Dr. Rachel Hardeman: Racial inequities in pregnancy-related death

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RACHEL HARDEMAN: I’m Dr. Rachel Hardeman, and I’m the Blue Cross Endowed Professor of Health and Racial Equity at the University of Minnesota School of Public Health and the founding director of the Center for Antiracism Research for Health Equity at the University of Minnesota. And in my role as a director of a research center and as a professor and researcher, I work to understand, to identify and to dismantle structural racism. And so my work really seeks to build health equity for Black birthing people and people of color who experience adverse birth outcomes.

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RACHEL HARDEMAN: When we think about infant mortality, for instance, which is the death of an infant within the first year of life, that not everyone is safe from that. So, Black birthing people and their infants in particular are at greater risk, in fact, two times more likely to experience infant mortality. And one of the primary causes of infant mortality is preterm birth­—so a baby being born too soon or a low birth weight, a baby being born too small.

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RACHEL HARDEMAN: For Black birthing people, what we see is that they are four times more likely to experience maternal mortality. So, in the United States, where we have access to a lot of great prenatal care, a lot of technology and a lot of resources, we are seeing birthing people­—we are seeing women dying excessively during childbirth. And what we also know is that nearly 60%­—so at least over half of those deaths­—are preventable.

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RACHEL HARDEMAN: So, the factors and underlying causes of the racial inequities that we see in maternal mortality and infant mortality are complex. They’re multifactorial. But they all stem from one underlying foundational cause, and that’s racism. And I think it’s important to break that down in a­—several different ways because it operates in different ways in people’s lives. So, I often talk about structural racism, and I’m referring to the totality of ways in which racial discrimination is showing up in someone’s life, whether that’s in housing, their access to credit, to their access to buying a home or living in a safe neighborhood.

Structural racism shows up in, you know, the health care system as well. And what we see is that when people are impacted by where they live, their ability to get a job, where they can send their kids to school or where they can receive an education, all of that matters for health and well-being, generally speaking, but for reproductive health. And one of the ways we see that playing out is through the weathering hypothesis, which was actually put forth in the early ’90s by a researcher, Dr. Arline Geronimus. And what she found was that the constant stress of racism, the constant stress of disadvantage across the life course was impacting health and well-being. It was weathering and literally biologically aging people’s bodies. And for Black people in America, after 400 years of oppression and dealing with racism, that weathering is an important part of the life course. And what we suspect is that it’s bringing people into pregnancy at less than optimal health, right. So, at a time when your body is becoming vulnerable due to pregnancy, you’re already experiencing vulnerabilities due to that weathering process. And that long-term stress has an effect on the body. It can raise cortisol levels, which we know is a stress hormone. And, you know, the body isn’t meant to withstand that level of stress for a long period of time.

We also have to think about how acute stress plays into that, too. So, some of the research that my team is doing­—what we found is that the acute stress, for instance, of living in a community where there’s been a disproportionate amount of police contact or police surveillance has an association with higher levels or higher risk of preterm birth­—so again, that baby being born too soon. We’re also doing work right now to understand how both the chronic stress, that weathering across the life course, coupled with living in communities where a Black person has been killed by the police and that­—and ways that it’s been sort of highlighted throughout our communities­—what that acute stress does to the body and how it impacts reproductive health outcomes.

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RACHEL HARDEMAN: We’ve seen many high-profile cases from, you know, women like Beyonce and Serena Williams describing their experiences during childbirth and what happened to them. And those aren’t anomalies. These are day-to-day experiences that are happening to birthing people as they’re accessing the health care system. So, our research has found that, you know, birthing people who may report declining care for themselves or their infant during the childbirth hospitalization phase are going to be more likely to report poor treatment based on their race and ethnicity. Our results suggest that within that context of childbirth, that birthing people pay a significant penalty for exhibiting behaviors that may be perceived as sort of uncooperative. And this penalty is more prominent for Black birthing people. Our research has shown that Black birthing people are more likely to report not being heard, not being listened to, not being respected when they are visiting with their clinician and getting care during pregnancy.

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RACHEL HARDEMAN: One of the things our research has shown is that culture is protective. So, when we­—what we see is that when Black birthing people receive culturally centered and relationship-centered care during their pregnancies, not only do they feel more respected and feel more satisfied with the care they’re receiving, but their babies and themselves­—they’re healthier. Those outcomes are better. And so we’ve studied this over the past three to four years using Roots Community Birth Center, a free-standing midwifery-led birth center here in the Twin Cities. And what we’ve seen is that their culturally centered model of care has improved outcomes for the families that are accessing care there. They are working really hard to meet every single person where they are, meaning understanding and embracing their lived experience, encouraging them to bring all of the support people and support systems that they need into the space during a prenatal visit or during the childbirth period and even postpartum, as well. They think a lot about what informed consent should look like and ensuring that that the pregnant person has the opportunity to engage in their care in ways that is empowering and lets them lead and be the experts in their own bodies.

We also know that improving care­—one solution to the disparities and the inequities that we’re seeing is with racial concordance­—so meaning that when a clinician shares the same racial identity with the pregnant person that they’re caring for, the outcomes can be improved. And in fact, our research has shown that for Black infants, Black newborns, that when they are cared for by a Black physician in the newborn phase, they are more likely to survive. And so we have to think about what diversifying the health care workforce really means and what that looks like and ensuring that there are more opportunities for people to become physicians and to care for people in their communities and make those connections. We also need to be thinking about big policy changes, right? So, how do we ensure that the social determinants of health, the things that we know matter for health, like housing, you know, transportation, being able to get to a health care appointment, living in a neighborhood that feels safe and living in a neighborhood where there is access to food, healthy food­—you know, and all of those things are incredibly important for reproductive health outcomes and for maternal health outcomes. But not everyone has access to those things. And so by thinking about how health and social policy, our solutions­—we have to be, you know, really digging into making critical investments in those spaces.

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RACHEL HARDEMAN: What we’ve seen in the data that’s been put out to date is that, you know, an abortion ban, a nationwide abortion ban, will lead to a 21% increase in the number of pregnancy-related deaths for all women in the United States and a 33% increase for Black birthing people specifically. So, not only are abortion bans going to put all birthing people at risk but that there’s going to be an even additional burden, an even greater burden on people who identify as Black.

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RACHEL HARDEMAN: Structural racism­—while it is the fundamental cause of the inequities we see in maternal and infant health—it is a fixable problem. We each have a role to play in the solutions. And so, you know, for some people, that may mean self-educating and becoming more aware of these issues. You know, for others, it may mean getting involved in local, you know, community advocacy, finding out what work is happening in your own communities, in your own backyards that you can contribute to. And so, I don’t want anyone to walk away feeling like this is such a big, you know, issue and not something that I can fix or contribute to fixing because we each have a role to play in our own sphere to really undo the ways that racism has contributed to racial inequities in maternal and infant health.