t music) - Sadly, Black women are dying at disproportionate rates based on something that is totally preventable.

- As a Black pregnant person, when you walk into a hospital, there's no way to know who's gonna be the next statistic.

There are a lot of people very afraid that it's gonna be them.

- Why do so many of us have these issues?

- We ask these questions all the time, why are we here?

But we don't really talk about the effects of structural racism.

- It's kind of this perfect storm where new mothers really get short shrift in ways that can kill them.

(dramatic music) - They're wheeling me away and I cannot stop it.

Like I could not stop it.

- [Erikka] Briana Medina's birth did not go as planned.

Just before going into labor, her blood pressure shot up to dangerously high levels, a condition known as preeclampsia.

- I was just terrified.

I just felt like a scared little kid, you know?

- [Erikka] After hours of labor, Briana and the baby were both in distress, and she was rushed into emergency surgery to deliver by cesarean section.

Briana's birthing experience is all too common for Black women in this country.

- So this person already has been diagnosed with preeclampsia, so they're coming- - [Erikka] The US has the highest rates of pregnancy-related complications and deaths by far of any country in the developed world.

- The maternal mortality and morbidity that's currently happening in the United States is exactly what we've been calling it, which is a crisis.

For every 100,000 births, we have 33 people dying, and for Black women, that number is about two to three times higher.

- [Erikka] Nearly 70 Black women die for every 100,000 births and many thousands more suffer life-threatening complications or morbidities.

- At every step, it was, you know, how do I make it out alive?

I don't know when that fear started or how, but I just knew it was always there.

Even as like a teenager, it was, oh, Black women, they just die during childbirth sometimes.

And no one knows why.

- Can you imagine being a Black woman and being told that you are more likely to die over and over again, and having that fear in your mind?

That can completely impact your pregnancy experience.

- [Erikka] Ana Sofia De Brito is a certified nurse midwife at Women and Infants Hospital.

For Black women, she says, it's often a leap of faith to go into a hospital setting.

- Hi, I'm Anna Sophia.

I'm one of the midwives here.

Very nice to meet you.

When I walk into a room and it is a Black patient, I think there's an audible sigh where they're like, "Okay, maybe I have an ally here," or "Maybe this person does understand what I'm going through."

And the one thing that I make sure to do as a Black woman is acknowledge that.

- [Erikka] The number of pregnancy-related deaths for all women in the US has been on the rise for decades.

But the disparities among racial and ethnic groups has also grown.

- The gap in disparity between Black and white women in maternal mortality continues to widen.

One feature of disparities generally is that if you do not address them head on, they don't get better on their own over time.

They actually get worse.

- [Erikka] Past efforts to address the disparities have done little to turn the tide.

Heart conditions are the leading cause of pregnancy related death for Black women.

High blood pressure is often at the root, but high blood pressure is only part of a much more complex story.

There has long been a lack of understanding in the medical community about what contributes to this risk factor for Black mothers.

- Hi, I'm Dr. Stanwood.

It's really nice to meet you.

When I was in medical school and you were studying a certain disease, and you would say, what are the risk factors for that?

You know, family history, and they might say, race, and they might say that Black people were more likely to have a condition.

And there was always this underlying assumption that it had to do with genetics.

- [Erikka] What was once thought to be genetics does not bear out, nor does the belief that the poor health outcomes are solely a result of lifestyle, lack of education, and poverty in Black communities.

- What we've learned is that race is not the risk factor, it's racism.

- [Erikka] For Black women, even wealth education, and access to healthcare do not necessarily protect them from poor birth outcomes as they do for other groups.

- A Black woman who is highly educated, makes a lot of money, does everything quote unquote right, is still at a high chance of having something happen to them during childbirth or pregnancy, either a morbidity or mortality.

And we even see that in Olympic athletes.

- [Erikka] Last year, Olympic sprinter, Tori Bowie died from respiratory distress and eclampsia while she was in labor.

Eclampsia is a complication that occurs when pre-eclampsia is not treated and leads to seizures and death.

It's often caused by hypertension.

After Bowie's death, two of her three teammates on the gold medal winning Olympic relay team, Allyson Felix, and Tiana Madison revealed they too had suffered life-threatening complications during childbirth.

And one of the world's most powerful athletes, Serena Williams, came very close to death during her childbirth.

