COVID-19 has exposed the fragility of our medical system. We know that maternal mortality and morbidity disproportionately affects black women and during this time, with rapidly changing policies and lack of support, we know that there are gaps that will leave black mothers exposed and can potentially exacerbate their health risk. During Mama Glow’s webinar, Birth Equity: A Spotlight on Systemic Disparities & Black Maternal Health with Joia Crear-Perry, MD, Founder and President of the National Birth Equity Collaborative, we explored the health disparities that black women face, unpacked the policy gaps and framed what birth equity really means. We looked at the structural obstacles and the work being done to challenge the system and make it safe for all of us. We want to move away from fear and step into self-determination. We want people to feel empowered to take action and advocate for themselves and take steps toward a more equitable future.
A Fight for Bodily Autonomy
Women and black people have been fighting for their rights over full bodily autonomy throughout history in the U.S., and their desires and wishes have been devalued long before the COVID-19 pandemic. This is especially apparent when it comes to how birth is treated in hospitals. The medicalization of birth handles it like an illness, rather than a miracle. Deliveries done inside of sterile operating rooms with strict regulations, a practice put in place with health and safety in mind, can actually pull birth away from the community experience it was ancestrally known as and draw attention to where the healthcare system can actually fail pregnant women (especially women of color).
Dr. Crear-Perry’s path to obstetrics and gynecology was a deeply personal one. She says she became an OB/GYN because she was pregnant in medical school and all the black OB/GYNs were already booked out. When her son was born prematurely at 5 1/2 months, Dr. Crear-Perry believed their was something innately about her blackness that made her have her baby early – because that’s what she was taught. Once she realized that was not the case, Dr. Crear-Perry recognized not only the opportunity that a dearth in black female OB/GYNs presented, but the responsibility she had to help change the way black women are treated and represented when it comes to reproductive health, pregnancy, and childbirth.
Race, Racism and Birth Outcomes
Dr. Crear-Perry reminds us that racism causes bad medical outcomes, not race. In order to achieve birth equity, some areas that need to be addressed include research, education, and policy. She says we need to generate more research that comes from black women to collect data about what respectful care means to them, change how we teach and talk about what blackness means, and work with advocates to establish policy that will not be harmful to black and brown people.
Prior to COVID-19, there was no consistent policy around how many people black and brown people could have in their delivery room to assist them, so the new delivery room restrictions in place are not actually new – it’s just new that they are impacting all people (and therefore finally getting media attention). Latham Thomas and Dr. Crear-Perry urge everyone that if you care about what these restrictions mean for birth outcomes and experiences now, you need to care about it when this is over and black people are trying to have people assist them and that support is kicked out of the room. The pandemic exposes what “high-risk” means in the U.S.; if the strategy during the pandemic is to call your provider, people who are not insured or don’t have access to healthcare might not even know what preexisting illnesses they might have that put them at greater risk. It is imperative that we use this moment as an example of what the health system should have looked like, and move forward from it agreeing that health is a right.
Capitalism in Health Care
In the U.S., the word “consumer” is often used to refer to patients, highlighting the presence of capitalism in healthcare as though, Crear-Perry indicates, “health is something you need to consume.” People are healthier in places with less consumption, which means that how we think about health in the US is, in many ways, backwards compared to other places. As an example, Crear-Perry explains that OB/GYNs get paid for patient’s care after they give birth in the hospital, as though that “transaction” is the end goal rather than an overall positive birth experience for the mother. In the postpartum stage, the OB/GYN schedules a postpartum visit 6 weeks after birth and there’s no medical reason or data supporting that framework. The only significance about that postpartum checkpoint is that you can resume sexual activity after 6 weeks (so the follow-up seems more concerned with birth control rather than on the care/health of the mother).
Dr. Crear-Perry tells us that low-risk women are being coerced to have c-sections because it’s a more sterile environment. For a woman placed into this situation, it could be a tough one to navigate because it could feel like you don’t have power over your body and birth experience. Recognize that advocating for yourself is critical, even if it may come with pushback from providers. There is also potential for provider bias to show up when it comes to prenatal care, since providers are not doing as much prenatal care in-person. Since prenatal care is, by default, a very individualized plan at this time, Dr. Crear-Perry urges pregnant people to advocate for themselves when talking to their providers, making sure that the decisions made meet the patient’s needs in the form of a co-created prenatal care plan.
Doulas & Patient Safety Net
When a doula is considered a visitor rather than a non-clinical care provider and is removed from the birth process, we are taking away access to all of the non-clinical skills that a doula brings to the birth experience that have been proven through research. As the COVID-19 pandemic persists, Dr. Crear-Perry says that the entire health system is being devalued, and it shows the cracks. OB/GYNs are struggling and feeling traumatized, having emotions and feelings of being undervalued in a way that doulas have always been. While OB/GYNs are not being provided with protection now, Dr. Crear-Perry stresses that this is the time for them to come together with doulas and midwifes as a unit. There is no safety net for doula services, and needing them now shows that they’ve always been needed. This also means that what is and has always been needed are protections and a system in place for them at all times, not just in emergencies and times of crisis.
If we want to reduce black infant and maternal mortality, Thomas and Dr. Crear-Perry say supporting birth workers outside of the healthcare systems is a critical place to start. COVID-19 has exposed the long-term need for birth center access in black and brown communities and the importance of having a patient advocacy safety net in all hospitals – particularly when it comes to doulas. Having advocates in the hospital requires the hospital giving up some of their power. Dr. Crear-Perry says that in order to establish an effective infrastructure in which doulas can do their work freely within a hospital setting, the hospitals have to value what those advocates bring and not penalize them when they do advocate for the patients, recognizing that having doula advocates is beneficial to their patient health as a whole and is not the bottom line. She reminds us to that, especially during this time, doulas need the support of others because they are also figuring out how to support themselves at this time; their help is needed, but they need to be able to take care of themselves before they can take care of others. As birth and medical professionals face and process their own traumas during this time, Dr. Crear-Perry says they should learn from the doula community about what it means to hold your own mental health and centering while caring for other patients.
Black Communities are Hit Hard By Coronavirus
Dr. Crear-Perry practices in New Orleans, where she says the same conversation that was had in NY is being had in New Orleans in terms of maintaining support in birth. New Orleans’s culture around birth and death has been uniquely challenged during this time of coronavirus, since births and deaths are treated as big social celebrations in. Dr. Crear-Perry acknowledges the concern that the NOLA community and culture will face PTSD from those missed experiences.
While the pandemic is ongoing, we cannot know what the transition to getting support back into the labor and delivery units will look like or what the longterm effects will be; however, Dr. Crear-Perry stresses that it must include educating the accrediting bodies on what equity and respect looks like for all people, not for the healthcare system. People should anticipate that the rollout back to “normal” will be haphazard and dependent upon the status of each state, just as it has been going into this current situation. What we can know, however, is that lasting change will be possible if activists within the space turn COVID-19 era conversations (like this one held by Latham Thomas and Dr. Crear-Perry) into policy and structure.
- American College of Nurse Midwives(ACNM)
- American College of Obstetricians and Gynecologists (ACOG)
- Black Mamas Matter
- Centering Health Care Institute
- The CDC
- CDC’s Guidelines for Pregnancy and Breastfeeding
- Harvard Medical School
- Johns Hopkins University
- March of Dimes
- National Birth Equity Collaborative
- The World Health Organization’s Advice for the Public