Note: Why do we capitalize White? As Kairis Chiaji, VBAC Facts® cultural sensitivity editor and consultant, shared here: “I made the judgment call to capitalize ‘White’ in this instance in congruence with procedure in writing Assembly and Senate bills that are tasked with making the distinction. It is a reference to a specific people group, not color and certainly not supremacy of that group. We would capitalize Black, African American, or Chinese, or Spanish the same way. Nuance is as necessary as it is complicated.”
<SLIDE: Ground Rounds slide> Welcome to the June 2020 Grand Rounds. I’m Jen Kamel, VBAC Facts® Founder. Thank you for joining us for “Understanding Systemic Racism in Maternity Care: The Voices of Black Researchers.” I’d love to get an idea of who is joining us live. What kind of perinatal professional are you and where are you joining us from? Normally, our grand rounds consist of recently published research relevant to perinatal professionals who believe in increasing access to vaginal birth after cesarean. But this month, we are diving deeper into the research on racial disparities and racism in healthcare.
<SLIDE: Black Lives Matter> These past weeks have brought us images of brutal police killings and rightful anger and protest into all of our awareness. The pictures and events put systemic racism directly in our faces, on the streets, in the news. Those of us who are White have the privilege to live without constant fear for our or our babies’ lives. However, the deaths of Black folks due to systemic racism only make the news when it shocks those of us with privilege. What is real is that Black individuals in our country die all the time due to systemic racism, and racism within healthcare is one huge reason for these unneeded deaths.
<SLIDE: Black Maternal and Infant Mortality and Morbidity> In research circles, even in obstetric and midwifery circles, it is well known (Backes, 2020) that Black women in the US are 2-3 times more likely to die during or just after pregnancy. Black infants are 3-4 times more likely to die than their White counterparts, twice as likely to be born too small, and three times more likely to be born prematurely. This disparity holds even when controlling for income, health insurance, pre-existing conditions, and pregnancy risk factors. Abundant large scale studies show that racism is killing Black mothers and babies. We need to do better.
<SLIDE: Abundant Research> How do we start looking at racial disparities in maternal mortality, and in pregnancy and birth care? Just looking at research published this year is overwhelming. Do we talk about how the chronic stress of being Black changes pregnancy outcomes (Kim, 2020a) or how that stress changes the very gene expression of Black folks (Leimert, 2020; Riggan, 2020)? Do we talk about the fact that Black pregnant women are more likely to get poor sleep (Feinstein, 2020)? Do we discuss the high rates of incarceration of Black pregnant women and what that does to pregnancy outcomes (Jahn, 2020)? Or how where a person lives, primarily determined by generational wealth, affects their risk of premature birth (Janevic, 2020; Kim, 2020b; Shrimali, 2020)? Or that only one-half of Black women in the US have health insurance for their pregnancy, birth, and postpartum time (Daw, 2020). Sometimes, wealth does not matter, and a Black woman will still have poor pregnancy outcomes (Johnson, 2020; Gupta, 2020). Do we talk about implicit bias in healthcare? Where do we even start?
<SLIDE: Time to Listen to Black Women> This month at VBAC Facts® grand rounds, we bring you a few articles that are meant to lift the voices of Black researchers and Black mothers. The first is a dissertation by Lucinda Canty that brings us the voices of Black women who nearly died during pregnancy, birth, or postpartum highlighting their resilience . We then look at how mother blame covers the systemic and structural racism behind health disparities in an article by Karen Scott. Later, Monica McLemore and Shafia Monroe offer researchers and providers long term and immediate solutions to disparities. Finally, we hear Ifeyinwa Asiodu’s voice criticizing the high levels of unnecessary cesareans in the US.
<SLIDE: Listen more, Do more> We cannot pretend that this information is new. For the past 100 years, researchers and the American government have known that being Black puts women and children at risk (see Tandy, 1940). How about we stop talking about Black women and their babies and start listening? We are not listening well to the people harmed by systemic racism. Look more at writings of these and other Black researchers and make it part of your work to become an accomplice within your healthcare practice. At the end of this presentation, we offer a few suggested resources and readings that you can start with. If you look, you will have no trouble finding the voices of Black folks in research and in the community. Let’s jump in.