All of these athletes had emergency C-sections to save their lives and the lives of their babies.

- One of the things that I think is the most astounding in the data is that these trends of Black birthing people being more likely to die don't follow the expected patterns.

So it looks like this is her first pregnancy.

- [Erikka] Dr. Ayiti Maharaj-Best is a family practitioner and the medical director at Planned Parenthood of Southern New England.

- And so, for example, myself as a Black doctor who does obstetric work, a family physician, I know a lot about this topic, and yet still the chance that I would die is higher than a white woman who has not completed high school.

And so I think that that just tells you that these trends are so pervasive and the impact of structural racism is so deeply rooted that it defies all logic.

Do you think you could help me with that ultrasound at the beginning before we get started?

- Okay.

Absolutely.

- [Ayiti] Alright.

- [Erikka] Healthcare providers are now looking not just at their patients, but at themselves.

- When you're learning medicine, there's all kinds of bias.

As you go through the process of training in healthcare in America, you know, you do learn racism even as a Black person because it is intertwined and you don't know when you're learning it.

- The implicit bias that we as healthcare providers may have towards Black and brown patients culminate in the bad outcomes that they have, is not because there's something fundamentally abnormal with that group, but it is because of the history of how that group was discriminated against, the manner in which structures for healthcare were often not designed for their benefit, and sometimes actually in a way that could harm them.

- [Erikka] A history of racial bias still infects the healthcare system from medical algorithms and devices not developed with Black patients in mind to the implicit biases of healthcare teams.

- We hear all the time now, I think, "Doctors don't listen to Black women."

But what does that mean?

- [Erikka] Black women regularly report that they feel dismissed by healthcare providers.

Their pain is not taken seriously.

They're not fully informed of their options in order to make decisions about their own bodies.

And the most common complaint is that they are not listened to when they say something doesn't feel right.

Ignoring these complaints can mean the difference between life and death.

- And when we make people feel dismissed, or if we don't listen to them in early pregnancy or in their prenatal visits when they're trying to tell us, you know what they want their birth experience to be like, if we don't listen to those things, why would they think that we would listen when they have a headache?

It could be a sign of preeclampsia, but why would we listen?

Or when they have some leg swelling, which could be a blood clot, but why would we listen, right?

Unless it's an emergency, - The patient should be at the center of what we do, and we have to listen.

Patients know their bodies, we know medicine, and the combination of the two is the magic pill.

- [Erikka] But it is also true that chronic health issues associated with poor birth outcomes like hypertension, preeclampsia, and heart conditions are in the works long before a woman becomes pregnant.

There is now solid evidence to show that the relentless strain of societal racism is taking a toll on the bodies of Black and brown people.

- Structural racism and systemic racism is that these things can be there without the signs.

- [Erikka] 30 years ago, university of Michigan professor Dr. Arline Geronimus, coined the term weathering to describe the effects of systemic oppression on health.

- I postulated that the impacts of social injustice, racism, classism, other kinds of denigration or stigma on health accumulated over time.

My ideas had been met with quite a bit of hostility at the time.

- [Erikka] But three decades of continued work by Dr. Geronimus and by others studying genomics and stress physiology have built a body of research now published in her book on weathering.

- And I felt that over those 30 years, maybe I had been remiss.

I felt guilty that I hadn't found a way to bring weathering more into the public conversation, as I saw more and more people were dying.

- [Erikka] Dying from the conditions that arise from living with the chronic stress caused by discrimination.

- This life condition is going to cumulatively have more and more dysregulated body systems, weakened body systems, chronic diseases.

You're causing enormous erosion or wear and tear on your blood vessels on your heart.

It can lead to hypertension.

- [Erikka] It's the result, Dr. Geronimus says, of being in a persistent state of stress arousal.

That stress takes its toll.

For many Black women, their pregnancy and childbirth is where weathering shows up.

- While they may not have a nameable diagnosable disease when they start their pregnancies, it doesn't mean they're not weathered.

Pregnancy itself puts enormous stress on the body.

For anyone, if you have a already weathered body, even if it's just the beginnings of weathering or it hasn't reached the level of diagnosable disease, that stress test may just be too much.

- Mama, you wanna gimme a kiss?

Mwah!

- [Erikka] Briana's childbirth became the stress test that Dr. Geronimus describes.

Her health issues did not start with her pregnancy.

