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.
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.
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.
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.
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
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.
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
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.
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
Redgrave, Naida and Alleanna Harris. The Extraordinary Life of Mary Seacole. Puffin. 2019.
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.
Caption and research compiled by Tyler Jean Dukes (@birthandbooks), supported by her doctoral fellowship
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.
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
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.
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.
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.
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
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
Cooper Owens, Diedre. Medical Bondage: Race, Gender, and the Origins of American Gynecology. Athens: University of Georgia Press, 2017.
Chances are, you’ve never heard of Dr. J. Marion Sims, even though you may have had his medical invention- the Sims speculum- inserted into your vagina. Sims is regarded by many as the “Father of Modern Gynecology.” In the 20th and 21st centuries, however, people have labeled Sims a “polarizing figure.” Likely, because of Sims’ “ethically fraught history” and racism, which included perfecting his gynecological surgical procedures on enslaved female bodies without the use of anesthesia.
Between 1845 and 1849, Dr. Sims, an Alabama surgeon, repeatedly operated on enslaved women in order to find a cure for gynecological fistulas. Slave owners saw women with this condition as “unfit” for their “duties required as a servant” and so they were happy to “lease” these women to Sims for his surgical experiments (Cooper Owens).
In the past decade, scholars like @deirdrecooperowens have challenged us to shift the focus away from a discussion of Sims and the illnesses he treated and on to the 3 black women who were both patients and nurses. Their names were Anarcha, Betsy, and Lucy. Dr. Cooper Owens states we should consider these women as the “maternal counterparts” to Sims, or the Mothers of Gynecology.
In the book Medical Bondage: Race, Gender, and the Origins of American Gynecology (2017), Dr. Cooper Owens uncovers Anarcha, Betsy, and Lucy’s roles as Sims’ surgical nurses AND as women who continued to do physical labor on the plantation, care for their children, and serve as experimental subjects. As Dr. Cooper Owens says, Medical Bondage is “not so much about historical recovery as it is about a holistic retrieval of owned women’s lives outside the hospital bed.”
Let’s begin to honor the Mothers of Gynecology. Say their names: Anarcha, Betsy, Lucy
#medicalbondage #lucybetsyanarcha #jmarionsims #gynecology #slavery #sayhername #blacklivesmatter #blackmaternalhealth
Read Dr. Diedre Cooper Owen’s book: Medical Bondage: Race, Gender, and the Origins of American Gynecology. Athens: University of Georgia Press, 2017.
Caption written by Tyler Jean Dukes (@birthandbooks), supported by her doctoral fellowship.
Black Mamas Matter Alliance, Policy Working Group. Advancing Holistic Maternal Care for Black Women through Policy. Atlanta, GA. December 2018.
The term White Paper is used to refer to an official report from an authority, usually describing and proposing a solution to a problem. In a genius reversal of words, the Black Mamas Matter Alliance (@blackmamasmatter) published their first Black Paper in April 2018. In it, they outlined a vision for holistic maternal health care centered on reproductive justice and human rights.
According to the BMMA, holistic care: addresses gaps in care and ensures continuity of care; is affordable and accessible; is confidential, safe and trauma-informed; ensures informed consent; is centered around Black women and Black families; is culturally-informed and includes traditional practices; is culturally competent and congruent; respects spirituality and spiritual health; honors and fosters resilience; includes the voices of all Black Mamas; is responsive to the needs of all genders and family relationships; and provides wraparound services and connections to social services.
The BMMA’s second Black Paper (December 2018) describes policy solutions to help achieve the vision of holistic maternal health care for Black women and families. In brief, the three policy priorities that they identified are to 1) “Identify and ensure mechanisms for engagement and prioritization of Black women and Black-women led entities in policy and program development and implementation,” 2) “Establish equitable systems of care to address racism, obstetric violence, neglect, and abuse”, and 3) “Expand and protect meaningful access to quality, affordable, and comprehensive health care coverage, which includes the full spectrum of reproductive and maternal health care services for Black women.”
For full details, we encourage you to read both of the BMMA Black papers on their website. We also encourage you to donate and learn more at blackmamasmatter.org.
