"Is it really surprising that we have maternal health disparities?"

The Black maternal health crisis through the lens of stress

adapted from art by: Hanna Smolska for iStock

Four out of five.

That is the number of pregnancy-related deaths that are considered preventable.

Preventable. Deaths.

And if that statistic is not horrifying enough, consider that Black perinatal people are THREE times more likely to be included in that number.

How did we, as a country, get to a point where being in a Black body in America puts you at a disproportionate risk of not surviving this very survivable life stage? How did we get to a point where we can acknowledge that 80% of people, who die before, during, or after childbirth should have lived, without a clear path towards fixing that statistic? 

And what is the role of stress in all of this?

For that answer (and more!), I turn to Dr. Karen Sheffield-Abdullah — a researcher, a nurse-midwife, a mindfulness expert, a mom of four, and an all around brilliant mind — to better understand the role of stress before, during, and after pregnancy as it relates to the Black maternal health crisis.

(Learn more about Black Maternal Health Week 2024 — find resources, help raise awareness, join the week of activism — HERE).

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MOLLY

When I think about how we can or should be thinking about stress in the context of Black maternal health, I always immediately think of you, Karen – your work in this space, your research, the way you deeply think about all the issues and the interconnected nature of it all. 

Can you talk a little bit about you — your work and view on this very broad topic?

KAREN

I'm a stress and anxiety researcher. I'm a mental health advocate. I'm a certified nurse-midwife of 19 years and I'm also a mindfulness instructor trained through Brown University's Mindfulness Center. 

The things that I am most passionate about are healthcare outcomes for women and birthing people across the life course, as well as mental health concerns, in particular anxiety and depression. I examine and explore integrative health approaches or non-pharmacological ways to manage psychological distress in communities of color. 

If I were to really think about my positionality: I identify as a Black, cisgender woman who is married, has insurance, and has not had any major complications with any of my pregnancies. I did have one miscarriage which has given me deeper insight, especially as a healthcare provider, into the grief and pain associated with a perinatal loss.

With that being said, I am really, really interested in why there are such disparate outcomes and birth inequities for the most marginalized, minoritized, overlooked, and underserved populations. In particular, my focus is on Black perinatal people – why is it that we continue to have twice the rate of preterm birth compared to our white counterparts? Why is it that we are three to four times more likely to die due to a pregnancy-related cause compared to white women and birthing people? Why is it that we have a higher prevalence of low birth weight infants? 

We think we know what the issues are and, to some extent, we should  because these adverse pregnancy and birth outcomes have persisted for decades. This is not new. 

So what really drew me to this work is “what are we missing?” And that is where, I believe, stress comes into play. 

From my perspective – my thoughts, my hypothesis, my curiosity as I reviewed the literature during my predoctoral and formative work – we know that stress and anxiety are key drivers of outcomes like preterm birth, but how do the experiences of stress and psychological distress in Black communities and Black perinatal people look different than other communities? And how might that be contributing to the abysmal disparities? 

My work considers: what are the unique experiences of stress and psychological distress for this population that we have not elucidated in the past? I believe the community has the answers and so I turn to them to guide my work and solutions. This work absolutely requires a deeper dive and a closer look at the fundamental questions and that is where I started over a decade ago when I began this work.

MOLLY

On that level of what we know and what we should know, can we talk a bit about the research gaps? We know that the pregnancy and maternal health space has been historically underfunded, under-appreciated, and under-researched, but then you need to factor in the question of “who are the participants in the studies that do exist?” 

Most research, until very recently, mostly (or only) included participants who are married, middle to upper class white women in their 20s. So even when there is data available, the research does not apply to huge swathes of the population, especially those individuals and communities that need better data and more evidence-backed insight the most. 

KAREN

I also think that, historically, when we have had any research that includes minoritized populations, it's an afterthought. The researchers may be studying a particular pregnancy outcome, and then as an afterthought decide “oh, yeah, let's control for this factor” or “let's just see, based on certain demographics, how outcomes change if we do a comparison” and the ‘target population’ was typically white individuals.

