How Our Health Care System Treats Black Mothers Differently

KENNETHA GAINES: African American women have the highest rates of infant mortality and adverse outcomes of all major racial ethnic groups in the United States. And as of 2016, based on some statistics, the U.S. infant mortality rate for African American women was 11.4 percent compared to 4.9 percent for whites, and that’s almost three times higher. So what does that really mean for our health and our population health care in the United States?

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. This is our third episode on disparities in health care, and you just heard from our guest, Kennetha Gaines. Kennetha is the clinical nurse manager for the UCSF Health System in San Francisco. She’s also studied African American studies, urban planning, and most recently nursing, all with the goal of understanding how structural inequality impacts health. Last year, she became one of the first experts to receive the Posen Commonwealth Fund Fellowship in Minority Health Leadership at Yale University.

Kennetha, welcome to the show.

KENNETHA GAINES: Thank you for having me.

SHANOOR SEERVAI: So tell me a little bit more about what researchers, other people like yourself, found when they started looking into why there’s such a high disparity between African American women and women of other racial groups in the United States?

KENNETHA GAINES: So since 2007, even though the infant death rates have declined, there still is a racial inequality gap when you look at white versus black. Just for some context, so babies delivered preterm before 37 weeks gestation and low birth weight, which is less than 2,500 grams or five pounds, they are at the greatest risk of dying close to birth or before their first birthday. And so given that African Americans have a higher incidence of infant death, it’s also not surprising that they have high rates of preterm delivery and low birth weight.

At the time people were studying this, they were confused because they weren’t really sure what are the causes and why African Americans are so different when it comes to white women in terms of birth outcomes. So there are of course the social determinants of health, there is your neighborhood composition, there’s your socioeconomic status, there is your educational attainment, transportation, availability of resources. However, even controlling for these factors, there is still a problem.

SHANOOR SEERVAI: What you’re saying is that even once we control for access to transport, housing, educational attainment, income, African American women are still more likely to give birth to preterm infants, are still more likely to have babies of lower weight than white women?

KENNETHA GAINES: Yes. Specifically looking at socioeconomic status. Although health improves in a stepwise fashion as your income increases, racial disparities persist at each rung of the socioeconomic ladder. So in the case of infant mortality, the gap widens surprisingly as your socioeconomic status improves.

And we saw this example with Serena Williams, who’s African American, who’s wealthy, and she had some adverse outcomes, and even controlling for wealth and income she still had some adverse birth outcomes. So one explanation for this persistence of racial differences, after income has been taken into account, is that level of socioeconomic statuses are not equivalent across all racial groups given the historical obstacles that minority communities have had to face. So, for example, at every level of education African Americans have lower earnings and less accumulated wealth than whites.

Another interesting thing to note is that the black middle class really didn’t start to form until after the passage of the Civil Rights Act of 1964. That’s not that long ago. And previously, African Americans were living in abject poverty. For example, myself, my children, my daughter is 14 and my son is six. In my family, they’re actually the first generation to not have been born into poverty. So it will be really interesting to see based on that aspect of their lives, where their lives will actually develop from that point on. Further, the researchers noticed something startling. That grandchildren of immigrant parents were born smaller than their mothers, and they were more likely to be preterm, similar to African American infants.

SHANOOR SEERVAI: There is something about being African American in the United States that has an impact on you from the time that you are born, and an impact — an adverse impact — that potentially makes it worse than being born in a developing country?

KENNETHA GAINES: Right. I think the question, the foundational question, is: What is it about being born black in America that has adverse and fatal outcomes on birth outcomes and maternal health?

And so controlling for these social determinants of health and socioeconomic status and genetics, what research has looked at is that the day-to-day encounters with racial discrimination is actually linked to preterm birth in African American women based on chronic stress. So African American women live a more stressful life, which increases stress hormones that can have an adverse effect on labor.

So when we look at racism, it’s not the only unique stressor which African American and other minority groups have to face, but it also heightens exposure to and impacts other types of stressors. So what I mentioned before in terms of chronic stress, so chronic exposure to racism and inequality produces a link to prematurely aging the female reproductive system via stress-induced pathways that render a woman vulnerable to adverse birth outcomes before she can even become pregnant.

SHANOOR SEERVAI: Would you mind if I come back to the point that you made about your own children? They’re the first generation in your family who will not have been born into poverty. But I wonder if there is some sort of generational stress? Is there research or evidence that shows that even though they were not born into poverty, the legacy perhaps that they carry of decades and centuries of discrimination could still have an impact on them?