Boyd, R. W., Lindo, E., G., Weeks, L. D., et al. (2020). “On Racism: A New Standard For Publishing On Racial Health Inequities, ” Health Affairs Blog, July 2, 2020.
An article published on the Health Affairs Blog in July called for a new standard for research on racial health inequities.
The authors wrote that “despite racism’s alarming impact on health and the wealth of scholarship that outlines its ill effects, preeminent scholars and the journals that publish them, including Health Affairs, routinely fail to interrogate racism as a critical driver of racial health inequities.”
This new, higher standard calls for researchers to define race within a sociopolitical framework (not a biological one) and specify why race is an important variable to include in the study. Authors should explicitly name racism, as well as identify its form, the mechanism by which it may be operating, and other intersecting forms of oppression that may worsen its effects.
It is important for authors to avoid listing race as a risk factor. Racism, not race, causes health disparities. When researchers acknowledge this in their work, then interventions to address racism can be appropriately viewed as health interventions.
Researchers should not try to explain racial differences in health outcomes by stating that there may be unmeasured genetic or biological factors. There is no scientific evidence that the social construct of “races” represents distinct genetic identities.
Other recommendations for researchers were that they should get community input to make sure their research priorities reflect those of the community being studied. Authors should discuss the broader implications of their research for public policy and clinical practice. Finally, researchers should cite the experts, especially scholars of color who are experts on racism as the driver of racial health inequities.
Read the full article by Rhea W. Boyd, Edwin G. Lindo, Lachelle D. Weeks, and Monica R. McLemore here.
Changing Woman Initiative (2020). A Native American Centered Women’s Health Collective 501(c)(3) Non-Profit Organization. http://www.changingwomaninitiative.com/
The Changing Woman Initiative (CWI), a 501(c)(3) organization in New Mexico founded by Native American midwife Nicolle Gonzales, is working to ensure access to decolonized, traditional maternity care options for Native American women.
One of their projects is to create the nation’s first Indigenously focused birth center on tribal lands. At this dreamed birth center, mothers would be able to have a ceremony with Indigenous midwives, eat traditional foods during labor that give strength, use plant medicines, and move about freely in a space designed to feel sacred, calm, and safe. There would be tubs, showers, fireplaces, and ample space for supporting family members.
The building itself incorporates elements of the natural landscape in the design and utilizes natural light, solar power, and water preservation— in keeping with traditional values about people’s connection to the land.
“We want our building to be a living embodiment of wellness and healing.”
In contrast, labor and delivery units in the Western medical health care system often impose strict hospital protocols forbidding food, as well as restricting mobility during labor, dictating positioning during birth, and limiting the number of visitors.
In addition to planning the birth center, the CWI also offers homebirth services and an easy access clinic that serves Indigenous women regardless of their ability to pay.
There are high rates of chronic health conditions, such as diabetes, in Native communities. Colonialism and its destruction of food systems have cut Native people off from their traditional lifestyle and diet, and this has led to food-based diseases. To address this, the CWI partners with local Indigenous farmers to develop food baskets for prenatal and postpartum families.
The visionary leader of this organization is telling us ways to help heal Native families and future generations. We must listen and act now to support their Mission!
Jamaa Birth Village (2020). A 501(c)(3) Non-Profit Maternal Health Organization. https://jamaabirthvillage.org/
At Jamaa Birth Village 501(c)(3) in Missouri, people of color are empowered with education, respect, and holistic midwifery care with skilled doula support.
Brittany “Tru” Kellman, Founder and Executive Director of Jamaa Birth Village, created Jamaa through a vision received while in Africa, standing at the same seaside where her ancestors were forcibly captured, torn from their loved ones, and brought to the Americas in horrific, inhumane conditions. In that vision she understood that her work was to bring traditional, holistic, African-centered midwifery care back to St. Louis. In order to combat U.S. racial and health inequities, she would work to restore and reclaim the traditional ways of caring for birthing families.
Tru experienced obstetrical abuse giving birth as a teen mom in St. Louis. She was mistreated, ignored and left feeling disempowered. She knew she deserved better care than she received. At Jamaa (which means “family” in Swahili), clients are treated the way you would want your family member treated.