Of note, there are a couple of exciting initiatives happening right now. There is a very big push by the Biden administration, in particular Jill Biden, to elevate and prioritize research that is focused on women's health issues, recognizing that women have not been prioritized in empirical research studies. And importantly, there is also a push for health disparities research.

I think part of the reason that these initiatives  have come to the forefront is because highly resourced individuals like Serena Williams, Beyonce, Allyson Felix, have come forward to share their experience with their own pregnancy complications; they’ve elevated the fact that this is happening to us. That message has gotten the attention of the media and the attention of funders. 

These outcomes were already happening for highly resourced individuals, it just wasn’t as visible before [celebrities] started sharing their stories. It is staggering to recognize that a PhD-prepared Black woman is more likely to experience a poor pregnancy outcome compared to an eighth grade educated white woman. 

So it's not necessarily just about educational attainment or income level. There's something else that we need to be thinking about in terms of lived experiences, at the intersections of racism-related stress and gender-related stress. And that is what I have really been interested in and exploring as a mixed methods researcher, who brings in the lens of both qualitative work – doing things like interviews and focus groups – and quantitative approaches – like measuring things through surveys or questionnaires. 

We can measure somebody's anxiety with a scale, but that only tells part of the story. Bringing in that context of “why are you more anxious?” or “why are you more stressed?”  And doing a deeper dive into what is that lived experience of stress is absolutely critical. The bigger question to ask is how do perinatal people define their stress and psychological distress? What is that experience for them?

MOLLY

What just came to mind for me was how, in the stress literature, researchers have historically avoided the impacts of racism and instead painted any race-related differences as a poverty issue. There has been extensive research on the stress related to low socioeconomic status and we know financial stress is intense but this  completely disregards the fact that you bring up – health disparities still show up in highly resourced, highly educated Black women. 

The concept of weathering has been so monumental for reframing race-related health disparities in that way that emphasizes the physiological impact of racism. It just makes so much sense when you think about it, especially in terms of pregnancy and perinatal complications – pregnancy pushes the body so far to support the basic biological demands of pregnancy, but a body that has experienced weathering is starting at a different baseline. When every system in the body has been pushed due to stress across the lifespan, this body starts the pregnancy closer to an overload state. Closer to the edge. Closer to an unhealthy outcome. 

How has thinking about stress, in terms of weathering and the load on the body before it even enters the perinatal period, factored into the way you think about health and mental health during this time of life?  

KAREN

Yes, weathering is the work of Arline Geronimus. I had the opportunity to meet her a couple of years ago and talk to her a bit about her work. 

We oftentimes hyperfocus on the perinatal period when coming up with interventions to address birth inequities. But you bring up a very good point, a very important point, that actually the time when we should address pregnancy outcomes is during the preconception period. The time before pregnancy. 

As we think about the lived experience of Black perinatal people we must consider the impact of weathering across the life course, as Wadhwa talks about, the impact that stress has on premature aging, that it has on our telomeres shortening, the impact that has physiologically on the body – microaggressions, macroaggressions, gaslighting, racism, discrimination, institutional racism, systemic racism, interpersonal racism – all of these things impact us across time and really do weather the body. 

And as you mentioned, in some of my most recent work where I talked with Black perinatal people about their experiences of racism, discrimination, and contextualized stress, what struck our research team the most was how early in life these encounters occurred. When we asked about first experiences of discrimination – many talked about kindergarten, first grade, and elementary school as being their first memory of experiencing discrimination or racism. It was profound and sad and eye opening.

But, this is the unfortunate reality. The experiences of racism and discrimination that start during these early formative years and continue into the reproductive years, means Black women are starting at a baseline level of allostatic load and stress that is higher than other populations. This begs the question, what are the physiologic consequences of this load and what happens when you bring in the inherent stress of pregnancy? While it is most often a normal physiologic process, there are additional strains on the body during pregnancy – your heart is working harder, there are huge hormonal shifts happening and there are also physical demands on the body.

