Birth Equity Matters - An Interview with Dr. Crear-Perry

Black women in the United States are at a disadvantage when they become pregnant. Even before their baby comes into the world, Black mothers have to overcome glaring racial disparities and odds in the healthcare system that are stacked against them. Black American women are at a much greater risk for preterm and low-birthweight deliveries and are three times more likely to die from pregnancy or childbirth complications than their white counterparts.

Dr. Joia Adele Crear-Perry champions the view that it is not race, but racial bias that persistently leads to poor maternal health outcomes for Black women. Inspired partly by her own experiences as a Black mother, she is on a crusade to eliminate racial disparities in maternal health. In addition to being a board-certified OB/Gyn, Dr. Crear-Perry is the founder and president of the National Birth Equity Collaborative, a non-governmental organization that strives to bridge the gaps between communities, hospitals, and governmental systems and to eradicate racial biases in health care. We sat down with Dr. Crear-Perry to discuss why we need to value all women to achieve maternal health equity, how maternal care in the U.S. has been colored by the color of a mother’s skin, and why these issues are so important right now.

How does racism impact Black women’s health?

Firstly, you need to understand what racism really means because people in general tend to have a misunderstanding of the term. It’s not something that only evil, mean-spirited people do to other people. Racism is a belief in a hierarchy of human value based on skin color that has become embedded in our policies and in our healthcare system. Both historically and currently, it has found its way into our laws, our social world (e.g. movies and TV shows), and our value systems, which dictate how we see people.

Because of this deeply embedded bias in our culture, we’ve lately been seeing many cases of reaction without thinking. A policeman believing that he can put his knee on the back of George Floyd’s neck for 8.5 minutes because he didn’t value him fully as a human being is in many ways analogous to what is happening to Black birthing women inside hospitals.

What are some examples of racism you’ve come across in your research on Black birthing mothers?

A recurring issue is when Black birthing mothers tell their provider that they are having pain (e.g. headache, chest pain, etc) or some other kind of physical or emotional complaint, their complaints are frequently dismissed. Sometimes the symptoms aren’t serious, but other times they could be the difference between life or death. It's important for providers to listen to the needs of all patients in order to care for them. When a person's chest pain or bleeding is not taken seriously, it can lead to deadly consequences. [Serena Williams’ birth story is one example of this issue that resonated for Black women and crossed over into the “mainstream” thanks to her celebrity.]

“Disrespect can turn into death really quickly.”

Many women end up in the ICU or with long-term complications because they are not heard and believed throughout childbirth. Studies have shown quantitatively that Black women are not getting pain medications at the same rate during or after delivery as their white counterparts. We’ve also heard reports of patients having an episiotomy or another surgical procedure performed without permission or anesthesia. [In a 2019 study, WHO researchers found that women of color reported far higher rates of mistreatment than the broader population, causing them to feel as if their provider was not listening to them, leaving them out of decision making, or refusing their requests for help.]

How does the rate of death during and after childbirth in Black women compare to that of white women?

In the past decade, there was no official count of maternal deaths in the U.S. until 2018. The last one before that was in 2007. We don’t have accurate figures for maternal morbidity simply because our country has disinvested in public health. One of the ways to calculate maternal morbidity is to match all the death certificates to all the births that have happened in the country, and we haven’t invested in the infrastructure to do that counting. In 2018, I testified in front of Congress to incentivize the states to invest in public health for counting maternal deaths, which they are already required to do with clear metrics for infant mortalities. Since we haven’t valued birthing women, we haven’t been keeping track of official numbers of their deaths.

“You don’t count what you don’t value.”

When the study came out in 2018, it showed that the U.S. has the worst maternal mortality rate in the industrialized world. It also showed findings like Black women who have an education higher than a college degree were five times more likely than white women with no high school education to die in childbirth. This large gap exists despite income and education, which is so important because it contradicts the historical myth of blaming and shaming Black birthing mothers.

The myth that has been perpetuated in our country holds that the reason Black women are more likely to die in childbirth is that they are less educated, less compliant, or overweight. When you pull and analyze the data, even when a Black pregnant woman is none of those things, she is still more likely to die. There is no biological difference between Black women and white women. Therefore, it is how Black women are seen and treated in the hospital system that has a huge impact on their ability to thrive during and after pregnancy.

What are the most common causes of death in Black mothers?

Currently, for Black women, the most common cause of death is cardiovascular disease. Other causes include hemorrhage [bleeding too much], blood clots (which travel from somewhere else in the body like the leg to the lungs), and high blood pressure. Often there is an assumption that Black pregnant women always have high blood pressure. But if high blood pressure is not treated with medication in a timely manner, then they’ll be more likely to die from complications.

Erica Garner, the daughter of Eric Garner, [who was murdered in a chokehold by a New York City police officer in 2014,] died at six months postpartum from heart failure caused by cardiomyopathy. Reenacting her father’s death and fighting for justice were traumas on her 28-year-old body, and her heart became enlarged. We’re now seeing increases in these sorts of cases in Black women.

The Maternal Mortality Review Committees set up in various states have reviewed their states’ cases and determined that if 60% of deaths related to pregnancy were handled differently, the women would have lived. You should not bleed to death during childbirth in the U.S. We have all the medicine and infrastructure needed to treat a heart attack or blood clot. If we know that roughly 700-900 women per year die within a year of childbirth in the U.S. and 60% of those deaths are preventable, then that number should be closer to 300.

Do certain parts of our country have glaringly high rates of Black maternal mortality and morbidity?

