Research on Racism and Maternal Health

In the days following George Floyd’s murder, I had the honor of connecting with Ihotu Ali, MPH, LMT, CLC, an EBB Professional Member and the co-founder of the Minnesota Healing Justice Network, about their work on the front lines in Minneapolis. Ihotu and other members of the Minnesota Healing Justice Network, including Daniela Montoya-Barthelemy, MPH; Shayla Walker; Rhonda Fellow, CD (DONA), EBB Instructor; and Jennifer Almanza, DNP, APRN, CNM, made the following suggestion: 

EBB should work to make the research evidence on racism and maternal health more readily accessible to our audience.

We greatly appreciate the suggestion from the members of the Minnesota Healing Justice Network. Moving forward you can expect EBB to regularly share especially poignant research findings about Black maternal health.

Please remember that *RACISM* and white supremacy are the cause of any racial disparities. And remember that there ARE known solutions… Black midwives, Black doulas, and Black nurses hold the key!! Black midwives such as Jennie Joseph and Uzazi Village and Mamatoto Village and Jamaa Birth Village, and San Antonio Nurse Midwife, among so many others, are living proof that we can eliminate and reduce disparities under their leadership. Read and share the research, but recognize the opportunities for justice and equity.

-Rebecca

 

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Source:

Giscombé, C. L. and Lobel, M. (2005). Explaining Disproportionately High Rates of Adverse Birth Outcomes Among African Americans: The Impact of Stress, Racism, and Related Factors in Pregnancy. Psychological Bulletin, 131(5), 662-683. Click here.

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I had the honor of speaking with Ihotu Ali @ihotuali , an EBB Pro Member and the co-founder of the Minneapolis Healing Justice Network (@mnhealingjustice), about their work on the front lines in Minneapolis. Ihotu suggested we make the research evidence on racism and maternal health more readily accessible to our audience. We greatly appreciate Ihotu’s suggestion and for the next few months, you can expect EBB to share especially poignant research findings about Black maternal health each Thursday. Please remember that *RACISM* and white supremacy are the cause of any racial disparities. And remember that there ARE known solutions… Black midwives, Black doulas, and Black nurses hold the key!! Black midwives such as Jennie Joseph (@iamjenniejoseph) and Uzazi Village (@uzazivillage) and Mamatoto Village (@mamatotovillage) and Jamaa Birth Village (@jamaabirthvillage), and San Antonio Nurse Midwife (@sanantonionursemidwife), among so many others, are living proof that we can eliminate and reduce disparities under their leadership. Read the research, but recognize the opportunities for justice and equity.
– Rebecca⁠

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 Gyamfi-Bannerman, C., Srinivas, S. K., Wright, J. D., et al. (2018). Postpartum hemorrhage outcomes and race. Am J Obstet Gynecol. 219(2), 185.e1–185.e10. Click here.

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 We just spent 9 months reviewing the research on postpartum hemorrhage (PPH) and the use of Pitocin in the third stage of labor (ebbirth.com/thirdstage). During this review, we learned that a high-quality study found that Black birthing people with PPH were five times more likely to die of PPH than White birthing people with PPH (Gyamfi-Bannerman et al., 2018). ⁠

⁠It’s racial bias, or racism, that leads to a higher rate of severe illness or die from PPH. How? Racial bias in the assessment of PPH is a major concern, because poor recognition of PPH delays treatment. Racism in the lack of prompt treatment of PPH is also a huge problem (As @iamjenniejoseph told us in Evidence Based Birth Podcast Episode 136, some health care workers will say, “Oh, we don’t need to get the hemorrhage cart just yet. She’ll be fine”).⁠

Other researchers have found that Black, Hispanic, Indigenous, and Asian women in the maternity care system were twice as likely as White women to report that a health care provider ignored them, refused to answer their request for help, or failed to respond to their request for help in a reasonable amount of time (Vedam et al. 2019).⁠

Racism, not race, causes this shocking disparity in PPH-related deaths. It’s time for health care workers and health care institutions to address this racism head on. Black midwives and Black nurses and Black doctors know the solutions. Today, we encourage you to follow the work of Black maternal health advocates @timoriamcqueen and @4kira4moms. Support their work! #blacklivesmatter

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Josephs, L. L. and Brown, S. E. (2017). The JJ WAY®: Community-based Maternity Center Final Evaluation Report. Visionary Vanguard Group, Inc. Accessed July 2, 2020. Available online.

