Comments Prepared for the National Academies of Science, Engineering, and Medicine

June 7th and 8th, 2021

Hello. I want to thank the organizers of today’s meeting especially Dr. Brindis, a mentor of mine for allowing me to share some of my thoughts with you. I use she and her pronouns. Racism has been declared a public health crisis. From the increased rates of COVID-19 infections and deaths among Black and Latino populations, to the perpetually higher rates of violence and police brutality Black, Indigenous, and other People of Color communities face, there are prevalent, persistent flaws in our nation’s structures that negatively impact determinants of health and outcomes.

COVID-19 has laid bare for all to see, so many of the flaws that need a do-over, a reimagining, and re-conceptualization. If the last year and a half, have taught you nothing, it is that — this was all built, and it doesn’t have to be this way. I’m convinced that our panel today has many answers, and this could all be different if we only choose to listen and ACT. I have organized my comments today around three important aspects of the root causes of poor maternal health outcomes for Black and indigenous people. I have also included suggestions and strategies to reimagine and disrupt these root causes because critique without action in my view is not going to move us toward the solutions necessary to mitigate harm. For far too long, we have as Dr. Camara Jones aptly described, settled for “inaction in the face of need.”

With that, let me bring forward three aspects of the root causes of poor health outcomes, namely,

· Mistreatment and Disrespectful care;

· Reproductive Injustice;

· Lack of diversification of the healthcare workforce

Mistreatment and Disrespectful Care

In 2019, I wrote for Scientific American To Prevent Women from Dying in Childbirth, First Stop Blaming Them. I stand by every word and as a matter of fact, they will be re-releasing an updated version of this data visualization project in July in a special edition about racism. In that piece, I summarized existing knowledge about the root causes for maternal morbidity and mortality in the United States. I carefully explained that these deaths were preventable, and that symptom surveillance, early symptom recognition, and reporting are critical components to prevention.

Unfortunately, disrespectful care and mistreatment during pregnancy and childbirth have been shown to be widespread in the U.S., where one in six birthing people report experiencing one or more types of mistreatment, including being shouted at, scolded or threatened; being ignored, refused or receiving no response to requests for help. While I won’t go into extreme detail about the data from the Giving Voice to Mothers Survey, since my collaborator, colleague, and co-conspirator, Dr. Saraswathi Vedam is participating in this workshop, I will ground us in the notion that mistreatment, namely, being ignored, refused, or receiving no response to requests for help contribute to significant delays in the provision of care to pregnant people. I will also make the point that patient mistreatment and clinician burnout are two sides of the same coin — because I believe our workplaces are inhumane and until we address that structural issue, we will continue to see the provision and receipt of disrespectful care. One mechanistic consideration is the work specific to birth settings and auxiliary maternity units because for far too long, birthing people have had limited options in shepherding new humans to this plane and they deserve better.

Reproductive Injustice

The purpose of today’s meeting is to attempt to achieve health equity and I view it as the scientific equivalent of evidence-based truth and reconciliation. To be blunter, as I wrote in Scientific American, maternal morbidity and mortality are significant public health issues that highlight shameful health disparities that burden BLACK AND INDIGENOUS communities. However, disparities in maternal morbidity and mortality in my view are a symptom of the underlying problem — reproductive injustice in the U.S. as disparities in reproductive health outcomes are not exclusive to the perinatal and postpartum periods. Across the reproductive spectrum (e.g., adoption, abortion, contraception, family planning, maternal fetal medicine, reproductive endocrinology and infertility, gynecologic oncology), BLACK AND INDIGENOUS individuals have poorer outcomes when compared to white pregnant capable people. These observations of poor reproductive outcomes for BLACK AND INDIGENOUS individuals is important because it is already known that experiences of care during the reproductive years has lifelong implications for if, when, where, and how healthcare is accessed in the future. I will not spend a huge amount of time on this point as a I know my colleague, collaborator, co-conspirator and friend, Dr. Karen Scott will highlight her important work with Dr. Dana-Ain Davis specific to obstetric racism.

A second important point specific to reproductive injustice is the notion that disparities in the distribution of disease, illness, and wellbeing are NOT exclusively determined by the behavior of individuals. Highlighting the potential mechanisms of how reproductive injustice is fueled by institutional racism, class oppression, and gender discrimination and exploitation clarifies why addressing the social determinants of health requires structural approaches. In other words, interventions that target individuals are insufficient to address structural problems.

