the tip of the iceberg of harm and disrespect Black people often deal with in all areas of the medical system. So how do we access health care without fear of mistreatment?

The love letter to Black birthing people gives valuable suggestions which are possible to implement in some parts of the US, but often impossible in rural and poor areas. Finding a culturally congruent (Black) or sensitive (non-Black) doctor or midwife may involve some trial and error and depends on insurance coverage. There is a shortage of Black midwives and doctors. And doctors of all ethnic backgrounds are not often trained to center the needs and preferences of their patients. In addition, the medical industrial complex puts production pressure on providers, which limits the time even the most compassionate clinician can spend listening mindfully to their patients.

Doula support improves birth outcomes and experiences for birthing people who can find and afford it. Group prenatal care and the midwifery model of care are also beneficial. Research shows these solutions positively impact maternal and infant health. While we await slow change in the provision of maternity services and the elimination of racism in medicine: the Black community can SOS, “Save Our Selves” – as Home Birth Midwife Nubia Martin in recommends.

In NYC, Doula collectives like Ancient Song Doula Services and Bronx Rebirth and Progress, give away diapers and food and offer free or low-cost doula support to birthing families.  Midwives like Nubia Martin raise funds to cover the costs of home births for families who prefer autonomy or want to avoid hospital birth. Black women led community based prenatal care and birthing centers are growing in number, albeit slowly due to scarce funding.

Digital platformed initiatives, developed by Black women, include the Irth App with Yelp like reviews of maternity services, the Believe Her peer support app, and the Health In Her Hue App which connects to culturally competent providers. These can help steer consumers away from poor performing health care services and provide important mental health support.

A mixture of modalities from virtual workshops to social media is used by the Black Coalition for Safe Motherhood (where I am a principal) to promote its ACTT Curriculum in Black communities nationwide. ACTT is an acronym for the powerful and self-affirming steps mothers and their supporters can take to engage with providers. Knowing about patients’ rights to self-determination and respectful care, and practicing ways to assert those rights  helps ACTT participants navigate maternity services with confidence.

• Ask Questions until You Understand the Answers
• Claim Your Space – Physical and Mental
• Trust Your Body
• Tell Your Story

In Black communities across the nation churches, women’s groups, sororities, nonprofits, doctors, midwives, and doulas are mobilizing to protect and empower birthing families. They are continuing the African tradition of Ubuntu – in recognition of our shared humanity – knowing that it takes a village for Black families to thrive with hope and joy.

White supremacist ideology has influenced scientific research from the 1700’s to the present. The evidence abounds in the subjects and topics “researched”, the language and images used, and the assumption that the norm is of European descent. Everyone else is racialized and characterized as biologically or genetically or socially less than.

Research from the white supremacy perspective informs theory and doctrine in all the helping disciplines. The policies of public health and social work departments, health systems, institutions of learning, and the training of professionals are thereby based on ideology which maintains white advantage and devalues people of color. The behaviors and practices of social workers, therapists, teachers, nurses, and physicians are influenced by the way they are trained to see and think about non-whites. From early childhood, mainstream culture ingrains racial bias in future helping professionals so that, between their upbringing and their training, these professionals have the potential to visit harm instead of help on the children they teach, the poor they are supposed to support, and the sick they are supposed to heal. They become instruments of ongoing oppression, despite their good intentions. They say Black children are behavior problems, Black people don’t have strong families, and Black patients are non-compliant, poor historians with low health literacy. There is little or no understanding of how US history – and present – perpetuates the disadvantage Black people have struggled with for centuries. And no attention has been paid to how we have excelled and overcome the obstacles of a society rigged against us.

Its time to flip the script and study the practices of the Black midwives – before modern obstetrics put them out of business. It’s time to cite African American academicians with culturally afro-centric, Black feminist, and human rights perspectives, and learn from education innovators of color. Its time to listen to Black women on committees and in the exam room, and not interrupt or dismiss them – disparaging their contributions, perspectives and symptoms. Changing the deeply embedded white supremacist mindset and behaviors in the helping professions will take study, guidance and life-long practice. Hence the need for consultation, training and long term follow-up from an organization or firm with years of experience in Dismantling Racism.

Americans who read The Unequal Distribution of Health in the Smithsonian Magazine may be shocked to learn that US women today are 50% more likely to die in childbirth than their mothers, and that our death rate is 3 to 5 times higher than European countries. They may have thought this was a tragedy only in the Black community and not a problem with obstetrical practice in the US. Most Americans also do not realize that we are the only country where 90% of births are attended by physicians instead of midwives.