So we're coming into the pregnancy with that lived experience, that allostatic load, and then on top of it, we’re experiencing the unique stress during pregnancy related to race and racism. Now add on the burden of navigating the healthcare system and things get even more complicated. 

What does all of this do physiologically? We know that stress has an impact on cortisol levels, we know that stress can cause a cascade of events with stress biomarkers and physiological changes. So what is the impact on the baby? What is the cumulative effect on the mother? 

With all of that in mind, is it really surprising that we have maternal health disparities?

MOLLY

Something that you bring into your own research are the comorbidities. A lot of health outcomes that are linked as comorbidities – higher risk of cardiovascular disease, diabetes, autoimmune disease, and mental health disorders – are exacerbated by chronic stress but also pose a higher risk during the perinatal period. During pregnancy and postpartum, these health complications may relate to how the systems (cardiovascular system, metabolic system, immune system, endocrine and nervous system) operate at an elevated level to support and maintain a pregnancy. 

But, when you have negative health outcomes that relate to both pregnancy AND chronic stress, you have a bit of a perfect storm when considering the complexity of these issues. 

How should we be thinking about mental health and comorbidities in the context of stress?

KAREN

Certainly as we think about chronic stress, which we just laid out, related to all of the -isms that I mentioned earlier, we don't need more research to show that inequities exist. We already know that the Black population is disproportionately impacted by chronic stress related health conditions and that these comorbidities lead to complex health consequences.

It isn't even so much that we can develop complications during pregnancy, but for many, we are coming into the pregnancy with pre-existing conditions. We may have chronic hypertension, which puts us at greater risk for developing severe preeclampsia or HELLP syndrome. Or we come in with pre-diabetes or diabetes, which we know has implications for the pregnancy. We may also come in with potential cardiac conditions or mental health concerns. We may not be formally diagnosed with a clinical level of anxiety or depression but we have anxiety and depressive symptoms.

I am interested in anxiety symptoms and depressive symptoms because I think they also need to be addressed. It's not about putting a label on the person, but addressing the symptoms. If an individual is already coming in with these comorbidities and mental health concerns, pregnancy can exacerbate those mental health concerns. And those mental health concerns can have very real consequences for the pregnancy. Mental health issues can complicate pregnancy and pregnancy can complicate mental health issues. 

I would also elevate that mental health concerns have an added layer of complexity because, often during pregnancy, the obstetric provider – whether it's a midwife or a physician – says “Oh, that's a mental health concern. We are going to send you to a mental health provider.” And then the mental health provider – whether it's a psychiatrist, psychologist, licensed clinical social worker, psychiatric mental health nurse practitioner, or mental health therapist – says, “Oh, you're pregnant, you have to go back to OB.” 

So what can happen in that time is that in unskilled hands or with practitioners who don't know much about the psychopharmacology of medications that are safe in pregnancy, the individual may be counseled to stop their medications during pregnancy, thereby increasing the chances that they're going to have an exacerbation in their mental health. The literature shows this could result in a 50% increase in exacerbation of mental health concerns or worsening mental health conditions. And that, of course, can impact the pregnancy and lead to complications.

MOLLY

Making stress an even more complex concept as it relates to being a Black woman in America, you have to layer on the Superwoman Schema, the framework that you have used in the context of stress-related comorbidities during pregnancy in your research. Can you walk us through that framework and how this adds those additional layers of complexity? 

KAREN

The Superwoman Schema is a conceptual framework developed by Dr. Cheryl Woods-Giscombé, who, in full disclosure, was my dissertation chair. She's a colleague, she's my mentor. She is the Interim Senior Associate Dean of  Academic Affairs at UNC Chapel Hill School of Nursing. 

She developed Superwoman Schema which posits that there are certain socio-cultural and historical events that have happened in this country related to racism and gender that have caused many Black women to develop five hallmark characteristics. Those characteristics are 1) an obligation to maintain an image of strength or stoic exterior, 2) an obligation to suppress emotions, 3) resistance to being vulnerable, 4) determination to succeed despite limited resources, and 5) an obligation to help others even at the detriment of our own health. 

