CPSolvers: Anti-Racism in Medicine Series
Episode 17 – ‘Just’ Births: Reproductive Justice & Black/Indigenous Maternal Health Equity
Show Notes by Ayana Watkins
May 31, 2022
Summary: This episode centers the roles of reproductive justice and anti-racist action in rectifying inequities faced by Black and Indigenous birthing persons. This discussion is hosted by Naomi Fields, MD, Chioma Onuoha, and Victor Lopez-Carmen MPH, as they interview Dr. Joia Crear-Perry—a physician, policy expert, and highly sought-after birth equity and racial health disparities expert—and Dr. Katy B. Kozhimannil—the Distinguished McKnight University Professor in the Division of Health Policy and Management at the University of Minnesota and Director of the Rural Health Research Center. Our inspiring guests highlight liberation-oriented solutions to addressing inequities and contextualize how we can facilitate birthing experiences grounded in reproductive justice for Black & Indigenous women.
Episode Learning Objectives
After listening to this episode, learners will be able to…
- Understand the magnitude of disparities faced by Black and Indigenous birthing persons and how forces of structural racism created and perpetuate these inequities
- Define Reproductive Justice and understand how clinicians can promote reproductive justice during pregnancy and birth
- Appreciate the importance of cultural reflexivity, community-centered initiatives, and midwifery and doula care in facilitating reproductive justice
- Recognize the impacts of climate and land injustices on Black and Indigenous communities and know that climate justice, reproductive justice, and racial justice are all connected
- Written and produced by: Naomi F. Fields MD, Chioma Onuoha, Victor A. Lopez-Carmen MPH, Rohan Khazanchi MPH, Sudarshan Krishnamurthy, Utibe R. Essien MD, MPH, Jazzmin Williams, Alec J. Calac, LaShyra Nolen, Michelle Ogunwole MD, PhD, Jennifer Tsai MD, MEd, Ayana Watkins
- Hosts: Naomi F. Fields MD, Chioma Onuoha, and Victor A. Lopez-Carmen MPH
- Infographic: Creative Edge Design
- Audio Edits: David Hu, MD
- Show Notes: Ayana Watkins
- Guests: Dr. Joia Crear-Perry and Dr. Katy B. Kozhimannil
03:57 Magnitude of maternal health disparities for Black & Indigenous birthing people
09:31 Impact of guests’ identities and lived experiences on their work
25: 30 Defining reprodutive justice
29:42 Importance of community-centered initiatives and access to midwifery and doula care
35:15 Impact of Climate and Land Injustice on maternal health inequities
42:43 Role of family planning within reproductive justice
58:00 Key takeaways
- We have a responsibility to unlearn the harmful hierarchies that unequally value people. The institutions of science, medicine, and academia perpetuate and codify racism. We all must recognize the codification of racism within our institutions and work to unlearn these hierarchies in order to better care for Black and Indigenous patients.
- Be present in the birthing moment and see the full humanity of the birthing person and the life-changing nature of birth. Dr. Kozhimannil reminds us that birth is transformative and a gift to witness. As healthcare providers, we must listen to our patients and use the power of our presence to see birthing people’s full humanity and empowerment.
- Black and Indigenous birthing people are 3-13 times more likely to die in childbirth, with the rate varying by location and level of investment in communities.
- Dr. Crear-Perry describes the magnitude of maternal health disparities faced by Black and Indigenous birthing people. The exact statistics vary by location and by the overall level of investment in each community. For example, in places that invest more into their communities through services such as childcare and parental leave, like in New York City, Black birthing persons are 8-12 times more likely to die in childbirth, while in areas with an overall lower level of investment, such as in areas in the Deep South, the increased likelihood of death in childbirth for Black birthing persons is lower, around 2-3x.
- Dr. Kozhimannil reminds us to look past the statistics and zoom into the personal level. She urges us to recognize that maternal mortality changes the life trajectories of individuals and communities. These statistics not only reflect the number of birthing people dying in childbirth but also evince the number of children growing up without a parent and the number of families losing a loved one. She also reminds us that while mortality is the worst possible outcome, it is not the only thing we should be concerned about; that we must also ask the question: What are we doing to ensure that birth is as beautiful and empowering as possible?
- “I have worked to imbue the credibility of my lived knowledge into the credibility that I now receive as a fancy person with a Ph.D. and a professor.”
- Dr. Kozhimannil describes that her identity and her background—growing up in a rural area, having family living on tribal lands, and the intergenerational impact maternal mortality has had on her family and on her people—inform and motivate her work. She recognizes that academia and medicine traditionally do not listen to the people closest to the harm of structural racism and thus aims to use the credibility and privilege she receives from academia as a “Distinguished Professor” to persuade people with power to change the way they allocate power, resources, and opportunities.