To a retired Black Obstetrician, and a student of the history of Obstetrics and Midwifery, what is almost as concerning as the racism in obstetrics is the lack of attention to the failure of Obstetricians to critique their own management of maternity care.  There is a lack of awareness of what has transpired since the pathologizing of pregnancy and birth, and the virtual elimination of midwifery practice in the US one hundred years ago. Yes, Black women are mistreated more than whites when accessing healthcare and we need culturally congruent and community-based care, but all women are at risk for mistreatment and harm, and the majority of those who die or suffer complications of pregnancy are white women. If doctors were faced with the clear connection between their interventions, patriarchy, and racism, and the rising maternal death rates of all mothers in the US, might they begin to employ the solutions advised by Black Midwives and Birth Justice Activists who are leading the charge to transform hospital based obstetrics to respectful maternity care?

Let us spotlight the flawed obstetrical experiment of medicalization of what is for 85% of birthing people a natural, powerful, joyful, and nonmedical life experience. Let us shine a light on rising c-section rates, labor inductions, traumatic births, and postpartum depression. Let us publicize the surveys of women which report verbal and physical abuse (known as obstetric violence) when giving birth in the hospital, especially when they try to assert their rights to bodily autonomy. This is an American problem, a lack of accountability and oversight of our medical and maternity care industry.

 

When we only focus on the racism in medicine and call it a problem for Black people, we allow doctors and hospitals to deny their complicity in perpetuating our dismal maternal mortality and severe morbidity statistics. That’s because most white Americans in the medical professions are in denial about their own bias, and they still believe that Black people are to blame for poor health outcomes. Doctors believe they are the best trained and educated to care for women, and midwives and out of hospital birth are the lesser options. Our statistics and studies of Midwifery care show otherwise. The American College of Obstetricians and Gynecologists (ACOG) has recently begun to change their guidelines to lessen obstetric intervention in order to reduce c-section rates, but they have no means to change the long held belief of Obstetricians in Active Management of Labor. ACOG also has a strategic plan to address racism, but it can not change the power differential which doctors cling to and the biases they deny.

Let’s call attention to Doctors’ and Hospitals’ controlling policies and procedures, along with the patriarchy and racism embedded therein. We can shift the narrative and revisit the safer and more supportive option for low-risk mothers – the traditional midwifery model of care which has served human beings for millennia. We can reduce the obstacles faced by people of color to a career in midwifery and establishment of birthing centers. Midwifery works for the rest of the world so why not the US? Let’s end Obstetric Supremacy.

Though they belonged to a healing profession and pledged to “First do no harm”, physicians in the Antebellum:

• Worked at slave markets attesting to the health of enslaved peoples to improve the profitability of the slave trade.
• performed experimental surgeries on enslaved women to develop techniques, procedures, and instruments. J. Marion Sims was the most famous because he was self-promoting, but there were several documented early Gynecologists who honed their craft on enslaved women. They also trained the women who were recovering from surgery as surgical assistants according to historian Deidre Cooper Owens.
• used no anesthesia for those surgeries – even when it was available – claiming that Black people did not feel pain like whites, despite the need to hold the bondswomen down so they wouldn’t move while they were operated on.
• contributed racial pseudoscience to the medical literature, disparaging and dehumanizing the enslaved as biologically inferior to whites. Their research and writings were flawed and contradictory. They used the bodies of the enslaved to perfect surgeries and they would then use the same techniques on white women. The proof that all women had the same organs and tissues escaped those early physicians. They would attribute poor healing in Black women to hypersexuality – not on being forced to work after surgery and poor nutrition or being raped by their oppressors. White physicians made up diseases which were unique to Black people.

For example: Drapetomania was a conjectural mental illness that, in 1851, American physician Samuel A. Cartwright hypothesized as the cause of enslaved Africans fleeing captivity.

Physicians did not “care” for enslaved people except in so far as they were able to develop surgical techniques and tools or increase the profit off those in bondage.

Contrast that role with that of the Granny Midwife who assisted birthing mothers and cared for the sick and injured and passed down traditional skills and knowledge. This is a rich history which should be further elaborated.