As a child, she had asthma.

She had ovarian cysts as a teenager.

And when Briana got COVID in 2020, she faced one of the worst case scenarios.

Months after contracting it, she was having difficulty breathing and collapsed.

- Jeremy rushed me to the ER, and when we got there I was like, I cannot breathe.

And the doctor came in and she was like, you have pulmonary embolisms actually so bad that your left lung might collapse.

And we were like, what does that mean?

I was like, "Am I gonna die?

Like am I gonna die?"

Because some people get a blood clot and that's it.

- [Erikka] Briana was hospitalized and put on blood thinners and managed to recover without further complications.

Once she and Jeremy decided they wanted to start a family, Briana knew it wasn't going to be easy.

- And I see Serena Williams almost died because of a pulmonary embolism.

I'm like, she is probably one of the greatest athletes ever.

And so like, who am I?

- [Erikka] In addition to risks posed by her pulmonary condition and the blood thinners, Briana faced another issue, infertility.

- So I was told basically at puberty, "It's gonna be difficult for you."

So I had that just in my mind and I kind of just ruled out having kids.

- [Erikka] It took a year and a half and fertility treatments for Briana to conceive.

At first, the pregnancy felt precarious.

- Going through what I went through trying to get pregnant, I knew that there was kind of this emotional toll.

So I was just very intentional about trying to stay calm and relaxed, nourishing my body, because of all the stresses that I feel every day.

I didn't want that to affect my pregnancy.

Hi.

- Hi.

How are you?

- Good, how are you?

- [Erikka] Briana also started working with a doula in her final trimester, and created a birth plan for a natural birth.

- I wanted to work with a doula before I even got pregnant.

It made me feel better to have people by my side to kind of, you know, guide me through that process.

- [Erikka] The pregnancy went well and Briana felt confident in her final weeks.

But things changed at her 40 week checkup.

- [Briana] I went into the appointment, and they were like, "Oh, your blood pressure's kind of high."

- [Erikka] Further tests confirmed: Briana had preeclampsia.

Her plans for a natural birth quickly dissipated.

They would need to induce labor.

- There was too many risks with the preeclampsia.

Coupled with my history.

You know, they were like, "We don't want you to go through a stroke or a heart attack or a seizure," which is what preeclampsia can cause.

- [Erikka] But Briana was holding off on other interventions and trying to maintain control of her birth.

She especially wanted to avoid a cesarean section.

- Because my history was so complex and kind of the horror stories that I had heard about Black women opting for an intervention too early.

I wasn't against these interventions, but I wanted to the best of my ability to rule them out as long as I could.

- [Erikka] But 72 hours into labor, the baby was in distress and Briana's blood pressure was rising.

- And I pushed for a while and they were like, "No."

And I was like, "What do you mean no?"

The doctor just calls it, she's like, "Before this becomes like a really bad emergency, we're gonna take you in for a C-section."

And I just broke down, like I bawled.

The first thing I thought of was C-section was like, great, I'm gonna bleed out.

Like that's the first thing that I thought of.

I was like, I'm going to bleed out.

And that's it.

- [Erikka] It's Briana's worst fear because of the risk of hemorrhaging associated with blood thinners.

As her cesarean got underway, Jeremy and her doula worked to keep Briana calm.

- I just want to make it out of this alive and healthy.

- [Erikka] And finally Noah came into the world, - They pulled her up and she cried and I cried again.

I made it through.

They wheeled me back to the room and I was looking at Noah on Jeremy's chest and just being like, "I did it.

We did it."

Okay.

It's all okay.

Like we're okay.

- It's like the biggest kept secret.

No one really talks about it, the ups and downs, and really the downs.

No one really wants to talk about how things can go wrong.

- How about you?

How have you been sleeping?

- Pretty good.

I'm actually, in the beginning it was hard.

- [Erikka] Briana's doula, Marlene continues to help her through her postpartum recovery.

She had to go back on blood thinners and carefully monitor her hypertension, which is now under control.

- Yeah, jumping, jumping, jumping.

- [Erikka] But there have been other complications.

10 months after her surgery, Briana deals with chronic pain.

- I have nerve damage from the surgery, which you know, isn't anyone's fault.

It's just how my body has healed from this trauma.

But I was just glad that the hardest part was over, which was a risk to me living.

