- Just ahead on Black Issues Forum, how the undoing of Roe V Wade could impact the health of black women and why black maternal health is in crisis.

Stay with us.

[upbeat music] ♪ Welcome to Black Issues Forum, I'm Deborah Holt Noel.

We know that here in North Carolina women have the choice to decide what to do in the case of an unintended pregnancy.

However, there are regulations and restrictions around exercising that choice and there's interest among Republicans to broaden those restrictions.

Together with Roe V. Wade no longer upholding a woman's constitutional right to choose, many are sounding the alarm about how these changes could impact black women, especially, but how?

I wanna welcome Tenaja Henson, campaign coordinator for ReproAction, a reproductive justice and abortion advocacy organization.

Thank you so much for spending the time to be with us Tenaja.

- Absolutely, thank you for having me here.

- Tenaja, what is ReproAction?

- So at ReproAction, we are an abortion access advocacy organization that aims to advance reproductive justice.

So for us, that means looking at expanding education on self-managed abortion with pills, as well as exposing the dangers of anti-abortion fake clinics around the country.

- Well, it's important to understand that women, once again, still have access to abortion services in North Carolina, but should that change, however, say with the imposition of the 20 week abortion ban or a complete ban, how might that affect current health disparities among black women?

- So black women are disproportionately affected by medical racism when it comes to carrying their pregnancies to term.

So when we have a limited access to abortion care, it becomes more dangerous for women to carry their pregnancies fully to term and limits the ability for them to access care that aligns best with their needs at the time.

- And there are statistics out there about the rate of abortion and the CDC reports that black women in the US are nearly four times more likely to have abortions than white women.

Why is the rate so high among African American women and is targeting at play?

- I would not say targeting is at play.

I would say the reality of the world we live in as black people is at play.

We are made to make choices that are difficult and live in a world where accessing food and housing and healthcare is incredibly more challenging than it is for our white peers.

No black women are not targeted for abortions.

I think that that is a talking point that can be used in ways that negatively affects the access to abortion.

I would say that black people get abortions for many reasons.

And I think a lot of that has to do with the inequality that black people face in terms of access to healthcare, in terms of access to food, and in terms of access to housing which are all things you need to have a child and to birth safely and to raise a family.

- So some of those challenges might be the reasons why someone has made the decision, the difficult decision, to terminate a pregnancy, knowing that bringing a child into the world could land them in poverty.

What would you say then if that's the primary case and quite frankly, there is documentation out there, there is research that's been done to show that a lot of the times, the reasons why people are making those choices, in particular African American women, has to do with environmental conditions.

Can you talk a little bit about some of the environmental conditions in addition to access to food and jobs and that kind of thing, impacting their economic status?

What are some things that are happening in areas for black women that might also impact their need or desire to terminate pregnancy?

- Yes, I think a big one that I particularly think about is housing as a human right.

We cannot expect people to raise children in places where they cannot make a meal and give their children a bath and spend quality time with their families.

And so until we can create the circumstances in which our environments value us as full humans, deserving of homes and food and healthcare, it is really difficult to raise a child and it's very dangerous to make abortion bans.

- Well, what do you say to those who would argue that people make a decision that could lead to an an unintended pregnancy?

What about the responsibility of those individuals to make the kinds of decisions and choices before they get pregnant?

- Again, we live in a world where birth control is not accessible, in a world in which sex education is not comprehensive.

And it is our rights as humans to live in our bodies and do what we want with them in safe ways.

And if that is the argument somebody is making, I might ask them to reevaluate and mind their own business a little more.

Why do you care about this issue so much?

- I care about this issue because I have lived a life that has shown me the value in getting to choose when to start a family.

And I am deeply grateful for the care that I have received in my life and for the care that other people in my life have received.

- Women who choose to carry their babies to term want a positive experience and a healthy baby, but there are racial disparities in the outcomes for black pregnant women.

This fact was brought to greater light recently when tennis great, Serena Williams, revealed to Elle Magazine the life-threatening medical ordeal that she endured after delivering her baby, all because her medical providers dismissed her complaints.

According to the CDC, black women are three to four times more likely to die after childbirth than white women from preventable complications.

To share more, I wanna bring to the discussion Dr. Jennifer Tang, a practicing OB-GYN at UNC Health and co-lead on a study called, A Cure For Moms Aimed At Decreasing Pregnancy Complications For All Women, But Especially For Black Women.