<SLIDE: Lucinda Canty, RN, MSN, C.N.M.> Lucinda Canty is a midwife, teacher and researcher in Connecticut. Read her professional biography, listen to a radio interview with her discussing the importance of doulas, and look at her beautiful artwork illustrating the experience of being Black and pregnant in the US. See below this lecture for links. If you are attending live, I’ll email you the links. Canty’s dissertation, published this year, is titled “It’s Not Always Rainbows and Unicorns: The Lived Experience of Severe Maternal Morbidity among Black Women“. Covering dissertations is not the norm at VBAC Facts®, but we just could not wait for the published articles to come out of this research. Canty used her PhD work to ask Black women about their experiences with severe maternal morbidity or near miss potentially fatal pregnancy-related complications.
<SLIDE: Historical Facts > Canty starts her dissertation by offering a narrative of the social history of maternal morbidity disparities going back to the 1930s discussing the range of many experiences including segregation, the criminalization of Black midwives, and economic disparities that have prevented Black women from obtaining health care.
<SLIDE: Current Events> She summarizes the current social context of being Black and pregnant in the US and the research that shows up that 60% of the Black women death and severe illness from things like heart attacks, sepsis, hemorrhage, high blood pressure, renal disease, DIC, eclampsia are preventable. You might note that the pictures I’m showing of Black women here are joyous ones. Because while what we are hearing is the reality, Black women are resilient, thrive, and lead joyful lives.
<SLIDE: Sepsis then and now> It is worth noting that sepsis was a leading cause of death for Black women in the 1930s and remains a leading cause of death for Black women today and that despite all of the research trying to puzzle out why being Black is an independent risk factor, we still know very little about why. but researchers assume it is a combination of social and economic risk factors. This is a nice way of saying, these disparities are probably due to systematic and structural racism.
<SLIDE: Listening to Black Women Who Nearly Die> Canty decided to focus her research on healthcare disparities and found that most of the studies were by epidemiologists working with numbers and that the voices of the Black women experiencing these disparities were missing. She decided to go to the Black women directly and ask them what it was like to be one of the many making up the statistical near misses. She interviewed nine Black women who have experienced conditions that are the top causes of death – pregnancy-induced hypertension, sepsis, obstetrical hemorrhage, cardiovascular disease, cardiomyopathy or postpartum hemorrhage. Most of the women were low risk by obstetrical standards, and most accessed prenatal care early and often. They varied in age and education levels. Here are the themes Canty found and some of the participants’ words.
<SLIDE: Knowledge.> The first thing Canty noticed was that most of the participants were not offered enough knowledge of potential or actual complications from their care providers. These “knowledge deficits” meant that many of the Black women interviewed did not recognize or respond to dangerous symptoms. The exception to this was the 29% who’s providers did entrust them with knowledge about their bodies. These Black women were able to quickly respond and advocate for their care, and their experiences of complications had fewer lasting effects on their physical and emotional health and well being.
<SLIDE: Experience with HCPs > One third of the participants reported they had NO positive experience with any health care provider during their complicated births and postpartum and another third had mixed experiences. Many participants felt as if they were just part of a routine and not an important individual having a baby or an emergent experience. They felt their providers lacked empathy and compassion. They felt dismissed, difficult, and unimportant. As one participant said, “I felt like, you know, the care is routine. You come and you have the baby? We do our part. You do your part, you go home. It wasn’t very personal.”
<SLIDE: I loved my provider> On the other hand, the one third of women who felt “safe and well cared for” described relationships with healthcare providers that emphasized knowledge, teamwork, close monitoring of physical and emotional concerns. These participants had providers that knew their lives, respected their choices, and listened to the wisdom the women brought about their bodies.
<SLIDE: Race Matters > Canty found that the lived body experiences of the participants, of being Black, was central to how they viewed themselves, how they perceived they were or would be treated and what care they received. They felt that providers stereotype them as uninsured or state insured, singles, or too dramatic. Some providers perceived the women as only looking for free programs or as lacking enough intelligence to understand what was happening.
<SLIDE: Heart transplant> As one participant said, “I knew a heart transplant would not have happened for me. I felt like that because I am Black. I would not have been a priority.”
<SLIDE: Mental Health and Well Being> Canty tells the stories of the participants’ resilience and recovery, and also of their pain. All of the participants said that their life threatening complications resulted in negative effects on their emotional and mental health. Several used the word traumatic to describe their experiences and several were diagnosed with depression and anxiety.
<SLIDE: CS Without anesthesia> As one participant who had a cesarean without anesthesia said, “It was very horrific. I literally, I think screamed, cried and yelled during that entire procedure.” These experiences of lasting mental health effects were months to years after their physical healing was complete. The experiences of the complication, the birth itself, or the way they were treated by health care providers were all sources of trauma and loss that were still causing pain in the present.