Clients are supported with a variety of services including comprehensive prenatal and postpartum visits with a midwife; individualized birth doula support; individualized childbirth and nutrition classes; massage and chiropractic care; newborn feeding support; and access to mental health services, herbal medicines, and even baskets of fresh organic produce.
In a celebration of cultural heritage, Jamaa created an Apothecary that is accessible and affordable to everyone. Holistic body workers provide relief from the toxic stress we know can impact pregnancy outcomes.
In 2019, Tru became Missouri’s first Black certified professional midwife (CPM), in order to serve families in the provider role. Jamaa has supported over 400 families since June of 2016 and trained over 90 doulas of color since 2016. When they first started this work there were only five practicing doulas of color in the St. Louis region.
I encourage you to support Jamaa Birth Village’s work and learn more from Tru herself by listening to our recent conversation on EBB Podcast Episode 148!
*The image attached above is a slideshow.*
Imagine you had a Cesarean with your first child. Pregnant with your second, you want a VBAC (Vaginal Birth After Cesarean). You are 33 years old and in the “normal” range for BMI. According to the VBAC Calculator endorsed by the National Institute of Child Health and Human Development, this means you are a favorable candidate for a VBAC.
BUT did you know that the VBAC calculators used by most U.S. physicians are racist? As the slideshow demonstrates, the white woman in scenario 1 is told they have a 72.5% VBAC success rate. But if you are Black, your rate is decreased to 57.4%.
In Scenario 2, the OB discourages you from having a VBAC. They cite racist beliefs in differences in “pelvic architecture” (Darshali et al) or pelvic connective tissue (Cahill et al). If you decide to attempt a VBAC anyways, the OB may treat you differently based on your lower score. That’s because being labeled with a high or low probability of VBAC can be a self-fulfilling prophecy if it leads to changes in how the care provider manages labor (to be more or less supportive of VBAC).
A scenario like this is not uncommon for Black parents desiring a VBAC, a practice proven to provide maternal health benefits. It’s time for clinicians to understand that VBAC calculators are racist. First, the algorithm implicitly accepts racial categories as “natural” rather than as “historically and socially constructed” (Darshali et al). Second, it’s racism, not race, that makes it harder for Black parents to have a VBAC (Darshali et al)–not anatomical differences.
We must reduce inequities in maternal health by addressing the racism in health care and education, rather than relying on a “calculator.”
Note: The MFMU Network (sponsored by the National Institute of Child. Health and Human Development) posted a note stating that “A new calculator without race and ethnicity is under development.” Although it’s encouraging that they plan to replace the calculator, we will never know how many Black families were harmed by this calculator.
Caption and research by Tyler Jean Dukes (@birthandbooks), supported by her doctor
Smith, W. A., Yosso, T. & Solorzano, D. (2006). Challenging Racial Battle Fatigue on Historically White Campuses: A Critical Race Examination of Race-related Stress. In book: Faculty of Color Teaching in Predominantly White Colleges and Universities.
There is a real phenomenon taking place that is harming the mental and physical health of Black people on a daily basis. Dr. William Smith, a professor and researcher at the University of Utah, coined the term “Racial Battle Fatigue” in the early 2000’s to describe what is happening.
Dr. Smith’s research focuses on his concept of Racial Battle Fatigue as an interdisciplinary theoretical framework that is useful for understanding the race-related experiences that contribute to disproportionate levels of stress among Black people. The term does not mean that Black civilians’ race-related experiences are the same as soldiers’ experiences in battle, but it draws a parallel between the battlefield and chronically hostile white spaces. Constant stressors in the form of racial microaggressions are taxing on Black people. Racial microaggressions are subtle verbal and non-verbal racial insults directed at People of Color by White people, often automatically or unconsciously. The stress from this onslaught of indignities causes a mental, emotional, and physical burden (i.e. Racial Battle Fatigue) that takes a toll on health and wellbeing.
This groundbreaking area of research is inextricably linked with the field of maternal and child health because the framework explains how racism impacts racial health inequities. For example, elevated blood pressure is one of the psychophysiological symptoms of Racial Battle Fatigue, and studies have shown clear racial disparities in risk of serious illness and death from preeclampsia and other hypertensive disorders of pregnancy.