When we think about how we show up as Black women in the world through this lens of Superwoman Schema, it’s truly complex and some say a double edge sword. Some Black women say there are both benefits and detriments to embodying these characteristics. In my research, when I asked Black perinatal women “Have you heard of the Strong Black woman or Superwoman Schema?” They said, “Yes”. And when I asked, “So where do you think that came from?” They said, “Our mothers, our foremothers, our aunties and how I saw them manage stress. From slavery times – you just had to do what you had to do.” 

One of the quotes that I hear often is “put your big girl panties on and keep it moving.” Because life is lifin’ and things are happening, we don't have time to sit and lament our woes. We still have to be able to take care of our family. We still have to be able to navigate all of the -isms, racism, sexism, structural racism, institutional racism, all of those things and still be able to provide. We don't have the option – with all the competing demands and stressors in our lives (finances, work, partner, children, ailing/aging parents or loved ones) – to stop. 

So when you add on the layers of stress, and the voice of Superwoman Schema, saying, “I'm not gonna see a therapist” (because I'm emotionally suppressing) or I show up to work and everybody thinks I'm fine (because I have a stoic exterior). People think everything is good when it's really not. Think about how that then impacts the body physiologically. And many of us have taken on these characteristics as a way of preserving ourselves. Because being vulnerable has not worked for us. 

MOLLY

What comes to mind for me, from looking at your research and from our discussions, is how that exact scenario exacerbates every part of the stressor map and makes the connections even more intense, without having outlets for it. So it impacts the severity of the internalization of stress and also affects the options for stress buffers. Is that accurate?

KAREN

So I would say that when we've asked individuals about Superwoman Schema, we ask “Is there anything beneficial about being a Superwoman and are there detriments?” In fact, that is what Dr. Giscombé has talked about as a double-edged sword. 

As somebody who absolutely has characteristics of Superwoman Schema, one of the perceived benefits is it has allowed me to be high achieving, high performing and get to where I am right now, but at what cost? At what cost to my mental health, to my physical health? So there are benefits and detriments. I have accomplished much and it has also taken a toll on my health

I would argue the detriments outweigh the benefits. I will say that many Black women talk about “breaking generational curses” and “breaking generational trauma”. Many say “I'm not going to do what I saw my mother do.” “How do I unlearn what I've seen done from my early childhood to the present day?”

I would also say, in my experience talking with Black women, when you talk to them about isolation, it is not necessarily seen as something negative. Isolation is a form of self preservation. Oftentimes, we just need a break. 

There is so much overload and overwhelm. This is how they talk about stress.

MOLLY

How they feel it in their bodies? Do you think that's how they tend to describe stress?

KAREN

Absolutely. Yes. 

And perhaps the way it's manifested is agitation, irritation, insomnia, headaches. All the things and, if you take the time to read through some of the things that have come out in the lay literature recently, you'll hear people talk about the fact that: “I just thought this was normal.”

They're so used to a ridiculously high level of baseline stress that they don’t even realize it's not normal. What's happening in their bodies is not normal.

That’s one of the reasons I bring in mindfulness. Because mindfulness is really about present moment awareness. According to Jon Kabat Zinn who created mindfulness based stress reduction over forty years ago, mindfulness is “awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally”. If I can help Black women dial down the noise and be fully present with what is arising in the body and not suppressing it, or resisting it, and start to notice “hey, my eye is twitching, my cheek is twitching, my heart is racing” – if they can become more attuned to their body and trust what they know to be true for their own body then maybe we can begin to see a shift in our health because we are becoming aware of things sooner and potentially seeking care sooner. 

However, I do not want to put too much of the onus on the individual. Outcomes can be improved through change at the individual, community, and institutional level. Healthcare providers need to be initiating conversations with patients as well AND listening. But that is another story. Getting healthcare providers to listen seems simple, but you may be surprised. I try to educate providers and emphasize that when a Black woman says something isn't right, listen to her and believe her. 