<SLIDE: Read the Dissertation> This short summary does not do Canty’s dissertation justice. In it she discusses things such as the lived experience of being Black in a racist world, of the history of racist medical maltreatment in the US, and of the great resilience that comes from generations of trauma. The dissertation is freely available to read and you can find the link to it at the end of this presentation. And we bet there is more coming from this researcher.
<SLIDE: Karen A. Scott, MPH, MD, FACOG> Karen Scott is an OBGyn and researcher at UCSF. Well, really she calls herself a “dissident, disruptive, and recovering” board certified OB GYN and she often speaks up against injustice in obstetric circles. She is currently running a research project, The SACRED Birth Study, which looks to support community led change to find equitable quality improvements to end violence and gendered racism in hospitals. There is a lot of talk right now about the vast differences between overt and systemic racism. In this 2019 article, Scott discusses how the individual blame of Black women covers the systematic racism that is the actual cause of health disparities for Black mothers.
<SLIDE: Health Disparities> We have a lot of available research that shows health disparities between Black and White mothers. Remember in the intro we discussed the children’s bureau data from the 1930s that shows poorer health outcomes for Black versus White mothers. Scott defines health disparities as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.”
<SLIDE: “Mother blame”> She points out that the large majority of research uses individually-focused reasons for disparities. She calls this practice “mother blame,” because the researchers focus on individual health issues as the reasons for poor outcomes. Things like diabetes, hypertension, and preterm-birth are thought of as things that are created by individual Black mother’s decisions.
<SLIDE: Social Determinants of Health> However, most things that cause health disparities do not stem from individual decisions but from what is called social determinants. “Social determinants of health are the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” These are things beyond the individual’s control. Research in the past two decades has begun to focus more on these social determinants of health, and on the effects of mistreatment, racism, discrimination, stress, and poverty have on Black women’s pregnancy outcomes.
<SLIDE: Health inequities> “Health inequities are avoidable inequalities in health between groups of people within countries and between countries. These inequities arise from inequalities within and between societies.” Social determinants of health are what are largely to blame for health inequities which are in turn largely to blame for health disparities which is what leads to poorer outcomes..
<SLIDE: Where to Focus> This figure represents the multitude of factors that influence outcomes for Black mothers and babies. The mother blame narrative focuses only on the center, on what the mother personally brings to the pregnancy, such as her age, and on lifestyle. The outer rings have just as great, if not greater, impact. Perhaps healthcare providers focus on the individual because it is easier than looking at the root causes of health disparities, things like differences in the availability of food or the social belief systems in which the Black woman experiences pregnancy. Scott uses this article to demonstrate concrete ways providers can and must shift away from the mother blame narrative and work to dismantle the systemic racism that creates health inequity.
<SLIDE: Mother Blame> “Mother blame has been defined as holding pregnant women exclusively responsible for the ill health of children.” Scott discusses the origins of mother blame including epigenetics, public health and development origins theories. These approaches often seek to study and change individual behaviors, focus on individual health risks of Black women, such as being generally heavier and older and have more illness, and ignore the systemic factors that contribute to these different risk factors. Scott uses four health conditions that disproportionately affect Black women and looks beyond mother blame at what might be behind the elevated risk of health concerns.
<SLIDE: Pregestational and Gestational Diabetes> The first two conditions that Scott examines are pregestational and gestational diabetes. She notes that Black women are far more likely to have elevated blood sugar levels before getting pregnant and more likely to develop gestational diabetes than their White counterparts. Yet, Black women are less likely to get quality care for their preexisting diabetes. So for a disease that affects Black women more often, they will get less care. Having uncontrolled blood sugars in pregnancy leads to a whole list of other complications.
<SLIDE: Hypertension> When someone has diabetes and hypertension together, risks increase greatly especially for things like preterm birth. Pregnancy hypertension rates double among Black mothers who have pregestational diabetes and hypertension is more common for Black folks to begin with. Hypertension leads to pregnancy risks such as preterm birth, preeclampsia, and fetal growth restriction. The risk of preterm birth rises with chronic hypertension regardless of race, but risks rise much more for Black women. Researchers are beginning to understand that social determinants of health affect the Black woman’s body in a way that places them at higher risk than White women. Things like poor blood sugar control result from lack of access to quality food and diabetes education. Chronic inflammation results from chronic stress of racism. Both high blood sugars and high levels of inflammation lead to higher rates of diabetes and hypertension.