- Both Dr. Crear-Perry and Dr. Kozhimannil describe experiencing rejection when submitting their work to journals because of academia’s resistance to acknowledging racism as a cause of disparities.
- Defining Reproductive Justice
- Dr. Crear-Perry explains that the term “reproductive justice” was coined in 1994 by 12 Black women and is defined as the fundamental human right to personal bodily autonomy, to have children, to not have children, and to have safe and sustainable communities in which to parent children.
- Reproductive justice first requires birthing people to be viewed as fully human. As Dr. Crear-Perry notes, Black women and other marginalized people in the United States have never been viewed as fully human. The second tenet of reproductive justice is the right to have children, and the third is the right to not have children. Certain policies have impeded birthing people’s ability to choose to not have children by taking away rights if people do not bear children. For example, at one time in Louisiana, only childbearing adults qualified for Medicaid. This policy reflects a societal belief that humans are not valuable unless they provide a service. Dr. Crear-Perry discusses a policy proposed in Michigan grounded in a similar notion: it required people living in urban areas to have a job in order to qualify for Medicaid. (To expand, this provision in Michigan was initially included in a State Senate bill for Medicaid expansion, but the work requirement was scrapped before the policy passed.) The final tenet of reproductive justice is the right to parent children in a safe, sustainable community. Parents deserve to raise their children in communities that value human life. For example, safe and sustainable communities have access to paid leave and equal pay, parks, and walkways, and lack dangerous aspects, like police violence and mass incarceration.
- Impact of climate and land injustices on maternal health equity
- Dr. Crear-Perry discusses previous research detailing the impact of climate injustice on maternal health transnationally. For example, Black babies born in communities that experienced redlining were more likely to die, and heat is known to cause premature birth. Additionally, scientists have used climate change to promote population control and to codify eugenics by falsely blaming climate change on high birth rates within poor, Indigenous communities around the world rather than uber-consumptive corporations.
- Dr. Kozhimannil asserts that “climate justice and reproductive justice and racial justice are completely the same thing.” The climate crisis indicates a tear in the connection between humans and the earth and between us and one another. Dr. Kozhimannil believes the most powerful way to reconnect humans to each other and to the earth is through a good birth, in which we are connected to the land and are surrounded by loved ones.
- Dr. Kozhimannil also describes an Indigenous philosophy of honoring the seven generations of ancestors that came before you and striving to be a good ancestor for the seven generations that will come after you. The process of childbirth is transformative for the birthing person and their community. Clinicians are able to shape the environment in which people give birth by caring for the earth and their patients.
- The extent to which “family planning” fits within reproductive justice
- Dr. Crear-Perry outlines the history of the term “family planning” and states that the idea of family planning stems from population control and eugenics. She urges us to remember that the abiltity to plan anything, is determined by generational access to power; and calls for discontinuing the use of this term. We should instead prioritize reproductive and sexual well-being and seeing Black and Indigenous birthing people as fully human.
- Dr. Kozhimannil discusses her work on rural maternity care and the lack of hospital-based obstetric services. The places with the least access to hospitals in which they can give birth are also the places where people have experienced forced sterilization, where people do not have access to choices surrounding contraception, sexuality, or termination of pregnancies. Dr. Kozhimannil asks what moms and families can do if they do not have access to pregnancy prevention or termination and yet also have no place to give birth.
- Asking the right questions, having the right intentions
- Dr. Kozhimannil shares an important story about how her groundbreaking work showing maternity deserts in rural areas only came about by centering and engaging community members. In research we always begin with the research question and perhaps wonder if we are asking the “right” question. Dr. Kozhimannil offers a different approach, and stresses the importance of “answering the right question, from the people [communities impacted], who know the right question.”
- Dr. Crear-Perry offers additional wisdom about interventions: “If your intention is off, your outcome is going to be off.”
Clarification: In this episode, Dr. Crear-Perry talks about eligibility for Medicaid expansion in Michigan requiring folks who lived in urban areas to have a job vs folks who lived in rural areas not needing to meet this requirement. What Dr. Crear-Perry mentions was a proposal that the State Senate wanted, but ended up doing away with before passing Medicaid expansion. See Reference 20 below for additional information.
- Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race lens to relationship-centered care in pregnancy and childbirth: An antidote to structural racism. Birth. 2020;47(1):3-7. doi:10.1111/birt.12462
- Sable-Smith B. As Rural Counties Lose Obstetrics, Women Give Birth Far From Home. https://www.kcur.org/agriculture/2017-10-02/as-rural-counties-lose-obstetrics-women-give-birth-far-from-home#stream/0
- Bekkar B, Pacheco S, Basu R, DeNicola N. Association of Air Pollution and Heat Exposure With Preterm Birth, Low Birth Weight, and Stillbirth in the US: A Systematic Review. JAMA Network Open. 2020;3(6):e208243-e208243. doi:10.1001/jamanetworkopen.2020.8243
- Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O’Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health. 2013;103(4):e113-e121. doi:10.2105/AJPH.2012.301201
- National Birth Equity Collaborative. Dr. Joia on BMHW & Why Black Women & Birthing People Are Experiencing Poor Outcomes | NBEC.; 2021. https://youtu.be/GPAlyT8tuhE
- Improving Equity in Birth Outcomes, a Community-based, Culturally-centered Approach. Robert Wood Johnson Foundation Interdisciplinary Research Leaders Program. Published January 16, 2019. https://irleaders.org/team/improving-equity-in-birth-outcomes/
- Improving Racial Equity in Birth Outcomes: The Roots Model of Care. Published online August 2020. https://2jywg813w195318ee51g9iti-wpengine.netdna-ssl.com/wp-content/uploads/2020/10/IRL-Issue-Brief02-Minneapolis-1.pdf
- National Birth Equity Collaborative. Injustice Anywhere: Why Climate Justice Is Reproductive Justice.; 2021. https://youtu.be/FhakcqNs_08
- Katy B. Kozhimannil, PhD, MPA. https://directory.sph.umn.edu/bio/sph-a-z/katy-kozhimannil
- Henning-Smith C, Kozhimannil KB. Missing Voices In America’s Rural Health Narrative. Health Affairs Blog. Published April 10, 2019. 10.1377/hblog20190409.122546
- National Birth Equity Collaborative. National Birth Equity Collaborative Annual Report 2020-2021. https://issuu.com/gafford/docs/nbec_2020-21_annual_report
- Hostetter M, Klein S. Restoring Access to Maternity Care in Rural America. Published online 2021. doi:10.26099/CYCC-FF50
- Hardeman RR, Karbeah J, Almanza J, Kozhimannil KB. Roots Community Birth Center: A culturally-centered care model for improving value and equity in childbirth. Healthcare. 2020;8(1):100367. doi:10.1016/j.hjdsi.2019.100367
- Plain C. Study shows growth of certified nurse-midwives practice in rural U.S. hospitals could improve access to high-quality maternity care. Published April 20, 2016. https://www.sph.umn.edu/news/study-shows-growth-certified-nurse-midwives-practice-rural-u-s-hospitals-improve-access-high-quality-maternity-care/
- Proujansky A. The black midwives changing care for women of color – photo essay. https://www.theguardian.com/society/2019/jul/24/black-midwives-photo-essay
- Kozhimannil KB, Henning‐Smith C, Hung P. The practice of midwifery in rural US hospitals.. Journal of Midwifery & Women’s Health. 2016;61(4):411-418. doi:10.1111/jmwh.12474
- The iEJ Project. What Is Indigenous Environmental Injustice?; 2018. https://youtu.be/kswUgZ2ctO4
- Lopez-Carmen VA, Erickson TB, Escobar Z, Jensen A, Cronin AE, Nolen LT, Moreno M, Stewart AM. United States and United Nations pesticide policies: Environmental violence against the Yaqui indigenous nation. The Lancet Regional Health – Americas. https://www.sciencedirect.com/science/article/pii/S2667193X22000722#bib0044
- Blakemore E. The First Birth Control Pill Used Puerto Rican Women as Guinea Pigs. History. Published March 11, 2019. https://www.history.com/news/birth-control-pill-history-puerto-rico-enovid
- Norris L. Michigan and the ACA’s Medicaid expansion. Healthinsurance.org. https://www.healthinsurance.org/medicaid/michigan/
- Kozhimannil KB, Casey MM, Hung P, Prasad S, & Moscovice IS. (2016). Location of childbirth for rural women: implications for maternal levels of care. American journal of obstetrics and gynecology, 214(5), 661.e1–661.e10. https://doi.org/10.1016/j.ajog.2015.11.030
- Kenneth J, Okun T. White Supremacy Culture. Excerpt from Dismantling Racism: A Workbook for Social Change Groups, by Kenneth Jones and Tema Okun, ChangeWork, 2001. https://www.thc.texas.gov/public/upload/preserve/museums/files/White_Supremacy_Culture.pdf
The hosts and guests report no relevant financial disclosures.
Crear-Perry J, Kozhimannil KB, Fields NF, Onuoha C, Lopez-Carmen VA, Krishnamurthy S, Calac A, Nolen L, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 17: ‘Just’ Births: Reproductive Justice & Black/Indigenous Maternal Health Equity.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. May 31, 2022.