The Atlanta Black Star published an excellent article on the topic of Racial Battle Fatigue in 2016. They wrote, “White America tells Black people to get over the past, while Black people are suffering from the trauma of past and present racial oppression, and are tired of engaging in debates over racism, and justifying or explaining their experiences.”
It’s time to acknowledge that the past and present trauma is real and the fundamental factor that underlies our shameful racial health inequities is racism.
In last week’s anti-racism post, our research editor was looking up the research on the harmful effects of micro-aggressions, and she found an excellent handout from Hopkins, with specific examples of what micro-aggressions look and sound like.
This is Rebecca speaking— the founder of Evidence Based Birth. I made a commitment this year to do everything I can to educate fellow white birth professionals and health care professionals about racism. This includes educating white folks about specific things we need to STOP doing, and START doing instead. (If you aren’t familiar with the effects that racism has on maternal and newborn outcomes, just scroll through our feed and look through the black tiles. Also, check out our comments policy at ebbirth.com/comments … we have a zero tolerance policy for comments denying the existence of racism).
In today’s anti-racism post, I implore you to educate yourself about micro-aggressions. This was not something that was taught to me in school, college (nursing school), or graduate school. I had to learn about it myself. Once I learned what micro-aggressions looked and sounded like, I could check myself and make sure I was no longer complicit in using them.
Listen up, fellow white folks. We have GOT to STOP participating in creating constant micro-traumas for our Black friends, family, colleagues, students, and clients. Racial weathering is real. And it’s caused by people like me, who sometimes aren’t even aware of what we’re doing. Read the handout from Johns Hopkins [Link in bio]— it has VERY specific examples and it’s quite thorough. The handout should be required training for every hospital, academic center, and workplace! Read it today!
Educate yourself. When you know better, you do better!
Kendi, I. X. and Reynolds, J. (2020). Stamped: Racism, Antiracism, and You. Little, Brown Books for Young Readers; 1st edition (March 10, 2020).
There is a new book out this year on racism and anti-racism that’s being hailed as essential reading for young people ages 12 and up. Stamped: Racism, Antiracism, and You by Jason Reynolds and Ibram X. Kendi is a remix of Dr. Kendi’s National Book Award-winning Stamped from the Beginning (2016).
The narrative is fast-paced and conversational, with large font and intentional breaks in the text (“Pause,” “Let’s all just take a deep breath”) that make it very accessible. The text discusses influential figures and events that propagated racist ideas from the 1400’s to present day, all the while reminding the reader “this is not a history book.” Dr. Kendi describes a racist idea as “any idea that suggests something is wrong or right, superior or inferior, better or worse about a racial group. Whereas an anti-racist idea is “any idea that suggests that racial groups are equals.”
Educating people (young and old) about the history of racist ideas has everything to do with U.S. maternity care. Our racial health inequities are shameful and we know that racism is to blame—not Black parents and babies. Seeking out resources such as Stamped (2020), its 2016 predecessor, and further reading is powerful because the information can help transform maternity care by illuminating racist ideas in daily life. As Jason Reynolds writes in the book, “We can’t attack a thing we don’t know.”
Carter, S. E., Ong, M. L., Simons, R. L., et al. (2019). The effect of early discrimination on accelerated aging among African Americans. Health Psychology, 38(11), 1010–1013.
The Family and Community Health Study (FACHS) is the largest study of Black families in the U.S., involving over 800 participating families. The study was established in 1996 at Iowa State University and the University of Georgia and is funded by the National Institutes of Health (NIH). It is a longitudinal investigation of the effect of various factors, including racial discrimination, on Black parents and their children. When the study began in 1996, every participating family contained a 5th grader. Those 5th graders are now adults in their early 30’s!
In the ongoing study, researchers have collected data from the participants every two to three years, including self-reported questionnaires on the experiences of racial discrimination (i.e. racially based slurs, insults, and physical threats) and depressive symptoms. In 2015, the researchers also started taking blood samples to assess biomarkers that predict diseases such as heart disease and diabetes, and to examine signs of aging on a cellular level. Over 200 papers have been published using data from the FACHS.