<SLIDE: Looking Upstream> In order to acknowledge and address health disparities, providers have to strategize ways to address the upstream structural issues that put Black mothers at higher risk. Some research has been done to look at ways to do this. Preconception care is known to reduce risks and is recommended by entities like the CDC, but is unfortunately not available to the 50% of women in the US on public health insurance. If implemented, preconception care would reduce premature births by 8000 per year. Group prenatal care models reduce the risk of preterm birth, low birth weight and newborn hospitalization, and lower rates of closely timed pregnancies. Home visiting and education by organizations like nurse family partnership or NFP reduce rates of preterm births and improve pregnancy planning. Kangaroo care improves outcomes for babies born early.
<SLIDE: Ethical Care of Black Women> Scott points out that all of these interventions probably work because they reduce stress, increase community support. However, they require a reproductive justice stance to be effective interventions for Black mothers. Reproductive justice or RJ is a broad ethical framework developed by Black feminists. It centers bodily autonomy and self-determination. Black women have the right to get pregnant, or not. To stay pregnant, or not. To parent without fear for their child’s well being. And to have sex for pleasure and not reproduction if so desired.
<SLIDE: A Code of Ethics> The American Nurse Association has a code of ethics that maintains standards to help the provider support reproductive justice for Black women. I am going to read them aloud for you and let’s sit with each one for a few seconds. The first two are entirely within the individual provider’s ability. “(1) Listen to Black women; (2) Recognize the historical experiences and expertise of Black women and families.” How many of you can honestly say that this is how you practice?
<SLIDE: Structural Workforce> The last four are ethics that require systems shifts in workforce approaches. (3) Provide care through a reproductive justice framework; (4) Disentangle care practices from the racist beliefs in modern medicine; (5) Replace White supremacy and patriarchy with a new care model; (6) Empower all patients with health literacy and autonomy; (7) Empower and invest in paraprofessionals; and (8) Recognize that access does not equal quality care.” Does your workplace have conversations about these points? Maybe they should? The immediate and most impactful shift in the structural workforce is to support paraprofessionals and professionals who are Black. There is abundant evidence that Black mothers have better outcomes when cared for by Black providers.
<SLIDE: But Hooooooow?> Scott offers some concrete tools that providers can start to use to adopt or move their workplace towards adopting this code of ethics. She discusses two validated instruments, the Mother’s Autonomy in Decision Making scale and Mothers on Respect index, that can be used to assess gaps in quality respectful care. The first was developed by patients and evaluates experiences of maternity care. The second evaluates human rights, safety and quality in birth. She discusses the Research Prioritization for Affected Communities protocol which can help researchers identify issues that matter to Black women and their communities.
<SLIDE: No excuses.> Scott points out that nurses already have a code of ethics that aligns with Black communities needs and that Black nurses and midwives, such as Jennie Joseph have worked hard with communities to develop programs that have been proven to improve outcomes. There is little justifiable reason that these models such as group prenatal care and home visiting are not put into practice across the US now, a step that would immediately begin to mediate the health inequities and disparities that arise from systemic and structural racism.
<SLIDE: Monica McLemore, RN, PhD, FAAN> Monica McLemore is a PhD nurse researcher at UCSF who focuses her teaching and research efforts on reproductive justice. McLemore was just featured in an interview discussing Black Maternal Health and COVID-19 and she consistently speaks out about health equity injustice. In her most recent 2020 article, McLemore and colleagues outline research priorities for reducing preterm birth.
<SLIDE: Research Needs According to Black Women> McLemore was interested in centering Black women in an effort to identify the most pressing research needs. She points out that Black women have largely been excluded from research conversations on preterm birth. Recall that in Karen Scott’s article, one recommendation is to use the Research Prioritization for Affected Communities protocol to identify research needs according to those most affected. In collaboration with women in the communities most affected by preterm birth and the California Preterm Birth Initiative, McLemore uses the Research Prioritization for Affected Communities protocol and a Reproductive Justice framework to identify and set research priorities. Despite research efforts to include patient and public involvement, this appears to be the first time preterm research priorities have centered Black women.
<SLIDE: Review of US Preterm Birth> Let’s do a quick review of preterm birth in the US. Preterm birth is defined as birth occurring before 37 completed weeks of gestation. Some methods of preterm birth prevention have worked on individual levels: things like nutrition and exercise, screening for infection, treating infection, progesterone use. But, there has not been improvements in population based rates of preterm birth. About 10% of all babies and almost 14% of all Black babies in the US are born preterm, rates that are much higher than any other high income nation. Preterm rates for Black babies continue to rise.