MOLLY

In the healthcare flow, as it relates to stress – knowing that stress isn't as well discussed and the recommendations are not always tangible – how should the context factor in, in terms of how to talk about, or how to describe, or how to identify stress, beyond words. Thinking about how it exists in the body. 

What is missing in the health care flow as it relates to stress and the potential impacts on health outcomes, especially for Black perinatal people?

KAREN

In my formative early work, I asked Black perinatal people whether or not they were having conversations with their healthcare provider about their stress or psychological distress, and there was a resounding “no”. They were not. 

As it pertains to psychological distress, in particular, maybe one or two individuals said “well, they asked me about depression. They asked me if I sleep a lot. But I'm pregnant so I like to sleep. Sleep isn't really ‘depression’ to me”. 

I think the way to capture things in a culturally relevant way is to think about how a population or community talks about depression or anxiety in their own words. It may not be the way in which other populations or communities talk about it. 

So, one, I don't think we (as healthcare providers) are having the conversations. Two, if we are having the conversations, we may not understand the nuanced cultural aspects of it. Three, Black women talk about mental health a little bit differently. And the way in which providers approach that conversation needs to be thoughtful, responsive, and through the lens of Superwoman Schema in terms of recognizing that Black women may show up as if they have it all together, and maybe some do. However, it is important to take time to actually have an in depth conversation with them. As healthcare providers, we need to be screening everyone for perinatal mental health issues, not just those who look like they need it.

Also, I would like to highlight that when we think about perinatal mental health, we should not just focus on depression. I think we need to consider and assess for anxiety, especially in Black communities. We can start with creating better anxiety screeners that are culturally relevant. When we screen for psychological distress, like anxiety, we need to remember that they are screeners, they are not meant to be diagnostic, but can be used to initiate conversation. 

What people often say, though, is that they'll receive a screener. Somebody scores it. The provider or nurse will see whether or not the person circled the suicidality question. If they didn't circle it, providers often assume everything is ok. Or the opposite may be true – the person admits to needing immediate care where they need to go to an ER.

If a person is in between the two ends of the spectrum, though, this is where it gets a little sticky. Typically, there can be a three month wait or longer to get in with a mental health care provider.  Even then, there is the issue of finding out if the provider will take your insurance. That's the frustration that many of the participants in my research studies have talked about. 

When I said “Are you being asked?” and they responded, “No”, I would follow up with “Would you have wanted to be asked?” (this context is very important because we cannot assume that everyone wants to be asked about their mental health especially within the context of Superwoman Schema). When doing my research, I assumed they would answer this last question with “I don't want people in my business.  No, no, no, I don't want to be asked.” But, instead, they answered “YES. But only if…” 

And the “if” is if they have a mental health care provider that is actually going to be able to see them. Someone who is stellar.  They don't want mediocre care. They want good, quality care. And they want somebody that will take their insurance – “don’t send me somewhere that will say they don’t take my insurance because now I’m back to the beginning”. And then they’re frustrated with the provider and the whole healthcare system. And they’re not trusting the provider because they just told us this vulnerable thing and we send them somewhere that doesn't take their insurance or they can't get in, and now they are just there struggling. 

There is a resistance to being vulnerable or if the person opens up, they worry that somebody will call Child Protective Services because they’re sharing a “weak” moment they had. They fear someone is going to show up on the postpartum unit after they deliver their baby and take their baby. That's what they're also concerned about.

MOLLY

This brings to mind how addressing stress exists in that subclinical, gray space of preventive care. It sounds like the clinical setting may be introducing stress but there is also a real opportunity to decrease overall stress.

Considering that screening tools, themselves, can be stressful, and the solutions before and after the diagnostic stage can be stressful, where can we build in solutions that allow for more prevention, in terms of stress, before it even gets to that point?

How should we address where healthcare is adding stress and think through solutions in healthcare that could limit stress exposure?