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Congratulations to Jennie Joseph (@iamjenniejoseph), Licensed Midwife, on receiving MEAC accreditation for the only Black-owned private midwifery training school in the U.S.!! Jennie is also the founder of the JJ Way® Maternity Care Model– one of the solutions to the extreme racial disparities in pregnancy outcomes. Black mothers who receive care the JJ Way® have a preterm birth rate similar to White mothers in Orange County and in the State of Florida. In other words, the racial disparity in preterm birth rate was eliminated! Also, the preterm birth rate among Latinx participants in the JJ Way® Model was less than half the rate in Orange County and the state of Florida (4% versus 9%)—also a huge improvement. ⁠

The innovative JJ Way® is the Midwives Model of Care© with key components for serving families who are disproportionately impacted by poor pregnancy outcomes. The Easy Access Clinic ensures everyone receives care—no one is turned away! Family members and support people are invited to participate in prenatal care. Clinicians develop relationships with clients and bond through mutual respect and education. Clients can choose to give birth in the hospital or out-of-hospital with a midwife, if they prefer. Each client carries a mini-health chart, which promotes self-reliance and ensures continuity of care. ⁠

We don’t need more research that finds more evidence of disparities without offering any new solutions. The JJ Way® works! Fund it, study it, grow it, and broaden its reach far and wide. To learn about The JJ Way®, visit https://savinglives.biz/the-jj-way  #blacklivesmatter #JJWay

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Thomas, M. P., Ammann, G., Brazier, E., et al. (2017). Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population. Maternal and child health journal, 21(Suppl 1), 59–64. Click here

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We need more programs like the By My Side program through Healthy Start Brooklyn! They hire doulas to provide support during pregnancy, childbirth, and the postpartum period. The program focuses mainly on supporting Black pregnant people, since this group has the highest infant death rate in the area. ⁠

Not only did program participants have significantly lower rates of preterm birth and low birth weight, they also expressed that doula support was highly valued (Thomas et al. 2017). For example, one of the participants described how their doula made a huge difference: “I would’ve had no one there; it was just me and her. If it wasn’t for her, maybe I wouldn’t even get through it, because she really helped a lot”.⁠

Access to continuous labor support from a doula is especially vital for birthing People of Color. However, the unjust reality is that those who could most benefit from doula care frequently have the least access to it. To address the existing health disparities, it is imperative that continuous labor support be accessible to everyone and provided by a culturally diverse doula workforce.⁠

Are you a Black doula? Please tag yourself in the comments so we can thank you! ⁠

#HealthyStartBrooklyn#BlackBrooklynParents#BlackBrooklynMamas#BlackBrooklynMothers#BlackBrooklynMoms#BlackDoulasMatter#BlackBirthsMatter

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Redgrave, Naida and Alleanna Harris. The Extraordinary Life of Mary Seacole. Puffin. 2019.

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If you were asked to name the most famous nurse in history, most people would say “Florence Nightingale.”

But what about Mary Seacole? A Black, Jamaican/Scottish doctoress, who cured illnesses with herbs and medicines? Who traveled alone as a woman in the 1800s? Who served during a cholera epidemic in Panama? Who paid her own way to the Crimean front after being told no more nurses were needed? Who brought her own medicines and food for soldiers? Why don’t we think about Mary Seacole as a famous nurse? [Short answer = white supremacy].

The long answer is that despite being well-loved during her time, Seacole was ignored by historians until the 1980’s (Redgrave & Harris). Now, her merits are questioned. Some suggest that Seacole’s hospital visits were merely “social” in nature (McDonald). Others say that Florence Nightingale published pamphlets and papers on nursing, while Seacole “only” published a memoir (Wonderful Adventures of Mrs. Seacole in Many Lands). Even more take umbrage with the fact that Mary supported herself as an entrepreneur. Making matters complex, Mary–as a multi-racial woman–showed colorism against those darker than her.