<SLIDE: How They Did the Study> This study used focus groups at community based organizations in three California cities, Fresno, Oakland and San Francisco, that have high rates of preterm births for women of color. The organizations offered various services including pregnancy and parenting classes, support services for families. Participants for the focus groups were pregnant or parenting adult women who were receiving services from the community based organizations, and identified as Black, mixed-race, Latina or Hispanic. The researchers used interview guides to ask the same questions at each group and they recorded the sessions. Participants were fed, childcare was provided, and the participants were offered small monetary compensation for their time. There were two sessions, the first was to have the participants generate questions and the second to have the participants prioritize the questions. The research group that performed this study made a great training video which we will link to outlining how to apply the RPAC protocol.
<SLIDE: The Groups> There were seven groups formed for a total of 54 women and 14 focus group sessions were held over two years. The participants were ages 20 to 44. Thirty were Black, 21 Histpanic and 3 mixed Race/Ethnicity. In total the participants had 122 babies and 37% had been born preterm. Eleven of the children had died between the groups. Most participants struggled to rank research priorities, but did so by focusing on what was of most immediate or urgent concern. Many said the groups were “healing” and the first chance they had to talk about their experiences with peers who had similar stories.
<SLIDE: Research themes and priorities> There were four research themes that came out of the participants’ research questions. These were: “Maternal Health and Care Before, During, and After Pregnancy; Newborn Health and Problems Related to Prematurity; Understanding Stress and Interventions to Prevent or Reduce Stress; and Research to Address Interpersonal and Structural Health Inequities.” Some groups also had other research needs identified depending on their location. The California Preterm Birth Initiative lists hundreds of research questions generated across these themes and priorities, and by location, that researchers can access and use to build their research protocols.
<SLIDE: Theme 1 – Maternal Needs> The first theme, “maternal health and care provision before, during, and after pregnancy”, reflected the participants desire to have researchers understand conditions that might affect pregnancy. Contraception and preconception counseling was a focus for before pregnancy. During pregnancy the women focused on the subjectivity of how tests and procedures seem to occur and asked for agreed upon standards. They wondered about the risk benefit of common procedures such as ultrasound, vaginal exam, and non-stress tests. They also wanted more research on the risks and causes of prematurity, on common and serious complications, and on inconsistent application of risk factors. Labor and delivery concerns included the safety and usefulness of epidural, extended pregnancies and labors, birth plans and doulas and midwives. The participants questioned interactions with their providers, saying they needed to know how to help providers help them, why there are quality of care differences between providers, and why the healthcare system makes it so hard for women to get sufficient and culturally appropriate care.
<SLIDE: Theme 2 – Newborn Needs> “Newborn health and problems related to prematurity” was the second research theme that was identified. Questions under this theme dealt with NICU care, infant mother separation, and breastfeeding. They wanted to understand more about medications being used and how doctors are deciding how to treat their babies. Long term development and health effects of prematurity were also identified as priorities. When discussing newborn needs and maternal needs, peer support was cited as an area that needed to be studied.
<SLIDE: Theme 3 – Stress> The third area of research participants identified was “understanding stress and interventions to prevent or reduce stress”. They wanted to know how stress affects pregnancy and what they could do and the systems around them could do to lower that stress. They specifically cited things like single parenthood, CPS involvement, and drug testing as factors in stress. They wanted to know why there is not more funding available for programs to better mediate and understand stress.
<SLIDE: Theme 4 -Healthcare Inequities> The last area of investigation the participants called for was “Research to address interpersonal and structural healthcare inequities.” The participants plainly want to know why ethnicity, race and racism, as well as insurance type seemed to greatly affect the care they received. They wanted to know if the effects of racism and insurance inequities had the same effects in other countries. And they wanted to know why there is a lack of respect, cultural humility, and communication between providers and patients.
<SLIDE: Broad Research> There were many things that McLemore and colleagues found that was similar to other researchers’ priorities on preterm birth and other participant-led research demands. There was one big difference. The women in this study were all women of color and most were Black, and they were far more focused on structural health inequities, interpersonal health inequities, and the social determinants of health. The research demands of these participants spanned all areas of social and physical sciences and provide a large platform from which researchers can form quality research that addresses the needs of Black women.