- [Erikka] Birth traumas like Briana's play out at hospitals every day, but new doctors and nurses are now learning to better understand the underlying causes that may contribute to poor outcomes for Black women.

- Oh, that's very minimal.

Okay.

Yeah, okay.

- [Erikka] De Brito is one of the clinical educators working with doctors in training at Women and Infants.

- And it's strange that her diastolic was 92, but her... What the midwives do and what I try to do in my everyday working with the residents is bring to the attention or bring to the fact that we have patients here who are suffering from social inequalities and racism.

So when we have a patient on the floor, we talk about what else could be happening.

- So let's call our psychiatry team, see if they're available to see her, if not- - We know that what happens to us in medicine, the health part is only 10 to 12% of our whole person.

Everything else is everything else we're impacted by.

It's our home structure.

It's what's happening at work.

It's our stress levels.

Hola, buenos dias.

(speaks in foreign language) - [Erikka] The United States is one of the few countries that does not systematically integrate midwives into maternity care.

This despite research that shows the more holistic care midwives provide results in better health outcomes, reduced cesareans and an increased sense of wellbeing for birthing people.

For De Brito midwifery is deeply rooted.

- My grandmother was a midwife in Cape Verde, and she truly, in all senses, was a midwife of the community.

That inspired me.

- [Erikka] At one time, community-based midwives provided pregnancy care and delivered most of the babies in this country.

But today, most work in hospitals.

It's the result of a transition that medicalized birth, treating it more like a sickness, needing medical interventions than a natural physiological process.

In that transition, the midwifery profession dwindled.

- When we look at the numbers of midwives that exist in the country today, there are about, you know, for certified nurse midwives, about 7,000 of us.

And we attend 12% of births now, right?

So almost 99% of those births are done in the hospital.

That's a very small number.

So we've completely shifted to medicalized birth and even midwives who are working are medicalized midwives, right?

'Cause we are working within a system that wasn't built for us.

- [Erikka] The numbers of Black midwives are even smaller.

Despite a long tradition of Black women tending to births in this country.

- Black women who were brought here from Africa, who carried the traditions of midwifery.

And at that time, especially in the South, in the deep South, those Black midwives were doing about 80% of the births in this country.

- [Erikka] They were called granny midwives or grand midwives, and were essential to birthing women throughout the 19th century.

But at the turn of the 20th century, efforts to modernize and standardize doctor training led to the specialized field of obstetrics and gynecology.

By the 1940s, Black midwives were deemed no longer qualified to deliver babies on their own.

They would now be trained and supervised by white doctors and nurses.

- (indistinct) midwives in this county have built up a wonderful reputation, and I know how difficult it is to keep things clean in some of the homes where you have to go.

- They're starting to use terms as dangerous, unhealthy, that it was better to give birth at the hands of doctors.

That doctors knew what they were doing.

Midwives didn't.

They were illiterate, they were dirty.

And this is at a time where most midwives are Black.

So there's an element of racism, there's an element of sexism.

- [Erikka] Black midwives were beginning to be pushed out of the profession.

And while grand midwives continued to deliver the babies of Black women well into the 1950s, that too started to change.

- He weights eight and a quarter.

- We see that it's still really a big part of the community.

I mean, even Life Magazine does a report on granny midwives or grand midwives.

But with the hospitals becoming where white women give birth, it makes sense that Black women want what is deemed to be the best at the time.

And so we see Black women starting not to use midwives anymore.

- [Erikka] Not only was the role of Black midwives being eliminated, but barriers were instituted restricting the training of Black doctors and nurses, too.

Medical care professionals of color are still in short supply today.

- An important part of the solution to equitable maternal care is to ensure that patients are taken care of by people who, frankly, look like them, speak like them, and know their culture.

- [Erikka] When this happens, patients report they feel better cared for and have a more positive healthcare experience overall.

Some experts believe disparities in maternal health outcomes could be reduced by increasing workforce diversity.

- Now that is not a simple problem to solve, because they're also disparities in the number of medical care providers and nurses of color.

- [Erikka] For Dr. Methodius Tuuli, who leads OB/GYN at Women and Infant Hospital, solving the hiring problem is a top priority.

The community organizing group, Sista Fire, is holding him to account.

- What is your commitment to the number of people of color you're going to hire?

How are you recruiting them?