A 2019 study by Carter et al. included a subset of data from the FACHS. They found evidence that early life stress due to racial discrimination leads to depressive symptoms and increased risk for accelerated aging. Their findings build on previous research demonstrating a link between experiences of racial discrimination and accelerated aging.
Next, the FACHS research team plans to explore the role of resiliency and early life interventions that could possibly help to protect against the harmful effects of racism. You can read a research brief on this topic here at The Conversation.
Racism. Where do you fall? www.racismscale.weebly.com.
The Racism Scale was created to help white people identify their racial bias towards People of Color along a graduated scale. At one end of the scale is “Terrorism” and at the other end is “Abolitionist.” In between, there are 11 other positions including “Subconscious racism,” “Defensive,” “Denial,” White Savior,” and “Performative Ally.” The creator notes, “It is common for many people to move back & forth along the scale regularly, especially the middle parts.”
The scale has been shared over 10k times and referenced in several articles. It has been updated and expanded five times since its creation. You can visit the webpage to see the progression of the scale from creation to its current version and to ask questions or suggest additions. Anyone is invited to use the graphic for non-profit social justice work (credit www.racismscale.weebly.com). For-profit enterprises that wish to use the scale may contact the creator.
The Racism Scale is a volunteer project! Consider donating to support this valuable initiative.
Dr. Kendi (author, professor, historian) teaches that there is no such thing as “not racist.” People in the U.S. grow up with constant exposure to racist ideas and racist policies that we learn to view as normal; we can’t just wake up one day and change all that. However, we can (and must!) commit to being antiracist, which means challenging racist ideas and racist policies on a daily basis.
“The heartbeat of racism is denial, is consistently saying, “I am not racist,” while the heartbeat of antiracism is confession, self-reflection, and seeking to grow change.”- Dr. Ibram X. Kendi, from The Millions Interview.
University of California, San Francisco (UCSF). SACRED Birth during COVID-19. https://sacredbirth.ucsf.edu/
The SACRED Birth Study is collecting information about Black patient experiences in U.S. hospital settings during labor, birth, and postpartum. The study focuses on six key areas identified from 2019 community-based focus groups: Safety, Autonomy, Communication, Racism, Empathy, and Dignity.
The goal of the study is to test a new survey called the Patient-Reported Experience Measure of OBstetric racism, also known as the PREM-OB Scale. This scale will provide valuable information to hospitals, researchers, and the public on how racism affects maternity care in the hospital setting.
Black women scholars worked with Black birthing individuals/parents and partners in the Black birthing community to design both the SACRED Birth Study and the PREM-OB Scale. By Spring 2021, the SACRED Birth Study team plans to create and share a validated PREM-OB Scale, a hospital-based quality initiative toolkit, and a summary report on obstetric racism during COVID-19. But first, they need 1,000 participants to test the PREM-OB scale!
You may be eligible to join the study if… you identify as Black or African American, are 18 years of age or older, and gave birth to a live newborn at a U.S. hospital in 2020. Participants will receive a $100 electronic gift card as compensation for completing a one-time online survey that takes 1-2 hours (after completing the online self-screening, informed consent, contact form, and enrollment survey). According to the researchers, “Some of the survey questions may make you feel uncomfortable or raise unpleasant memories. You are free to skip any question. You are also encouraged to take breaks if needed.”
Healthcare centers are needed to refer patients to the SACRED Birth Study! The researchers are especially focusing on California and Memphis, TN.
There is a tremendous need for research on obstetric racism to guide quality improvement initiatives that will save lives. Please share this study far and wide!
Tema Okun (building on the work of many people)
“White supremacy culture is the idea (ideology) that white people and the ideas, thoughts, beliefs, and actions of white people are superior to People of Color and their ideas, thoughts, beliefs, and actions.”