<SLIDE: Don’t stop here> Many of the issues identified by this study can be immediately addressed, such as coming up with evidenced based community standards on preterm birth prevention or implementing peer support programs. The research questions developed are freely available to researchers for use and may help guide research funding as well. In addition, McLemore and colleagues reflect on the RPAC process and encourage others to use RPAC, or a similar process, to help identify community research protocols.
<SLIDE: Black Mamas Matter> Finally, they encourage researchers to use the Black Mamas Matter Alliance guide to research. One. “Communities have a right to be recognized and own authoritative community expertise”. Two. “Communities have a right to know.” And, three. “Communities have a right to be heard.” Black Mamas Matter Alliance or BMMA offers a lot for researchers and providers. We strongly encourage you to look at their toolkits, webinar and training.
<SLIDE: Shafia Monroe, DEM, CDT, MPH> If you do not yet know who Shafia Monroe is, you really need to look her up. She is a midwife, community organizer, doula trainer, public health researcher and more. She has been a founding member of many organizations working for change for Black birthing people, including ICTC (now the NAABB). She provides cultural competency consultation and continuing education for providers and organizations. We at VBAC Facts® highly recommend her training for all providers who are for pregnant, birth and postpartum women.
<SLIDE: Disgraceful and flawed> Monroe’s 2020 review article in the North Carolina Medical Journal names the perinatal disparities experienced by Black folks and offers some solutions that can be implemented now. It also offers a scathing critique of a system that fails Black women and their babies. Monroe says, “Maternal mortality is a disgraceful problem in the United States” and “A nation that cannot protect its babies from preventable death before age 1 is seriously flawed.” I think most of us that know the statistics for US Black mothers and babies can agree with Monroe’s critique.
<SLIDE: Infant Mortality> Infant mortality is death of a baby before the age of one. In the US, infant mortality rates have declined for White babies as they have increased for Black babies. Monroe offers a concise list of the major reasons for infant mortality: genetic defects, premature birth, being too small, having accidents, SIDS and racism. Monroe, like Scott, cites the social determinants or systemic racism that is behind high death rates for Black babies. High cortisol levels or stress hormones affect Black women of all socioeconomic statuses and lack of housing, food and racial profiling in healthcare compounds these risks.
<SLIDE: Maternal mortality> Rates of maternal mortality have also increased in the US in the past generation. Black mothers die three times as often during pregnancy, birth and postpartum as White mothers. Today 16.7 women in every 100,000 will die from pregnancy related causes like hemorrhage and hypertension. For Black women, that death rate climbs to 40.8 in 100,000. Monroe points out that 60% of these deaths are preventable.
<SLIDE: Solutions> We can make changes to the healthcare system that change these outcomes. Some of these solutions mirror what Scott suggests, in the previous article. Monroe says that first all efforts must be made in partnership with the community. Top down efforts are not effective. Programs designed to improve outcomes for Black mothers must involve healthcare providers and community institutions like churches and schools. Second, providers must be required to have training in cultural competency and implicit bias. Everyone has implicit bias. I am going to say that again, everyone has implicit bias. See the resources at the end of this presentation for a link to Harvard’s Project Implicit.
<SLIDE: Solutions> Third, cover community doula services with Medicaid. We know that doulas improve outcomes, so they should be an essential and funded part of the care team. Fourth, we need more midwives of color. Just as outcomes are improved with doula care, outcomes are improved when Black midwives care for Black mothers. Fifth, all states should replicate efforts like the California Maternal Quality Care Collaborative which has dramatically reduced maternal and infant morbidity and mortality in California.
<SLIDE: Do we have the will?> The last thing Monroe suggests is that we LISTEN TO BLACK WOMEN. There are far too many cases where Black women have died after being ignored or dismissed by healthcare providers. Monroe offers these solutions to the vast disparities in outcomes between Black and White women and babies, and most of these can be implemented immediately or in short order. This is hopeful. It is also discouraging, because if these solutions are so easy to implement, why haven’t we as a society cared enough to make these changes. Monroe quotes Martin Luther King, saying, “Do we have the will?”
<SLIDE: Ifeyinwa Asiodu> Ifeyinwa Asiodu is a postdoctoral nurse researcher at UCSF. Asiodu writes in popular magazines and academic journals about intersectionality and breastfeeding among African American women. She works with organizations like the Black Infant Health and Black Mamas Matter Alliance to center the experiences of Black breastfeeding women. In this 2019 article, Asiodu and colleagues offer a critique of high cesarean rates.