There was a time when Texas and Georgia were fighting over who had the highest rates. Generally, most states that don’t offer Medicaid expansion or access to reproductive choice have the worst maternal health outcomes.

There are problems everywhere. Urban problems are just different from rural problems. Large swaths of the United States don’t have access to medical resources, and the women who live in those areas have barriers to proper health care. If you’re bleeding and you live an hour from the nearest hospital, there’s a good chance you won’t survive.

The places that do better are the places that have a better social safety net. These are areas where women have paid leave so they don’t have to rush back to work and ignore their symptoms...where new mothers don’t have to choose between working so they can put food on the table vs. going back to the doctor because they have a headache, and they end up having a stroke after having a baby. Women in the U.S. have to make all sorts of false choices like these because our government doesn’t provide an adequate social safety net including childcare.

How can we emulate countries that have better outcomes for maternal mortality and morbidity?

37 countries that are considered “high income” have all agreed that health is a right. When you believe health is a right, then as a country, you figure out what are your obligations to your people. Scandinavian countries such as Finland and Norway are the best models because they offer free college and free childcare. They have also worked on gender equity in the government and inside of Fortune 500 companies. These are the places that have better maternal health outcomes.

In our country, we talk a lot about “health care” and spend way more on health care than those other countries, but that is not the answer to improving maternal health outcomes. It’s the social safety net - everything around our ability to live freely.

“What would make us exceptional as a country is if we were to show that as a diverse nation we believe that every person has the right to health.”

Health care should not be treated as a transactional thing that you get or lose based upon your job, which implies that people who are unemployed don’t deserve it. If you believe that everyone has the full potential to be healthy, then you should provide social safety net measures to support that at a national level. We have never done that.

How can we improve the treatment of Black birthing women in the U.S.?

The WHO (World Health Organization) has created some global standards for respectful maternity care, which include an expectation that you should be able to have a baby and birth in a way that meets your needs and that makes you feel honored, listened to, and valued. Over the past year, we [at the National Birth Equity Collaborative] have partnered with ACOG, Johns Hopkins Bloomberg School of Public Health, and Black women-led organizations on the ground to work on what “respectful care” means in the U.S. context.

Asking the question, “What are some of the things you want for respectful maternity care,” on patient experience surveys for birthing mothers is one way we can hold the system accountable for respectful maternity care. Most providers think of “trust” in the sense that they want their patients to trust what they’re saying and regard them as an authority around the information they provide. But, when patients talk about “trust,” they mean it both ways. They want providers to trust that they know their bodies, that they are making the best decisions for themselves and their families, and that they are valuable. So many times for women of color and other marginalized groups, providers do not trust their patients’ ability to make good healthcare decisions or do not even see them as fully human.

How should healthcare providers be held accountable for disrespect or abuse?

That’s the next step in our work at the National Birth Equity Collaborative. We don’t currently have an effective, objective system of redress. Patients don’t have a direct line to the Joint Commission, which is the ultimate body overseeing all the hospitals. And if they did, they wouldn’t even know how to use it. This creates a damaging power dynamic.

“You’re at a power disadvantage to complain about mistreatment while still needing treatment.”

Let’s say that you’re a Black birthing mother in Philadelphia and you feel that you’ve been discriminated against by the nurse who is delivering your baby. Under the current mechanisms of redress, you have to get a nurse manager to write the person up. But it's hard to feel empowered to do that when you’re still under that person’s care. We need to rethink and reevaluate how we can ensure that patients are able to hold providers accountable for not giving them respectful maternity care.

What sorts of training and standards should be implemented to prevent mistreatment?

We have been able to get a conversation going at the federal and state levels about implicit bias. This is something that people understand now, and having training around implicit bias is something we’re striving for. In California, there is a law that requires all people who care for birthing women to take a training course on implicit bias, and there are bills at the federal level that would do the same.

Our goal is to move it a step beyond implicit bias to also include explicit bias since we know that some people are both unconsciously and consciously harming others. We cannot take it out of the context of the root causes of racism, classism, and gender oppression. It’s common to have some biases, but it’s not ok to have biases against obesity, the elderly, the disabled. Those are the types of biases that we have to work as a country and a people to undo. This is critical in health care because it can be the difference between someone living or dying.

How can the mission of the National Birth Equity Collaborative benefit from the Black Lives Matter movement?

We would not have the language or the tools to do the work that we do without the Black Lives Matter movement. They have created a space in this country to have an open and honest conversation about racism that we were not having. Right now, especially with the COVID-19 overlay, you can see how important the Black Lives Matter movement is and how it ties in with our mission.

We see ourselves as working in conjunction with the Black Lives Matter organization. Because the Black maternal health movement has been getting lots of attention as of late, we wrote a letter to Black Lives Matter about how we could invest in our nation’s social safety net. When a police department takes up over half of a city budget, [those in lower-income communities] don’t have access to things like mental health care services and adequate supplies in schools. Investing in these sorts of social supports are what allow Black mothers and families to thrive.

What can someone interested in supporting this cause do to help?

1. Go to birthequity.org, read our resources, and sign up for our mailing list.

2. Visit the Black Mamas Matter Alliance and make a donation to advance Black maternal health, rights, and justice. This organization is always underfunded.

3. Right now, the most important thing people can do to support our work at the National Birth Equity Collaborative is to support the Black Lives Matter movement. The more we can push for overarching reform and promote anti-racism, the more this progress will support Black birthing women.

With Warmth and Wellness,

Your EmmaWell Team