This ideology can show up in any group or organization because we are all influenced by the larger society in which we live. It can be difficult to identify white supremacy culture in our organizations because, although it is widely encountered, it is omnipresent almost to the point of invisibility. Tema Okun (author, activist, facilitator) put together a list of white supremacy characteristics and their antidotes. The list of characteristics includes:
• A sense of urgency
• Valuing quantity over quality
• Worship of the written word
• Belief in only one right way
• Either/or thinking
• Power hoarding
• Fear of open conflict
• Belief that I’m the only one (who can do this ‘right’)
• The belief that progress is bigger and more
• A belief in objectivity
• Claiming a right to comfort
Instead of falling into the destructive patterns above, organizations are urged to develop a culture of appreciation, where it is expected that everyone will make mistakes and those mistakes offer opportunities for learning.
Teamwork holds more value than individualism and the desire for individual recognition and credit. It is worth taking the time to encourage democratic decision-making that is thoughtful and inclusive.
Measurable goals are not all that matters; there is value in quality and process, and more than one way to reach the same goal. Relatedly, progress toward success does not always mean more growth.
More energy should be spent on taking steps to eliminate racism than defending against charges of racism. To counteract white supremacy culture, it has to be acceptable for people to raise hard issues, even when they make others uncomfortable. In fact, welcome these opportunities! “Discomfort is at the root of all growth and learning.”
For more details about these characteristics and their antidotes, click here.
*The image attached above is a slideshow.*
Vedam, S., Stoll, K., MacDorman, M., et al. (2018). Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. PLoS One. 2018 Feb 21;13(2):e0192523. Click here. Free full text!
A very important study called the “Access and Integration Maternity Care Mapping (AIMM) Study” was published in 2018 by a multidisciplinary team of experts (*trigger warning: infant mortality*). The point of the study was to find out if integrating midwives into the maternity care system changes health outcomes. They were looking at integration of all types of certified midwives (CNMs, CMs, CPMs). All of these midwives follow the Midwives Model of Care™- a holistic, client-centered model of care that has demonstrated excellent outcomes in every birth setting.
The research team developed the Midwifery Integration Scoring System (MISS), which scored each state on criteria such as whether the laws and regulations support or limit midwifery, the ability for midwives to prescribe medicine, access to insurance coverage, and the ability to make smooth transfers to advanced medical care when needed.
For the first time, this research established that states with higher midwifery integration scores (MISS scores) were associated with improved outcomes for birthing parents and babies, even when taking into account the impact of race. Increased access to midwifery care was linked to increased breastfeeding/chestfeeding, reduced medical interventions, increased VBAC, and lower newborn death—including race-specific newborn death.
The research team found that in states where more Black babies were born, integration of midwives was lower compared to states where fewer Black babies were born. Access to midwives and density of midwives were also significantly lower in states where more Black babies were born. The states with the most Black births reported the highest rates of newborn death. However, they found that New York State has a high density of Black births but one of the lowest rates of newborn death in the U.S., and it has a MISS score in the top 25%. North Carolina, Alabama, and Mississippi have a high percentage of Black births, high rates of newborn death, and very low MISS scores. This evidence strongly suggests that integration of midwives could help reduce racial health disparities.
You can learn about your state’s score at BirthPlaceLab.org and explore the maps at https://www.birthplacelab.org/maps/.
Julian, Z., Robles, D., Whetstone, S., et al. (2020). Community-informed models of perinatal and reproductive health services provision: A justice-centered paradigm toward equity among Black birthing communities. Semin Perinatol. 2020 Aug;44(5):151267. Click here.
A recent publication identified and compared two different perinatal and reproductive health care models: physician-centered models and community-informed models.
Physician-centered models, the authors explain, focus on individual level risk factors for poor health outcomes and prioritize individual behavioral interventions. They rarely address structural racism as a root cause of inequity among Black birthing communities. Provider types working within the physician-centered care model can include MDs, NPs, CNMs, and RNs. Care is provided in clinics and hospitals; professional training is institutionalized and narrowly focused (i.e., medicine, nursing); and the power structure is hierarchal.
On the other hand, community-informed models focus on larger systems of inequity from a framework rooted in reproductive justice. Instead of assuming that poor health outcomes are due to individual physiology and individual behavior (i.e. “Mother Blame” narratives), community-informed models understand that differences in power create different opportunities for health. Providers practicing within community-informed care models can include CNMs, CPMs, LMs, NPs, RNs, and MDs. Care is provided in homes, birth centers, clinics, and hospitals; professional training is multidisciplinary, experiential, and institutionalized; and providers work in collaborative partnership with the community they serve.