<SLIDE: Cesarean rates in the US> In the US, much like the rates of preterm birth have declined for White women while simultaneously increasing for Black women, cesarean rates are decreasing for White women and increasing for Black women. In 1965 the US cesarean rate was 4.5%. Now it is 30.9% for White women and 35.9% for Black women. This is much higher than the 10-15% rate that is recommended by the WHO. Cesarean rates above 10% no longer improve outcomes. Asiodu and colleagues look at this phenomenon in the context of the importance of physiological birth practices and the cultural shifts that have moved us away from physiologic birth.
<SLIDE: Physiologic Birth: Midwives and Doctors> Asiodu begins by discussing the core differences in the approach to birth between midwives and physicians as an underlying explanation of rapidly increasing cesarean rates. Physiologic birth is defined as “the spontaneous onset and progression of labor culminating in a vaginal birth of a term neonate and placenta.” Midwives, whether CNMs, CMs, or CPMs, practicing the midwives model of care promote the body’s ability for physiological birth and do not intervene unless clinically justified. Obstetricians, as a body, do not necessarily support physiologic birth but rather see labor, birth and postpartum as a series of potential interventions. Asiodu feels like this is an important distinction to make as it may help explain the large differences between cesarean rates for low-risk people with midwives vs doctors.
<SLIDE: What happens in Physiologic Birth> There are a multitude of complex factors that go into physiologic labor and birth. Asiodu’s article takes the time to discuss some of these, including the millennia old history of modern labor, the different effects of hormones on various tissues of the reproductive system, the changes that occur in the uterus, cervix, and fetus, and how environment can affect these processes. Her write up on these processes is really great and I encourage you to read through the article for the details. The sum, or what she calls “the main point: is that physiologic labor occurs and depends on a multitude of factors and experiences, and each may influence the next for better or worse.” She makes the point that physiologic labor has not changed in at least the last 10 thousand years, yet what physicians find acceptable labor has changed dramatically.
<SLIDE: Stress and Trust> Two things that influence physiological labor disproportionally for Black women and deserve mentioning are the experiences of stress and trust. Stress hormones and labor hormones don’t mix well and experiences of chronic stress in life or moments of stress in labor can affect physiologic birth dramatically. We know that Black women in the US experience higher rates of chronic stress, and the allostatic load or “wear and tear on the body” that accompanies it. Additionally, trust in care providers affects stress levels in pregnancy and labor, and women cite fear of healthcare provider incompetence and lack of trust as greater points of fear than pain or death.
<SLIDE: Keeping Time> Despite a lot of research in the past decade debunking “normal” labor progress and establishing that labors are highly variable in duration and pace, there is still an attachment to long labors being somehow more dangerous for mother or baby. This belief of a normal labor progress began in the 1950s with Friedman’s curve based on one small study of medically managed White women. There have been many studies since 2000 that have shown that labor takes much longer on average than Friedman originally stated, yet cesareans are done 35% of the time for failure to progress or FTP. Some might say that this is because longer labors are more risky, but large scale evidence does not support this. Asiodu goes into a deep discussion about the evidence on FTP and outcomes, and we strongly encourage any providers still using the FTP diagnosis to read it.
<SLIDE: Midwives, race and cesareans> According to a large Cochrane review, care by midwives leads to less use of pain control, fewer cesareans, and shorter labors. All of these factors directly tie into cesarean rates. Asiodu also makes the point to tie this into historical roots of race and physician management of labor. Historically, cesarean was a rarely used option due to risk and in the 18th and 19th centuries, when most births were attended by midwives. Yet cesareans happened much more often for Black women who were enslaved due to White owners who made care decisions for them despite the risk. Now, we have higher cesarean rates for Black women compared to White women and four times the maternal mortality rate for Black women compared to White women. Asiodu points out that these things are not separate and all have to do with historical and current power differentials between midwives and physicians, and Black folks and White folks.
<SLIDE: Assessing Distress> Asiodu then discusses the advent and use of electronic fetal monitoring or EFM, and how that has changed physiologic labor and labor management leading to higher rates of cesarean. When the EFM was originally developed it was supposed to be only used in cases of severe compromise, such as placental abruption. Its inventor thought it would decrease the cesarean rate, but the opposite has occurred. Absent any quality evidence linking fetal heart rate tracings to poor outcomes, physicians began to assume any tracings that were equivocal as abnormal and justifying a cesarean. One group of researchers estimate that the false positives on EFM leading to cesarean happen up to 99% of the time. (Sartwalle, 2017) Even ACOG says EFM does not hold predictive value, yet 9 out 10 US births include EFM. Let’s digest that last bit. 9 out of 10 laborers are monitored by EFM and 99% of cesareans due to fetal distress showing on EFM are unnecessary.