KENNETHA GAINES: Yeah. I mean, it does — I think their experiences may be a little bit different because when you are looking at the fact that not having to be born into poverty, and there is a lot of other nuances that comes along with that, and how that shapes your life and your future. But at the end of the day, my children are still African American. So yes, I do believe they will have to face challenges of what that means in the United States.

SHANOOR SEERVAI: And I mean, what is it like for you to study discrimination against African American women, being an African American woman? You’re looking at this system that’s been so horribly stacked against you, but you’re in a position where you can actually look at it and do research on it.

KENNETHA GAINES: Right. It’s an interesting question. And it’s one of those things where, you know, both of my children were born by C-sections, and for my second child it was something that was understandable based on my first experience.

With my first experience, you kind of feel like in the back of your head, if I had been white, would my experience have been different? I had labored for quite some time and I got to six centimeters, and my doctor, she was white, had come in and said that, you’re not projecting, so we’re going to have to give you a C-section, I do think of sometimes, if I had been white, would they have given me more time. I’m educated and I’m looking at my socioeconomic status, that didn’t seem to come to play when I was in my birthing room. But for my second experience, when I had my son, it was really important for me to really take control and have a voice in terms of how I wanted to drive my health care. And I think a lot of times, especially for minority communities, they sometimes don’t have that opportunity to understand their health care. And for them to be able to make their decisions, sometimes they have other people making their decisions for them. And so for my second experience, I was really looking at okay, I would like to try a VBAC, which is a vaginal birth after a cesarean section. I changed my physician. She was Latina, she was amazing, she listened to me, she agreed with me in terms of yes, if you want to have a VBAC I’ll support you in that. At the end of the day I ended up having another C-section, but it was very different because I felt like my physician actually listened to me.

I wanted to take my own experiences and say, hey these communities may not have advocates, but what can we do as a hospital to make sure that they get the best quality care that they can.

SHANOOR SEERVAI: So tell me more about that. Tell me how you took these experiences of your own and then applied them in your work.

KENNETHA GAINES: I gave birth to both of my children on the West Side of Los Angeles. Just the way that the staff, in terms of how they interact with me, the questions they asked in terms of breastfeeding, and how that was the norm. They didn’t even ask if I wanted formula or — it was just kind of known that that was the plan. And when I would visit some of the other hospitals I could see how staff would interact with different minority groups and the questions they would ask them were very different, than the experience that I experienced having my children in a more affluent hospitals in Los Angeles.

It’s really important to make sure that we are asking the questions the same way and giving all women the same opportunity. And so one of the things that I did when I was over at the maternal-child health department in both of my hospitals, I would ask the question: Do you have any questions about breastfeeding? Instead of asking: Are you going to choose to bottle feed or breastfeed? And by changing that question, I was able to open up more discussions with different patients about why they’re not choosing to breastfeed.

SHANOOR SEERVAI: Could you tell me about a patient who, when you had a conversation like this with her, actually you were able to change what she wanted to do?

KENNETHA GAINES: Yeah. So one of the first things that I did, which I think is really important, is really getting the nurses and the staff including the physicians educated. And so very specifically just talking about breastfeeding. And so really educating the staff so we’re all kind of saying — have the same message, was really important so that we can give that same message to the patients. And just having these conversations about the difference between breast milk and formula, in terms of nutrients, in terms of access, in terms of what insurance companies and health care plans are going to do more to increase support for moms that are breastfeeding, even just having those conversations with moms — and one of the things that was pretty amazing was when moms — first-time moms actually saw the first expression when you would express breast milk. And just seeing their face knowing that they’re producing food for their child, which was an amazing experience. We need to really start giving these moms education, and then letting them make their own informed decisions based on the evidence and based on the information that they have, because it’s not one size that fits all, but at least they have this information and they can make their own decision based off of that.

SHANOOR SEERVAI: So Kennetha, obviously when a woman comes in to have a baby, you can’t really compensate for the decades, the centuries of racial discrimination that we were talking about earlier. But what can you do to make sure that women are getting really good care?

KENNETHA GAINES: In terms of providing the best possible care that we can for our patients, irrespective of their race, their gender, and their class, it’s really important to normalize health care so that everyone is getting the same type of quality of health care, which hasn’t been the case in the past. Being an African American woman, what I wanted for patients that I was responsible for and that I took care of was that I wanted to make sure that we were providing the best possible quality care for these patients that may not otherwise get it any place else. And so one of the things that we looked at, so at one community hospital, we did receive a number of moms that were incarcerated.

And one of the things that was a little startling, was that there was a high — almost 50 percent C-section rate for these women. And what we looked at and tried to understand is that a lot of these women didn’t have advocates for themselves when giving birth. Because incarcerated moms, when they come to the hospital, they’re not allowed to have any other family member or anyone in the room with them. And so, who’s making the decisions for them, how are we making sure that they’re getting the best possible quality care?