Thank you so much for joining the discussion, Dr. Tang.

And what Serena Williams described is not uncommon, unfortunately.

Why are so many more black women dying after childbirth?

And what are some of those preventable complications?

- Well, black patients are, unfortunately, at much higher risk from not just dying from childbirth, but also pregnancy-related complications and having a preterm birth or low birthweight.

And it goes back to a lot of different social determinants of health that they've been disadvantaged to in this country because of our history of structural racism.

And even black, wealthy people like Serena Williams, who had access to excellent medical care and we're not facing the same social determinants of health, still have worse outcomes than white patients who've not even gone to college.

So that shows that it's not just about poverty, there is something else going on.

And we do think that structural racism, unfortunately, plays a large part in that.

- Tenaja, is this something that you've heard of, Serena Williams' story?

- Oh, absolutely.

And unfortunately, I was not surprised.

- Why weren't you surprised?

- It's incredibly common for black women, especially, to be overlooked or not particularly heard when they're in the hospital.

And doulas, in fact, play an important role in filling that gap to make sure that patients are listened to.

- Very well.

Dr. Tang, we know that the disparity exists.

How is this study that you're involved in designed to help save lives?

- So our study is called, A Cure For Moms, and what it aims to do is to randomize 40 prenatal clinics across the state of North Carolina to one of four groups.

So 10 prenatal clinics basically will randomize to standard cares, so no intervention, but 10 will be randomized to what's called data interventions.

And I want to emphasize that these data interventions are designed through community-based participatory research.

There's a group that's local called Greensboro Health Disparities Collaborative, which worked with UNC researchers for over 17 years to design interventions for the original Cure study, which focused on cancer disparities.

And what they were able to do through these data interventions was decrease the disparity between black and white patients completing their cancer treatments for lung and breast cancer.

And of course, it benefited all patients, because white patients improved their outcomes as well.

And so we wanted to basically implement these two data interventions to see if we could also make a difference for the disparities in pregnancy care for black and white patients.

So those two data interventions are to basically have race-stratified data presented to the practices every quarter for two years.

And what I mean by that is they will be able to look at their low birthweights or look at the maternal morbidity and mortality every quarter, but stratified by race so they can see what the outcome is for black patients and for white patients.

Because a lot of people will say, oh, I don't treat patients differently or there's not really a difference, but by showing doctors the data, what they found in the original Cure study was that it did help the providers to think together how they could make improvements for their practice and their patients.

The second data intervention that they implemented was what was called a warning system.

And so if patients weren't reaching their milestones for cancer treatment, getting chemotherapy or radiation, there was a nurse navigator who was alerted and who had then reach out to the patients and tried to figure out, what were the barriers?

Was it transport?

Was it childcare?

Was it the way they were treated in the office that made them feel unwelcome?

So we feel that we can also set up something similarly for maternal care where if patients don't reach their milestones or if they weren't screened for tobacco use or some other preventable, modifiable risk factor for bad maternal outcomes, we can address it at that time.

So again, 10 practices will be randomized to those data interventions.

So then in group three, we have 10 practices that will be randomized to community-based doula intervention.

And this goes along with what Tenaja was saying.

There is a lot of evidence that shows that doulas can really improve outcomes.

We're talking about randomized controlled trials, the highest-quality evidence out there.

And so there was a Cochrane review of over 27 studies that showed that doulas can help to reduce cesarean rates, improve the Apgar scores for babies, which is a sign of how they're doing at birth, and also reduce depressive symptomology.

And what we found also locally in Greensboro was that there was a study that used community-based doulas that offered them to patients who were predominantly black, and those who chose to have a doula throughout their pregnancy and during delivery and postpartum had four times lower the rate of a low birthweight, which again, was phenomenal, because people have been trying to reduce low birthweight for years and have not had any success.

- That is very interesting.

And it's exciting to learn that from the cancer study, that was very similar to what you're getting ready to do, doctors, once they learned what the issues were and that there were issues, they were open to making a change.

And I think that people need to understand how important that is, that there might be, people might be overlooking how they are treating you.

But once it is brought to their awareness, or once it's brought to your awareness awareness, you make the change.