<SLIDE: Constraining Consent> Many medical professionals will argue that consent must be obtained for cesareans or any other interventions. While this is a valid statement, 25% of women feel pressured to have cesareans and 60% of cesareans are performed for reasons with no or poor support in the evidence, things such as labor dystocia, ftp, and fetal distress. The physician is counseling the patient to consent to a cesarean for unsupported rationale 60% of the time. Three of four people report that their cesarean consent discussion included rationally for the procedure but none of the details about a cesarean procedure and its associated risks. People wishing to labor after cesarean or birth a breech baby vaginally often face the threat of or actual legal action and involvement of CPS. These so-called consent conversations often boil down to, as Asiodu puts it, “Comply with our demands or you’ll kill your baby.” This approach is not informed consent which should include all the benefits and risks of doing and not doing a procedure without coercion.
<SLIDE: “Midwifing the Future”> Asiodu ends their article by discussing that the solution to the issues of modern medical birth and high cesarean rates is to return to a feminist and community centered view of birth. Continuous support, such as offered by doulas or family, decreases cesareans and improves outcomes. While midwives learn and center physiologic birth, obstetricians may see more cesareans than vaginal births during training and ACOG does not make any commitments to low intervention. Midwives practice high touch low tech care that involve things like continuous presence, intermittent auscultation, and judicious use of interventions. Doing this midwives see equivalent or better outcomes and far lower rates of cesareans. Asiodu discusses one recent literature review that shows cesarean rates for low risk folks to be 13.4 to 36.5% for obstetricians and only 1.9% to 6.1% for midwives.
<SLIDE: SES constraints> Women of color, poor women, uneducated women and gender nonconforming folks do not have the same levels of access to midwives and doulas. This is important to note, because it means that folks who fall outside of being White, well-educated, upper to middle class women do not have the same chance for the better outcomes they may see with midwives. Additionally, the healthcare workforce, especially within birth care, continues to be dominated by White folks and lacking the diverse bodies that can understand and provide better care for Black women and babies. This is largely due to inequities in education and opportunity.
<SLIDE: Did we say midwives?> Just in case it has not been clear throughout our summary of this review article, the answer appears to be more midwives in general and more Black midwives specifically. Asiodu and colleagues make the point that what has been consistent in the history of human physiologic birth is midwives, and that with midwifery care we see better outcomes and fewer interventions including cesareans. If you want to do more to support Black midwives, see our links below.
<SLIDE: What to do now> If you are White and watching these grand rounds, I really hope you stuck with us through the review of these five articles. If so, I imagine you are asking what you can do right now to make a difference. Here are some ideas. First – Find and financially support a Black midwife or midwifery organization, we have included some suggestions. You can donate to a fundraiser or join an organization as an ally or accomplice. One of the staff here at VBAC Facts® makes it a habit to send $5 to every Black midwifery student’s fundraiser she comes across. You could also look at midwifery and obstetric schools that progressively fund the education of Black providers.
<SLIDE: What else to do now> Don’t stop there, because too often we toss money at something without looking deeply at why that something occurs. Second – Start reading about antiracism and do not stop. You will never know enough. We have included a resource list of recommended books and websites for you to start with. Third – Spend some time reading the work of the researchers highlighted here. This will lead you to other healthcare research by and for Black folks. Fourth – If you are a researcher, adopt a community driven model for your research. Stop researching the needs of diverse communities without those communities leading that research. Fifth, if you work at a hospital or physician’s office, start advocating for changes that serve the community, such as allowing doulas, integrating midwives, and offering group prenatal care. Last, and possibly the hardest, confront systemic bias and racism whenever you can. A great book that can help you do just that is included in our booklist.
<SLIDE: Closing> This concludes this month’s Grand Rounds. I’d love to hear if you had “ah ha” moment. Please type it in the chat or leave a comment below if you are watching the reply. Also, if you are a perinatal professional who is passionate about increasing VBAC access for everyone, I invite you to join the VBAC Facts® Professional Membership. Membership gives you access to grand rounds like these, continuing education trainings, a handout series for birthing parents and more. Please learn more about membership and the sliding scale for BIPOC at vbacfacts.com/membership. Until next time, I’m Jen Kamel. Be well.