For example, it is already known that regardless of routine prenatal care, socioeconomic status, education, insurance type and rates of pre-existing clinical conditions, among Black women, the burden of maternal morbidity and mortality is equally shared. Additionally, data from a recent study that examined the dual burden of severe maternal morbidity and preterm birth showed that these combined clinical experiences have the potential to disrupt maternal role attainment, lactation and breastfeeding, family transition, and postpartum mental health that have important implications for individuals. However, I would highlight that these data show limitations of exclusively relying on hospital-based data because they are a representation of a single episode, birth. Pregnancy occurs over time and happens everywhere. Therefore, I think community-based analyses are warranted and need to be prioritized with outcomes besides surviving birth.

Given that the risk of disrespectful care, mistreatment, poor reproductive health outcomes, are equally shared among Black women — regardless of education, socioeconomic status, insurance type — I believe Black community-centered interventions should be developed, deployed, and evaluated. Our research and the work of many others have described the healthcare seeking experiences of Black women across the reproductive spectrum including investigations of structural racism, strategies to improve maternal health services provision, patient satisfaction, and information and power exchange during healthcare encounters. We need to focus on community sensitive outcomes such as maternal role attainment, lactation and breastfeeding, family transition, and postpartum mental health.

One hypothesis generated from our previous community-engaged research is that access to racially concordant and culturally relevant teams (e.g., case management, doulas, midwives, nurses, nutritionists, physicians, and social work) are essential components that work synergistically to improve experiences of care and trust in health systems. Which brings me to my last point.

Lack of Diversification of the Healthcare Workforce

Racial discordance between clinical providers, clinician-scholars, and communities has profound implications. Interpersonal processes of care, including social concordance and communication, have been shown to be a significant aspect of quality care. A substantial body of evidence exists that describes health disparities between populations. Yet in my view, this important work has not spawned effective, novel, or sustainable interventions designed to mitigate disparities and achieve health equity.

Recent research that has evaluated models of care specific to the inclusion of racial equity lens to curricular development and clinical care provision have shown that cultural and racial concordance are essential components to improving experiences of care across the reproductive spectrum, but specifically, for pregnancy-related care. Qualitative research conducted by Dr. Rachel Hardeman and others, showed four distinct themes that were essential elements of racially concordant care specific to Black Birthworkers. First, clinicians need to acknowledge how the cultural identity of patients determines aspects of the clinical encounter. The other three elements include a stated commitment to racial justice, agency, and cultural humility grounded in the reciprocal nature of the relationship between clinicians and people seeking care.

One structural exemplar of reproductive injustice is the segregation rampant in health services provision. My co-author and pediatrician Dr. Rhea Boyd outlines this beautifully in work specific to segregation of hospitals and health services and particularly those who work within those institutions.

According to data from 2015, only 65.6% of the US population is White, however, 83.2% of licensed nurses and 90% of certified nurse midwives are White. While the physician community is more diverse (49% White), only 4% of physicians are Black or African American, 4.4% Hispanic and 0.4% American Indian or Alaskan Native.

Meanwhile 93% of licensed nurses or certified nurse midwives are women, only 34% of physicians are women. While there are more Black women are physicians (54.7%) than men (45.3%), in all other racial and ethnic groups, there are more men are physicians than women.

There have been attempts to diversify the clinical healthcare workforce using incentive and pipeline programs. These programs, funded by both the federal government and the private sector, have had mixed results. Fortunately, these programs have shown that 1) People of color in the health professions are more likely to serve minority populations; 2) Health care providers who are people of color are more likely to work with publicly insured and minority populations; and 3) Programs that provide financial incentives to any health care provider who serves minority populations have not been more successful than programs that specifically develop BLACK AND INDIGENOUS health care providers to ensure adequate workforce serving in under-resourced settings.

In closing, we have a unique opportunity today to curate a conversation about the data that are necessary to improve health outcomes and to achieve healthy equity. Doing so will require disrupting stigma, shame, judgement, and blame narratives that are grounded in gender oppression, patriarchy, misogynoir, and white supremacy. Doing so will require the need for partnership across disciplines and spectra who serve pregnant capable people, and finally, without a robust social safety net that includes paid family leave, expansion of insurance coverage and access to services, we will continue to pontificate about poor outcomes without constructing the care that is required to achieve superior outcomes. Thank you for allowing me to share my thoughts and insights and I look forward to the discussion.