One of the things that we had come up with is working with some of the jails in Los Angeles County and with a nonprofit organization to be able to provide doula services for these moms so they do have a support and advocate. And so working with them to put together this program so that these moms could have advocates for them while they’re giving birth, and see if that had an effect on reducing the C-section rate. The other thing that we noticed with these moms is that based on the fact that they’re incarcerated, how are they going to be able to breastfeed? And so we were on a process of working with them in one of the jails in — actually L.A. County has a program set up that moms can actually pump. They can store their milk and whoever’s taking care of their infant can come to the jail cell and actually pick up their milk so that they can be able to feed their infant.

SHANOOR SEERVAI: That is an amazing program. Coming back to some of the things we’ve been talking about, for some women it’s just a given that you will be able to pump or able to give your child breast milk. And for other women, it’s something that we look upon with amazement or as an exception to the norm, that there’s one jail that has this program.

KENNETHA GAINES: Right. Right, and this is — I mean, this is kind of one step — in the past it was if a mom was incarcerated then there was no way that they could breast feed their infants.

SHANOOR SEERVAI: And what you’re pointing to is basically that we have a sort of two-tiered system of care in this country, where there are women who have always been getting care like this. And this is sort of bringing me back to something you told me the first time we spoke about your previous work on communities and discrimination. At the time, we talked about food insecurity and how where people live has such a big impact on the access to food that they have, and then that in turn has an impact on their health. Can you tell me more about that?

KENNETHA GAINES: Yeah, so during my urban planning studies I did some analysis looking at food deserts, and just to give some context and background. So according to the United States Department of Agriculture, food deserts are defined as parts of the country vapid of fresh fruits, vegetables, and other healthful whole foods, usually found in impoverished areas. And this is largely due to lack of grocery stores, farmers markets, and healthy food providers. So based on my research, what I found is that in Los Angeles you see this in low-income census tracts that largely affects Hispanic, Latinx, and African American communities.

And so you would have — you have these communities where they don’t have access to a large grocery store. They don’t have access to fresh fruits. And what impact did this have on our obesity epidemic, the childhood obesity epidemic, because of not having access to these types of foods. People of the poorest socioeconomic status have 2.5 times the exposure to fast food restaurants compared to those living in wealthier areas. And 2.1 million households do not own a vehicle and live more than one mile from the nearest grocery store.

And one thing that I also noted in my studies is that low-income zip codes have more than 30 percent convenience stores actually which tend to lack healthy items than more in middle-income zip codes. And so not having access to fresh fruits and vegetables, this can add into obesity and some other types of chronic health issues. One of the other things that I noticed is that when we have higher-end grocery stores, they are actually using data and analytics to solidify where they would like to place their stores.

SHANOOR SEERVAI: So what you’re saying is that grocery stores are actually using data, demographic data, to perpetuate this vicious cycle that keeps people with low incomes from having access to healthy food?

KENNETHA GAINES: Yes. A lot of them say that a lot of that information is proprietary, and so they don’t release it. But they look at population density, education, demographics. And we kind of already intuitively know what that means. And so by using this data in order for them to be able to locate their high-end grocery stores in specific neighborhoods, it’s increasing this disenfranchisement of these communities in some of the lower-income and lower-educational-attainment areas.

SHANOOR SEERVAI: If there’s one thing that you could do to change the way that African American mothers get care, what would you do?

KENNETHA GAINES: So the long-standing nature of this disparity suggests that there needs to be a shift in focus from individual-level risk factors to larger social factors that shape disease risk in populations. And this can be in the form of maybe a national task force to bring attention and put pressure at all levels to acknowledge the problem and start problem-solving. However, this conversation needs to include African American women.

So just looking in general, African American women are multifaceted, they’re multidimensional, and they’re resilient.

And one of the things that we can start looking at is how to utilize social support for those communities, their churches, their family members, friends, and trusting relationships. Social support networks, African American women are present and they have the potential to tap in and to use as coping mechanisms to reduce stress and also increase their mental and physical health. There’s something in African American women coming together as a community, as a group, having conversations around their day-to-day stressors.

SHANOOR SEERVAI: I really like that. I think it’s, as you’ve pointed out, so important to really engage people and communities on the issues that matter most to them, because who knows them better than the people who experience these things every single day.

KENNETHA GAINES: Right.

SHANOOR SEERVAI: All right. Well, thanks so much for joining me on the show today, Kennetha.

KENNETHA GAINES: Thank you so much. I appreciate you having me.