Tema Okun’s article “white supremacy culture” (dismantlingracism.org) can help unpack the white supremacist culture responsible for critiques of Mary Seacole’s legacy. Okun explains that part of white supremacist culture is “worshipping the written word,” aka “if it’s not in a memo, it doesn’t exist.” Just because Seacole did not publish extensively on her nursing practice does not mean it did not exist or was not impactful. White supremacist culture values either/or thinking–people are either good or bad. In other words, it would be “easier” for historians to glorify Seacole’s work as a care provider if she did not have a complex existence as a human. Rather than engaging with the tension, people ignore Mary Seacole altogether.

Mary Seacole was a Black woman. A nurse and doctoress. And her ways of healing and determination in the 1800s deserve to be remembered.

#blacklivesmatter #spotlight #whitesupremacistculture

Caption and research compiled by Tyler Jean Dukes (@birthandbooks), supported by her doctoral fellowship

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Collins, J.W. Jr., David, R.J., and Handler, A., et al. (2004). Very low birthweight in African American infants: the role of maternal exposure to interpersonal racial discrimination. Am J Public Health, 94(12), 2132‐2138. Click here.

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Racism causes both acute stress from specific incidents experiences of discrimination and chronic stress from a lifetime of exposure. There is evidence that a lifetime of exposure to racial discrimination is an independent risk factor for preterm birth. In other words, racism significantly contributes to preterm birth even when other risk factors for preterm birth are considered. ⁠

Researchers conducted a case-control study in Chicago, Illinois with 104 Black women who gave birth to very low birth weight (<1500 g) preterm (<37 weeks) infants and 208 Black women who gave birth to infants >2500 g at term. Trained Black interviewers gave participants a structured questionnaire in the hospital after birth. They collected data on the mothers’ age, education, marital status, birth history, prenatal care, cigarette smoking, and alcohol use. All of the participants were asked about their lifetime and pregnancy exposure to racial discrimination in 5 areas: at work, getting a job, at school, getting medical care, and getting service at a restaurant or store. ⁠

They found no link between Black mothers’ self-reported exposure to interpersonal racial discrimination during pregnancy and very low birth weight infants; however, Black mothers who reported lifetime exposure to racism in 3 or more areas had increased risk of having a very low birth weight infant. ⁠

These findings have important implications for maternity care! Lifetime exposure to racism impacts pregnancy outcomes. So, it is not enough to focus only on reducing racism in health care. We need to take actions to address racism everywhere in society in order to improve outcomes for Black infants. ⁠

Black midwives are an important part of the solution! Randomized trials have found that people who receive midwifery care were less likely to have preterm birth or to experience fetal loss or newborn death (Sandall et al. 2016). ⁠

#blacklivesmatter #JJWay #BlackPreTermBirths#BlackMidwives#BlackMaternalCare#BlackPerinatalCare#BlackBirthsMatter

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Source:

1) Hinton, Perry. “Implicit Stereotypes and the Predictive Brain: Cognition and Culture in ‘Biased’ Person Perception.” Humanities & Social Sciences Communications, vol. 3, no. 17086, 2017. 

2) Roeder, Amy. “America is Failing Its Black Mothers.” Harvard Public Health, Winter 2019. 

3) Vedam, S., Stoll, K., Taiwo, T.K. et al. “The Giving Voice to Mothers Study: Inequity and Mistreatment During Pregnancy and Childbirth in the United States.” Reproductive Health, no. 15, vol. 77,  p. 1-18, 2019.

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If you are Black, Latinx, or Indigenous, you are far more likely to experience implicit stereotyping (aka racism), or cognitive bias, in a medical setting. Patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes can all be affected by a provider’s bias (Hall et al). ⁠

Behaviorally, implicit stereotyping may manifest as mistreatment via “verbal abuse, stigma and discrimination, and delays and refusals in care” (Vedam et al). ⁠

For Serena Williams, Winner of 23 Grand Slam singles titles, mistreatment came in the form of delayed treatment for postpartum complications. When Williams reported experiencing shortness of breath- a symptom she was familiar with; she had previously had a blood clot in her lungs- her nurse suggested she must “be confused” by her pain medication, delaying treatment for multiple blood clots and a hemorrhage in her C-section wound. This is one reason, among many, why entities like Harvard Public Health have declared Black Maternal Mortality in the U.S. a Human Rights Crisis.⁠