KAREN

Not having my mental health addressed is very stressful. Being labeled with a mental health condition and having that in my chart is very stressful. That's part of the work that I am trying to do – normalize the conversation surrounding mental health so that there's not a huge stigma associated with it. 

When people see that somebody has a history of anxiety, wouldn’t it be great if it’s considered a part of the medical record without an additional layer of stigma? 

There is a level of education within the healthcare system that needs to happen. Because there is stigma associated with mental health concerns, especially within the Black community, educating across levels – individual level, the family level, community level, systemic level, institutional level, and so on – is so important. 

For example, how we develop modules for medical residents to be thinking about how to provide culturally humble care to Black perinatal people. That's part of the way that we start having the conversations and helping those within the healthcare system to know how to have those conversations. How to not jump to “oh my goodness, she shared this particular aspect of her mental history, and now we need to involve CPS” and instead think about how to get a social worker or case manager or somebody that can help her navigate the system. There are drivers of health – like accessible transportation, for example – that impact the ability to get to appointments to manage mental health.

MOLLY

Normalization is such a key piece. 

And then, as you describe, there is the mental load of all of this. Not just navigating the healthcare system, but everything that is loading onto the stress of needing care during this time of life. And then factoring in the drivers of health – transportation as you mentioned, food security, complications accessing the social services that you may need. Then layer on Superwoman Schema – the natural response to say “Okay, I'll figure it out for myself”… 

That mental load must be intense.

KAREN

Absolutely. And then adding on the stress of childcare – if you can’t attend certain appointments because you don't have childcare – or if you have transportation issues. Has anyone put anything in the chart that you require additional help you get to your appointments? If not, it’s likely you're labeled as non-adherent or non-compliant if you don’t show up. And that adds to the stress, to the allostatic load. So we are back to what is happening physiologically? And how does that impact the pregnancy?

MOLLY

Another part of your research that I find that I found so fascinating tackles the solutions side of the equation. Specifically, the importance of diversity in medicine — the value of racial concordance between patient and healthcare provider. 

Can you speak a little bit to that research? And how it presents an opportunity to reduce stress or buffer the stress during this time of life, in the context of the Black experience within the American healthcare system?

KAREN

There is research that supports that if we have healthcare providers that look like us, we're more likely to feel like there is an inherent understanding of our lived experience and that engenders mutual trust and perhaps respect between provider and patient. Participants in the studies I have conducted reported feeling like they can let down some of those guards or barriers that would prohibit them from having a more candid conversation about what their needs are. 

This area of research is rather nascent. And within the last five years there's been more and more qualitative work that has come out to address this. A study I did with Dr. Nicole Teal in the last year focused on the importance of racial concordance between obstetric providers and Black perinatal people.  And from my own research and others, it does appear that, yes, Black perinatal people would prefer to have providers that look like them taking care of them because they feel that there's a potential reduction in harm to them. Having somebody in the room that looks like them is important. 

Anecdotally, from our study last year, one particular participant told us a story of her postpartum experience. She had delivered her baby and the nurse was doing her assessment and said to her “I don't like this bleeding. You're bleeding a lot”.  This nurse was Black and the patient was Black. The nurse called the resident who came in and said, “No, I think she's okay” and left. But the nurse did another assessment and said “Nope, I don't like this bleeding” and said to the patient “I'm about to press this button. When I press this button, there will be a lot of people coming into this room.” And she pressed the button. They came in. This person was having a postpartum hemorrhage. She had to go back for a procedure. And she attributes her survival to this persistent Black nurse. 

That is anecdotal, but we've heard story after story, narrative after narrative, recollection after recollection, of “I know for sure that, because I had a Black health care provider in the room with me, my outcome was different, I was listened to.”

What we're finding in the research is that, more times than not, there is a desire to have a racially concordant provider. Many are seeking that out. The idea is that having a racially concordant provider does improve outcomes in patients and improves patient satisfaction. 

Another thing we heard during our study was participants saying things like “my provider was white, because there just weren't a lot of options.”  