 

In the late 1800’s to 1960’s doctors organized professional organizations, continued to use Black people to advance their research, and built hospitals. In so doing they:

• convinced women that midwives were dirty, unskilled, and births were far safer in the hospital.
• instituted public policies to prevent midwives from practicing.
• under Jim Crow laws discriminated against descendants of the enslaved by not accepting them as patients in their hospitals
• segregated Black people into separate (and unequal) wards in the North, if they did admit them to the hospital.
• excluded Black physicians from professional organizations and practicing in white serving hospitals.
• perpetuated stereotypes about African Americans in medical research and education.
• Conducted Syphilis Experiment in the Tuskegee Alabama area
• Forced or coerced sterilization on women of color (recent reports of immigrant ICE detainees having unwanted gyn surgeries)
• Used Henrietta Lacks biopsy tissue for scientific advancement without her consent.

From the 1960’s to Present, despite the Civil Rights era and end of Jim Crow laws, structural and institutional racism, and personal bias and stereotypes continue to affect the health of African Americans.

• The determined agenda of white supremacists to preserve white domination generated a concerted backlash to civil rights era laws which impacted social determinants of health. From restricting Medicare to people over 65 to undermining affirmative action (why the % of physicians who are Black is still 5%) to non-expansion of Medicaid in southern states with the Affordable Care Act – just 3 examples of white backlash from the 1960’s to 2000’s affecting health of Black people.
• 1/3 of Black Americans report discrimination in healthcare settings
• 27% of Black mothers report disrespect or abuse while in the hospital to give birth
• 3 to 12 times as many Black mothers die of pregnancy related complications as whites (depending on city/region) in the US
• Black mothers with college degree are 5 times more likely to die than their white counterparts
• California medical professionals implemented improved obstetrical practices between 2005 and 2013 and cut Maternal Mortality in half in that state, but Black women still died at 3x the rate of whites. They are now focusing on racism as a root cause and mandating anti bias training for medical providers.
• 50% of physicians in training believe stereotypes about Black people’s bodies, which affects 40% of treatment decisions
• white doctors spend less time with their patients of color and communicate poorly
• Stress of racism and discrimination have been shown to contribute to many medical conditions including premature births, hypertension and heart disease.
• The theory of “Weathering” or premature aging of Black women’s bodies due to racism has gained more traction in recent years with biological studies supporting physical damage to telomeres, hormonal alterations, and inflammation in the uterus. *Think about Erica Garner who became an activist after her father was choked to death by police in Staten Island. A few years later during her pregnancy she was found to have an enlarged heart. She died of heart problems exacerbated by asthma 4 months postpartum.
• Medical providers often blame patients for bad outcomes saying they were poor historians or noncompliant.
• Despite Public Health research going back decades and the landmark report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare” from Institute of Medicine in 2003 – Doctors are mostly in denial that Black lives are not valued when accessing healthcare. The many stories of women who report symptoms of complications and are not listened to provide a different narrative. Take Serena Williams, for example, who knew she was experiencing a pulmonary embolism the day after giving birth by c-section. She was dismissed when she asked for what she knew was life- saving treatment. Only her white husband was heard.

Future

The Pandemic and the masses of people reacting to the deaths of George Floyd and Breonna Taylor, and racial injustice in general, are currently drawing attention to what Public Health experts, Reproductive Justice Activists, and others have been saying for decades – Racism is killing us.

There are movements, some led by Black Women, addressing racial disparities in multiple areas of medicine. These are gaining momentum because of the recent upheavals:

• Movement is Life Caucus – addressing disparities in joint diseases

• Respectful Maternity Care – decreasing disrespect and abuse of birthing people

• Decolonizing Birth – women taking back their roles as life givers – birth workers, Doulas, Midwives caring for birthing people in their communities.

• Black Mamas Matter Alliance – Black Women-led cross-sectoral alliance which centers Black Mamas to advocate, drive research, build power, and shift culture for Black maternal health, rights, and justice.

• Health Care Transformation Task Force which runs the Maternal Health Hub

Topics at Upcoming Decolonizing Birth Conference -RJ & BJ stand for Reproductive Birth Justice:

In addition to activists there are progressive politicians pushing for those sociopolitical policies and legislation which are needed to influence environmental injustice, access to healthcare, universal coverage, criminal injustice, discrimination in housing, living wage, etc.

Some examples:

H.R.6142 – Black Maternal Health Momnibus Act of 2020

Green New Deal

Attorney General of Philadelphia Larry Krasner is an innovative Criminal Justice reformer

NYC Standards of Respectful Care at Birth (from Dept of Health in collaboration with community members)

There are many more legal and policy innovations which can have some impact, but often they are band-aids on the abscess of white supremacy in the US. To achieve wealth and health equity will take decades of concerted effort and political will to effect substantive change. What is needed is the dismantling and restructuring of systems which were designed to neglect or oppress Black people.