Of the 2,7000 birthing individuals who filled out the U.S. Giving Voice to Mothers survey (@birthplacelab), 1 in 6 (17.3%) reported mistreatment by providers. Of those who reported being ill-treated, 8.5% were scolded or shouted at by a provider, 7.8% had providers delay care, 5.5% reported violations of physical privacy, and 4.5% were threatened by the withholding of treatment or given treatment the patient did not consent to (Vedam et al.). Indigenous people experienced mistreatment at the highest rate, closely followed by Hispanic and Black people. ⁠

It is important to note that EVEN THOSE PROVIDERS who “consciously reject stereotypes” and “seek to be fair in their judgment of other people,” still demonstrate bias against people of color, which can emerge as mistreatment (Hall et al; Hinton).⁠

Our health care providers, government, and communities need to address this mistreatment of Black, Latinx, and Indigenous individuals- now!⁠

#healthdisparities #blackmaternalhealth #BIPOC #racism #Latinx #Indigenous

Caption and research by Tyler Jean Dukes (@birthandbooks), supported by her doctoral fellowship.

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Collins, J. W. Jr., Wu, S. Y. and David, R. J. (2002). Differing intergenerational birth weights among the descendants of US-born and foreign-born Whites and African Americans in Illinois. Am J Epidemiol. 155(3), 210‐216.

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This difference in intergenerational birth weights is evidence that it’s the harmful environmental exposure of racism directed towards people with brown or black skin that is to blame for the U.S. disparity in birth outcomes. Black infants in the U.S. are more likely to be low birth weight (<2,500 g) compared to White infants. Researchers have considered many factors such as the birthing person’s age, marital status, income, number of prior births, time between pregnancies, and cigarette smoking, but they have not been able to explain this birth weight disparity.⁠

Researchers in Illinois analyzed birth weight patterns over three generations for US-born and foreign-born White mothers and Black mothers. US-born and foreign-born White mothers had significantly larger babies over time and fewer babies with low birth weight. US-born Black mothers had slightly larger babies over three generations, but the improvement was much smaller than that seen with the White mothers. Foreign-born Black mothers actually had babies with lower birth weights over time.⁠

The researchers previously found that Black infants with foreign-born mothers had birth weights similar to White infants, while Black infants with US-born mothers were at a birth weight disadvantage. These intergenerational birth weight patterns suggest that foreign-born Black parents experience harmful exposures in the U.S. that leads to deterioration in birth weight.⁠

We must preserve the health of foreign-born People of Color and support US-born People of Color in such a way as to counteract the harmful effects of racism!⁠

#BlackDoulasMatter#BlackBirthsMatter #BlackMidwives#BlackMaternalCare#BlackPerinatalCare

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Sharing race (called racial concordance) impacts a number of important outcomes. For example, academic performance is higher when students share race with their teachers, and risk of incarceration is lower when defendants are paired with judges who share their race. Now, researchers are beginning to examine the effect of sharing race on health outcomes, specifically in childbirth, where racial disparities are extremely severe.⁠

Greenwood et al. (2020) analyzed 1.8 million hospital births in Florida between 1992 and 2015 to see if sharing race had an effect on in-hospital newborn mortality. Overall, there was a clear racial disparity in the sample—the mortality rate was 289 per 100,000 births among White newborns and 784 per 100,000 births among Black newborns.⁠

The researchers found that when Black newborns were cared for by White doctors, they experienced 430 more deaths per 100,000 births than White newborns. When they were cared for by Black doctors, the racial disparity was reduced to 173 deaths per 100,000 births above White newborns, a difference of 257 deaths per 100,000 births and a 58% reduction in the racial mortality difference.⁠

So, Black newborns had higher mortality compared to White newborns under the care of both Black doctors and White doctors, but the disparity was halved when there was racial concordance. The mortality rate for White newborns was no different whether they were under the care of White doctors or Black doctors.⁠

These results show that White doctors are under performing when it comes to caring for Black newborns. The main implications are that: 1) health care organizations should immediately invest in efforts to reduce implicit racial/ethnic bias among providers and explore its connection to institutional racism, 2) more research is necessary to identify the differences in physician practice behavior responsible for low- versus high-performance, and 3) initiatives are urgently needed to address the fact that the healthcare workforce in the U.S. is disproportionately white.⁠

#blacknewborns #blackinfantmortality #infantmortality #birthjustice #blackbirthsmatter #racialmortality #implicitbias #institutionalracism

Recommended Resources

Parenting

Birth Justice Organizations

On this page, you can find an ongoing list of both local and national birth justice organizations led by Black, Indigenous, and People of Color. We encourage you to follow and support these organizations in whatever way you can. If you wish to add a local birth justice organization to this list, please use the contact form below.