And so that's very promising, not only in the the birthing space, but in other spaces as well.

So I wanna know more about what a doula is and what she does.

I know that, Tanashia, you're actually training to be a doula.

What can you share with us about what you've learned about what doulas do?

- So, something I like to say in the simplest of terms is doulas are your pregnancy bestie, pregnancy postpartum, even like in fertility treatments, you can have a doula.

And our job is to know the goals and the plan, and everything that the pregnant person wants for their pregnancy, and for their birth, and postpartum time, and to do our best to help them meet that.

And to also be confidants and support people.

And when we're in medical settings, be able to listen and be a helpful ear to make sure that all of the information that doctors are sharing is being absorbed.

And that also, the patients are being heard by the doctors as well, and making sure that the needs and maybe even concerns that patients have are being properly relayed.

- That's so interesting.

So they're really an intermediary.

And Dr. Tang, have you worked with doulas in your practice?

- I have been working with two community-based doula organizations right now to improve, you know, outcomes in this study.

And so yes, I have had exposure to doulas, although I haven't, you know, worked one-on-one with doulas in the delivery room yet.

But what I love, you know, about doulas is that they can really serve as the medical bridge, you know, as Tanashia, said, the intermediary, because as doctors, you know, we often only get 15 to 20 minutes to talk to our patients.

And then we sometimes use words, you know, one of my community collaborators, Cindy McMillan says, you know, we often use the word BMI, which is body mass index, but that's a medical term and not everyone knows.

So she'll say, you know, "People are always asking me after, like, 'What do they mean about my BMI?'"

You know, these are things that I just forget and other doctors, because we get so trained in, you know, medical terminology, we forget, you know, what is a medical word versus not.

And then patients don't feel empowered to speak up or you know, they may feel their doctor's already feeling rushed or behind.

And, you know, they come out of the appointment not knowing really what was said to them and what they were supposed to do.

And this is where the doulas really play such an important role, you know, as a team member of helping this patient have an outcome, have a healthy outcome, is that they can, you know, be that medical interpreter, that bridge between, you know, the doctor and the office and what the patient needs to understand.

And then she can also be that advocate.

If a patient doesn't understand, she can help to voice those concerns.

She can help to explain to both the doctor and the patient where there may have been some miscommunication.

So I really think they can play such an important role in helping us to improve pregnancy outcomes.

- And they're integral to the current study that you're involved in.

Are doulas expensive?

- Well, so, you know, doulas charged various rates.

But what is one of the biggest challenges in inequities is that patients who need doulas the most cannot afford to pay for them.

And yet the patients, the doulas who know the patients the best from the same community of the patients, who are higher risk can't afford to do this work for free, right?

And so we need to make sure that doulas are paid fairly for their work and that patients who can access it, that patients who need it the most can access it.

So it's very important that we find ways to make sure that doulas are properly reimbursed, particularly for those patients who are most vulnerable, at risk, and can't afford it.

- Let's talk a little bit about low birth weight in children.

What is one of the contributors, or what are some of the contributors to low birth weight regardless of the socioeconomic status of the birth mom?

- So there's two major drivers of low birth weight that I'll focus on.

One is a pre-term birth.

And pre-term birth, that rate is much higher, twice as high in black patients than white patients, both in the US and in North Carolina.

And pre-term birth has a lot of, you know, really negative consequences for the baby.

They end up staying in the hospital much longer.

It's really stressful for the baby, and the mom, and the family.

And if you want to, you know, think about holistically, it's really expensive for a healthcare system to be supporting all these babies in the NICU, because that care is really expensive, although essential.

The other major driver of low birth weight is what we call hypertensive disorders of pregnancy, which is the fancy way to say, you know, high blood pressure, and it's related preeclampsia.

Because what happens when people have high blood pressure is it reduces the blood flow to the placenta and then to the baby, and so it doesn't grow as well.

And this again is associated with long-term sequelae for the baby.

They might have more developmental problems, you know, if they're smaller than they were supposed to be at birth, whether it be from prematurity or, you know, hypertensive disorders.

And then also has long-term sequelae for the mom, because if somebody has hypertension, it's often a result of chronic weathering and stress that they've had in their life, which we know black patients face, particularly black women or people who identify as women, throughout their lifetime, because of all the microaggressions and other, you know, challenges that they face in their life.