The authors recommend that the OBGYN workforce move toward community-informed models through racial workforce diversification, reckoning with the professional legacy of racism in medical education, and innovation in interprofessional education and collaboration. For example, interprofessional training should be broadened to include Black and Indigenous midwives in community settings, as well as opportunities to learn from professionals in public health, bioethics, humanities, and social sciences.
Read the full article by Zoë Julian and colleagues to learn more.
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.
Black Mamas Matter Alliance | Visit
Black Mamas ATX | Visit
Melanated Midwives | 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
Arizona: Parteras de Maiz | Visit
Hawai’i: Birth Professionals of Oahu | Visit
Kansas: The Wichita Birth Justice Society | Visit
Kentucky: Louisville Doula Project | Visit
Georgia: JMM Health Solutions | Visit
Massachusetts: MA COVID-19 Perinatal Coalition | Visit
Minnesota: MN Healing Justice Network | Visit
Nevada: More Black Midwives | Visit
Ohio: Birthing Beautiful Communities | Visit
Rhode Island: Our Journ3i | Visit
Virginia: Urban Baby Beginnings| Visit
Washington D.C. Mamatoto Village | Visit
Webinars & Online Courses
- Dr. Traci Baxley at Social Justice Parenting: @socialjusticeparenting on Instagram
- Podcast interview with Dr. Traci Baxley on the Melanated Conversations podcast
- Prism Behavior podcast, Episodes 55 and 56, click here
- The Center for Racial Justice and Education has compiled a list of resources for talking with kids about race, racism, and racialized violence (includes many resources designed for kids of color)
- PBS has a comprehensive list of resources for parents talking with young children about racism
- NY Times list of books for children
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.
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.
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.
The EBB Podcasts, featuring BIPOC guests
Hear stories and experiences from BIPOC guests on the Evidence Based Birth® Podcast.
- EBB 138 – Healing after a Traumatic Birth with Bianca Marie Roberson
- EBB 136 – Solutions for the Crisis in American Maternity Care with Jennie Joseph
- EBB 135 – The Need for More Indigenous Birth Workers with Miranda Kelly
- EBB 132 – Teen Pregnancy Support, and a Surrogacy Story with Ambrosia Meikle
- EBB 130 – Home Birth in the Black Community with Isis Rose
- EBB 126 – Finding the right provider, and birth in the Dominican Republic with Leiko Hidaka
- EBB 124 – Health disparities, Advocacy, and the Coronavirus with Sabia Wade
- EBB 112 – How Evidence Based Birth®️ Changed Me as a Nurse with Jessica Hazboun
- EBB 108 – EBB Conference Series: Birth Workers of Color
- EBB 105 – Perspectives on the Evidence Based Birth Conference with Heather Thompson and Dr. Sayida Peprah
- EBB 103 – Identifying Areas for Social Justice with Danielle Jackson
- EBB 100 – Community Specific Birth Support with Ngozi Tibbs
- EBB 98 – Inside a Husband/Wife Childbirth Team with Tia and Dr. Wale Ajao
- EBB 95 – The State of Birth Work in NYC with Denise Bolds
- EBB 92 – Impacts of the Community Birth Worker Model with Aza Nedhari
- EBB 85 – The power of a well-planned birth – of twins!
- EBB 79 – Life of a Doula Part 1 – from cesarean to VBAC with Chanté Perryman
- EBB 74 – Hearing Black Moms’ Voices in the Birth World with Michelle Gabriel-Caldwell
- EBB 73 – Learn all about the hospitalist role with Dr. Nicole Rankins
- EBB 66 – Empowering Birth in Underserved Populations with CNM Olivia Favela-Gary
- EBB 65 – Navigating the Hospital Birth System with Midwife Afua Hassan
- EBB 57 – Connecting the birth community in Hawai’i with Courtney Carangian
- EBB 56 – Listening to Black Midwives: Ms. Charlotte Shilo-Goudeau
- EBB 53 – Reaching Underserved Populations with Education and Doula Support
- EBB 52 – What role should men play in birth?