National

Black Mamas Matter Alliance | Visit

Black Mamas ATX | Visit

National Association to Advance Black Birth | Visit

National Black Midwives Alliance | Visit

National Black Doulas Association™ | Visit

National Birth Equity Collaborative | Visit

Southern Birth Justice Network | Visit

Sister Song | Visit

Black Women Birthing Justice | Visit

By State

California: Diversity Uplifts | Visit

California: For the Village | Visit

California: SisterWeb San Francisco Community Doula Network | Visit

Hawai’i: Birth Professionals of Oahu | Visit

Illinois: Chicago Birthworks Collective | Visit

Illinois: Chicago Volunteer Doulas | Visit

Illinois: HealthConnect One | Visit

Kansas: The Wichita Birth Justice Society  | Visit

Kentucky: Louisville Doula Project | Visit

Louisana: Community Birth Companion | Visit

Louisana: Birthmark Doulas | Visit

Massachusetts: MA COVID-19 Perinatal Coalition | Visit

Michigan: Mothering Justice | Visit

Minnesota: MN Healing Justice Network | Visit

Missouri: Jamaa Birth Village | Visit

Missouri: Uzazi Village | Visit

New York: Ancient Song Doula Services | Visit

New York: Cihuapahtli Matriarch Council | Visit

North Carolina: SistasCaring4Sistas | Visit

Oregon: The Black Parent Intitiative | Visit

Rhode Island: Our Journ3i | Visit

Tennessee: Choices: Memphis Center for Reproductive Health | Visit

Tennessee: Homeland Heart Birth & Wellness Collective | Visit

Texas: Re+Birth Equity Alliance | Visit

Texas: Giving Austin Labor Support | Visit

Texas: The Natural Way Birthing Project ~ Fort Worth | Visit

Texas: Abide Women’s Health Services ~ Dallas | Visit

Virginia: Urban Baby Beginnings| Visit

Washington D.C. Mamatoto Village | Visit

From Rebecca

A Personal Message From Rebecca

Reading the news these days, I continue to be horrified that the country I live in still brutalizes and murders people with Black bodies. My heart goes out to all of you who are suffering and grieving and reliving trauma right now. The fact that these things still happen and are covered up in the year 2020 is an absolute travesty.

Racism in the U.S. doesn’t just take the form of murder. It also significantly impacts maternal health outcomes (leading to 3-4 times higher death rates for Black mothers and babies), as well as creates racial injustices everywhere we live and work and educate our children.

Below are Evidence Based Birth® resources I wanted to share with you, as you continue anti-racism and birth justice work.

– Rebecca

My Responsibility As A White Woman

This is a personal video message about my responsibilities as a white woman. I recorded this message in the days following George Floyd’s murder. You can watch that message in the embedded video below, or on our Instagram Stories Highlights under ‘Responsibilities’ at our Instagram page @ebbirth.

Personal Message from Rebecca – May 2020 from Evidence Based Birth on Vimeo.

Chapter 8: Woke - from Babies Are Not Pizzas

Read Chapter 8 of Rebecca’s book, Babies Are Not Pizzas, which addresses the negative impact of racism on maternity care. This chapter falls in the middle of the book, and so the middle of Rebecca’s journey through becoming awakened to the many systemic and structural issues our healthcare system faces.

Click Here to Read Chapter 8: Woke

The EBB Podcasts, featuring BIPOC guests

Hear stories and experiences from BIPOC guests on the Evidence Based Birth® Podcast.

 

Do you know about a Birth Justice organization or class/resource?

Please complete the form below with your suggested resource. Please put “Suggestion for Birth Justice page” in the message.

You can always email us at info@evidencebasedbirth.com as well!

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