- Yes, and the social determinants of health as well.

And we often talk about that, that's one of those terms that we use.

Can you kind of explain a little bit more about what social determinants of health are and how heavily they impact the health of black women in particular?

- So, you know, transportation, housing, childcare, these are all challenges that, you know, black patients particularly have been, unfortunately, disadvantaged to have good access to in this country because of historical things, you know, laws and other things that have happened in this country.

And so it makes it harder for them to get to the prenatal clinic.

It makes it harder for them to get healthy foods, and healthy foods are expensive too.

So finding, you know, nutritious foods, are what we call food deserts that are real issue for patients to be able to get the nutrition.

You know, having not adequate nutrition is another risk factor for low birth weight.

- And also, and I'm sorry to interrupt, but these are some of the things that are associated with a challenging or economically disadvantaged environment.

But there are women who do not have a socioeconomic disadvantage but are still experiencing low birth weight children and are affected by social determinants.

Maybe they have arrived at a place or a station in life, but early in their own lives, there was trauma or there was suffering or there was poverty.

And these are some of the, as I understand it, correct me if I'm wrong, social determinants of health and Tenaja, jump on in if you'd like to share what you've learned about social determinants of health, but it's attached to the things, as I understand, that you experience when you're two, three years old and I just think it's important to understand that these are impacts and that perhaps it's education for the women who are experiencing low birth weight to know that this is a challenge in your life or this could be ch a challenge in your life that could impact your pregnancy, that could impact your baby, and so even mental counseling and therapy and doing things to just nurture yourself are gonna help.

Are those kinds of interventions incorporated into the study, or do you evaluate those things, Dr. Tang?

- Yes, we are evaluating.

So we will be surveying about 100 patients from each of the 40 practices to understand their experiences with everyday racism, lifetime racism, as well as discrimination in medical care to see how that aligns with their outcomes.

During pregnancy, we only get about nine months to really intervene.

And it's true that our study won't be able to undo all of the lifetime racism that a patient has faced.

And so black patients will still be at a disadvantage because of that lifetime racism.

But what we'd hope to decrease is the institutional interpersonal racism, the implicit biases that patients' doctors and providers unfortunately sometimes have when where they're treating patients.

They may treat somebody just a little different based on how they look or how they act.

And so what we really wanna do is focus on making sure that patients during their pregnancy and postpartum care, get the same treatment as all other patients and are treated not in a condescending fashion, but in shared patient decision making fashion where we make decisions together.

And again, this is where the doulas can really play an important role.

And then we wanna just make sure any structural factors, if there is some kind of discriminatory practice that's happening at an institution that's disadvantaging black patients, again by looking at the data, we hope that practices and providers can help to undo some of the structural racism that may exist, as well as some of the interpersonal racism and implicit bias that exists during pregnancy care.

- Well, definitely the study that you're involved in is aimed and probably will be very successful in trying to identify some of those problem areas.

One last question I wanted to to get out to you, Tenaja, concerns funding, and if our state and our leaders are truly interested in making sure that more women are giving birth in a healthy way to healthy children then the funding I should think would follow that.

I know that there's an omnibus bill out there but there's also funding in pregnancy crisis centers.

But there's concern about that funding.

What can you share about those concerns, Tenaja?

- Well, I can share with you that crisis pregnancy centers, I call them anti-abortion fake clinics, their practices are not always in good faith.

And they use shame and misleading information to influence choices that pregnant people make about whether or not they can or should carry their pregnancy to term.

So funding those kinds of institutions that outnumber abortion clinics in North Carolina is taking away from the many, many many other resources that need to be funded in order to make sure birthing and abortion care in this state is safe and accessible.

- Well, Tenaja Henson, Dr. Jennifer Tang, thank you so much for your insights and for sharing about your work today.

I wanna thank all of our guests for joining us today and we invite you to engage with us on Twitter or Instagram using the hashtag #BlackIssuesForum.

You can also find our full episodes on pbsc.org/blackissuesforum, or listen at any time on Apple iTunes, Spotify, or Google Podcasts.

For Black Issues Forum, I'm Deborah Holt Noel.

Thanks for watching.

[upbeat music] ♪ ♪ ♪ - [Announcer] Quality public television is made possible through the financial contributions of viewers like you who invite you to join them in supporting PBS NC.