How are you sustaining the ones that you have?

- [Erikka] As part of its Black maternal health campaign, Sista Fire has been working with women and infants to address the issues contributing to racial disparities in care.

That includes recruiting and hiring practices.

- And so the hospital made a commitment that they would approach going out, recruiting at historically Black colleges, building more intentional relationships with CCRI, which is a local community college.

And so that increases another pathway for us to be able to hire.

- So how is Noah sleeping?

- She's sleeping good.

- [Erikka] Another important focus for Sista Fire was building a network of doulas of color.

Doulas are traditional birth companions who provide non-medical support for new mothers through pregnancy, birth, and postpartum.

- [Marlene] She's a fast learner.

- [Erikka] In 2021, the Rhode Island legislature passed a bill requiring insurance to cover doula care.

- The Doula Reimbursement Act being passed, that meant there was gonna be more doulas coming about, and we wanted to be part of helping to build the ground for that workforce.

And so we started to develop a doulas of color network.

- [Erikka] Building that network required training qualified doulas, and helping them set up their businesses.

- I have trained most doulas, most of the BIPOC doulas in the state of Rhode Island since 2021.

- [Erikka] Quatia Osorio is the founder of the Rhode Island Birth Workers Cooperative.

- I think at this point I'm almost over 88 doulas trained, and it has been amazing.

We just added 20 more new doulas into the networking cohort.

So I trained them and then I work on their entrepreneurship and I moved them through what does it look like to own and operate a business?

How to get your doula practice up and running.

- [Erikka] In light of the maternal health crisis, doulas have received tremendous support in Rhode Island.

They're part of the solution to better outcomes for women of color.

But birth workers caution against depending on doulas to fix the problem.

- I think people see us as easily accessible to kind of like fix this solution because they don't wanna look at the bigger issue.

Nobody wants to say, "Hmm, today I'm gonna take a bite outta racism."

Doulas are a great tool to addressing the maternal mortality disparities.

We are not the end all, be all.

- [Erikka] Increasing the diversity of our doctors, nurses, and midwives is critical to turning the tide in this crisis.

Osorio is training to be a midwife herself and has opened the Urban Perinatal Education Center in Pawtucket.

Her goal is to create a safe space for women of color to come for support, especially during vulnerable periods in early pregnancy and postpartum.

- They can come for the easy access clinic, which is focused on episodic care.

So we focus on the gaps.

You find out that you're expecting and your provider says, "We'll see you and 10 weeks."

And you're like, "What am I supposed to do then?"

So we wanted to kind of alleviate some of that anxiety, some of that unknown.

- [Erikka] Osorio says asking for help can be especially hard for Black women, but that is changing.

- Oftentimes we're like, "Oh, don't worry about it.

I got it.

Yeah, I'm fine."

But now we're like, "I actually need a little bit more help."

- [Erikka] The same holds true for asking for help for mental health issues and postpartum depression.

- So our focus is what is good, what is happening here in the maternal mental health landscape and what is working.

- [Erikka] Osorio organizes a Black maternal mental health summit to acknowledge that and imagine new policies and systems of care to improve mental health outcomes for Black and brown birthing people.

Rhode Island is a small state, which gives it a unique opportunity to affect real change in Black maternal health outcomes.

But it will take the entire community working together.

Doctors, nurses, midwives, and doulas have an important role to play, but it also requires collective action by lawmakers, community organizations, and healthcare institutions.

- There are so many reasons to figure out how to prevent these things from happening, and we have to stop thinking, that's by having the women do something themselves.

We have to see all the ways the structures of our society are wearing down their health.

And we have to make a social commitment to doing something about that.

- Everyone has a role to play in changing the conditions of our community to get healthy birth outcomes for Black families.

And you know, when we raise the level when it comes to Black families, you're gonna raise the level for everybody.

(soft music) - [Erikka] In our third episode of "The Risk of Giving birth," we focus on Latina maternal health and the troubling rise in the numbers of mothers dying.

- Instead of getting better, we are getting worse.

- [Erikka] We'll look at the challenges they face that impact their health outcomes.

- If you don't have someone advocating for the needs of the communities of color, these people would never get services that they need.

- [Erikka] And meet some of the healthcare providers going to great lengths to be those advocates.

(dramatic music) (dramatic music continues) (dramatic music continues) (no audio)