Black physicians make up 5-6% of all physicians. Black female physicians make up 2% of all physicians. If you only have a 2-6% chance of having someone that looks like you care for you. That's rough. 

So how do we increase those numbers in the hopes that it will improve outcomes?

MOLLY

What came to mind, from your anecdotal story, was the potential birth trauma at that moment. I haven't gone deep into the research of birth trauma, but from what I have read, a potentially big driver linking psychological birth trauma with negative mental health outcomes is a sense of control in those moments of intense stress. What you captured in that story was a nurse who not only took control, but also included the patient in acknowledging what was about to happen. 

A sense of control is a key piece in the internalization of stress. If the nurse had just hit the button and a bunch of people came in or even if she said, “you're bleeding, we need to fix this now,” that would have been a moment when control was taken away from that patient. Even in the smallest way, it can intensify the response to that stressor. 

Can you talk more about the value of having someone in the room who looks like you as it relates to giving a sense of control or having someone actively give you that control by bringing you in on those conversations? 

KAREN

There's already a power dynamic between provider and patient. And then think about the power dynamic between white provider and Black patient, and if we look at the historical record and just think about what those power dynamics have looked like and how there's a very real reason for why the Black community has medical mistrust and distrust of the healthcare system. From my own lens as a Black healthcare provider providing care, and also because I'm a nurse-midwife, it is really important to inform people about what is happening and not just doing things to them. We call this shared decision making or also just informed consent or having a conversation about this is what is happening in real time, instead of just doing things. It is true, we hear a lot of that – “They didn't tell me what was happening”, “They just took my baby away”, “They just put me to sleep and then I woke up and they said they had to do X, Y and Z.” 

There are true emergency situations where you can't spend a lot of time counseling about all the risks and benefits of what's getting ready to happen. But you picked up on something that's really important in that racial concordance piece, which is having someone who is more likely to say “let me tell you what's going on” because you have the shared lived experience of “I would want to know what is getting ready to happen” If I am in a room with somebody that looks like me it might be easier to say “can you take a moment to explain to me what's what's going on, what's happening?” 

That goes so far. For trust. For respect. We also know that many individuals who give birth remember their birth experience for decades and when you ask people about their birth experience, they are transported back to that time like it was yesterday. Think about how this imprints on the body. 

As healthcare providers, we have the ability to bring power into the room or take power away from the individual. 

At least helping them feel like they had some control or understanding over what was getting ready to happen to them or what was actually happening to them is such a key component of racially concordant care. Because we also know that one of the things that is a stressor for Black women is the fear of dying. That is also exacerbating the stress. Fear is a stressor. And then add on that people who are not talking to you in the moment when things are happening. It is terrifying.

MOLLY

To bring up another potential solution – community based care models, doula care, midwifery care and any other different care models that could impact health by decreasing the stress load at this time of life. Can you speak to any of those solutions?

KAREN

I would like us to also think about what has worked in the past and will continue to work: midwives. 

The literature supports the data. There is evidence to support that midwifery care improves maternal and infant outcomes. So how are we going to then increase the number of nurse-midwives? And also increase the number of diverse midwives? Thinking about how we support them.  And how to provide really good care to the patients that they serve, while understanding the cultural nuances and the importance of prioritizing what is needed for Black and Brown communities.

MOLLY

Is there anything you think we missed discussing?

KAREN

The only thing to add is just how exhausting it is for Black people, Black women, Black perinatal people to be navigating a healthcare system that is not set up to help them. There's only so much you can do to advocate for yourself if you're not being heard, or you're not being listened to.

I don't want to lose sight of that, and I don't want to sound like I'm putting a lot of responsibility on the person experiencing the disparity to fix it. It's so much bigger than the individual. But I think it needs to work at all these different levels– the individual level, the community level, systemic level – and there's plenty of work to be done. 

There is a collective exhaustion that is happening right now for both poorly resourced and highly resourced Black women.

We’re all just tired. Really, really tired.

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