Researchers are beginning to look at how whiteness influences design of studies, and the language used. Some are centering marginalized groups. Community led or guided research is more common now. There is the idea of studying medical professionals to figure out how to change their behavior with patients.

What the Black Community can do Now to improve Health and Well-being:

• Increase numbers and use of Black midwives, nurses, doulas, physicians
• Healthcare Advocacy – Amplifying Black voices in medical settings for example the ACTT Curriculum of Black Coalition for Safe Motherhood
• Ubuntu – Caring Community

Neighborhood Gardens

Healthy food collectives and food banks

Drive through Baby Showers

Chocolate Milk Café (lactation support groups)

       Doula Support

       Community Health Workers

       Community Based health services

       Age Friendly Community Initiatives

       Holistic Community support for Birthing people

       Support Black Owned Businesses (wealth is key to health)

Thank you for this opportunity to shed light on why racism is a public health crisis AND how racism impacts health and well-being of birthing families in NYC. Some community-based solutions will be discussed in a panel later today.

First, I will explain that I am the daughter of an interracial couple who experienced frequent episodes of bigotry and discrimination so I was not surprised that some of my white colleagues were prejudiced. I have overheard disdainful comments about patients of color made by white medical professionals because they did not know I am Black.

What I did not realize for most of my career was how bias and paternalism led directly to mistreatment and neglect, resulting in harm and traumatic birth experiences. I did not learn until about 5 years ago that higher rates of complications among Black mothers are often related to the biological impacts of the chronic stress of growing up Black in America. The prevailing medical opinions in the 80’s and 90’s were that life style and infections were the cause. This is called “Mother Blaming”. There are several stereotypical narratives which are passed down since slavery blaming Black people for poor health outcomes and these are part of medical education. Even today 50% of doctors in training believe that Black people have higher tolerance for pain. Despite data proving otherwise, many medical professionals cling to their biases and don’t realize they are mistreating, disrespecting, and not listening to their Black patients. Tennis Greatest of all time Serena Williams pointed this out after her birth complications.

Maternal health crisis statistics in the US and NYC:

754 women died and 50,000 almost died of pregnancy related complications in 2019. 658 died in in 2018. According to the CDC, 2/3rds of these deaths and complications are preventable. The US maternal death rate has doubled since the 90’s, while the rest of the world has been reducing maternal mortality. We rank 55th behind Russia and just ahead of Ukraine. And despite the fact that the US spends at least twice as much as all other wealthy nations, our maternal death rates were at least 3 times higher. I think its worth noting that births everywhere else are attended by midwives and here 90% of babies are “delivered” by doctors. Black women with college degrees die 5 times more than their White counterparts. These disparities exist even when allowing for preexisting risk factors like age and obesity.

In 2017 in NYC out of 21 deaths from pregnancy related causes 11 were Black mothers, 6 Latinas. 3,000 birthing people almost died, 947 of whom were Black mothers. In NYC 8 times as many Black women die of pregnancy complications as White women. And I want to repeat the point that most of pregnancy related deaths are preventable. Too often Black women report warning signs and their concerns are dismissed. In a recent survey of birthing people mistreatment was reported by 1 in 6 mothers, and was twice as common for people of color than whites.

In a 2017 survey by Harvard School of Public Health and NPR, 32% of African Americans report discrimination in healthcare settings. Racism in the healthcare system is one root cause of this public health crisis. Another is racial oppression influencing every aspect of Black life since slavery and continuing in the present with discrimination in hiring and housing, segregation and underfunding of schools and hospitals, racial profiling and mass incarceration, I could go on. African features have been stigmatized as part of white supremacist ideology to justify slavery and oppression. It remains embedded in society.

Experts in public health today will tell you that it’s racism that’s killing Black mothers. And racism also is the reason Black infant mortality is two to three times that of white babies. I will give you just two studies to show how we know it’s racism and not race or socioeconomic status that is deadly. Recently in a study in Florida of 1.8 million births, the death rate of Black newborn babies under the care of Black doctors was half the death rate under the care of white doctors. A study in Detroit comparing birth weight of babies born to African American mothers, white mothers, and African immigrant mothers showed that African babies and White babies had the same birth weight but African Americans babies were significantly smaller. African ancestry does not increase risk of death. Race is a social construct, not a biological difference. Pregnancies of mothers who experienced racism through their life course are at increased risk due to the biological impacts of stress. Cardiovascular health is also impacted by racism and discrimination. This is why African Americans need and deserve better medical care not worse.  Racism is a public health crisis and has been for centuries.

The Ongoing Tragedy – An Iceberg of Harm

The main message to take away is that the premature deaths of Black people, either in the care of doctors, or at the hands of the police, is the tip of an iceberg. When it comes to maternal health, the disproportionate numbers of Black women dying of pregnancy related complications is the tip of an iceberg of harm experienced by Black families, in this city and throughout the African Diaspora.

Interviews conducted by NYC DOHMH of 15 mothers who almost died in NYC hospitals revealed that most experienced microaggressions and disrespectful communication with their providers.

During pregnancy, and especially during the birthing process, treatment decisions, which go against patients’ wishes, are frequently made without their input. Labor & Delivery routines are often not based on medical evidence, and go against the natural process of human labor and birth. Informed consent to undergo obstetrical interventions is often based on opinions of providers and not sound evidence, and birthing persons’ preferences are not respected. Worst of all birthing people experience coercion without regard for their human rights. For example, a birth companion in Brooklyn told me that a Haitian Creole speaker was forced to have an emergency C-section without an interpreter. Doulas I speak to tell me laboring women are pressured into vaginal examinations and procedures as if they had no bodily autonomy, which is basically rape culture. It’s called Active Management of Labor and its part of the training of doctors in New York City hospitals, it was the same when I trained.

A Brief History of Maternity Care

We must study the history of racism and patriarchy in maternity care to understand why deaths of both white and Black women have been rising in the United States since the 90’s.

For centuries women with skills supported other women giving birth. The traditional midwifery model of care supports a spontaneous birth under a birthing person’s own power, usually without intervention.

In the 1800’s US doctors experimented on poor and enslaved women to develop the medical specialty of Obstetrics and Gynecology. They introduced instrumental delivery with forceps and surgical interventions like C-sections and episiotomies. They pathologized and medicalized the natural process of birth.  In the early 1900’s hospitals and doctors began to capitalize on birthing. They put traditional indigenous and Black midwives out of business by spreading the narrative that midwives were dirty and uneducated and that birth was a dangerous condition requiring a doctor’s services. Midwifery was essentially outlawed in the 1920’s and 30’s. C-sections and other medical Interventions have increased in the 100 years since, leading to increasing complications. The medicalization of birth and development of technological innovations have increased revenue for hospitals. Since the late 1980’s Doctors have been under increasing production pressure to see more patients at a faster pace due to declining reimbursement from health insurance and increasing costs. Nurses are expected to do more in less time. Hospitals serving Black communities and rural communities have closed for lack of funding.

Many doctors don’t realize how medicalization of birth and lack of respect for mothers’ autonomy and dignity interferes with the natural power of human birthing. About 80% of birthing people are low risk for complications and don’t need the obstetrical model of care controlled by hospitals and physicians. There should at least be the option to receive culturally congruent community care. The research evidence supports making person centered care with a midwife, and the support of a birth companion also known as doulas, available to improve maternal health outcomes. There is excellent work happening in the community by the NYC DOHMH, but their efforts are underfunded. From the White House and Congress to the state house to the Mayor’s office there are efforts to improve care, including access to out of hospital birth, but the needed transformation of maternity services requires bolder action within hospitals and among doctors. I want to emphasize that the steps currently being taken to address the Black Maternal Health Crisis are just baby steps compared to the centuries of racial oppression and trauma which continues today.  We are a long way from the culture of respect in medicine.

I believe most clinicians care about their patients, but they are affected by our society and the culture of medicine.  My nonprofit, the Black Coalition for Safe Motherhood, is offering a toolkit for communicating with and hopefully partnering with providers.  Knowing what I do about the biases they have and the pressures that medical professionals are under I have cocreated the ACTT Curriculum with other birth justice activists. ACTT stands for:

Ask questions until you understand the answers

Claim Your Space – both physical and mental

Trust Your Body

Tell Your Story

I cofounded the Black Coalition for Safe Motherhood to spread these self-affirming and potentially lifesaving steps in Black Communities nationwide and beyond. Using the ACTT steps, my hope is that Black birthing people and their families and supporters will be better equipped to navigate healthcare until it is transformed into compassionate person-centered care that everyone deserves.