The Quest for Equity in Reproductive Health

SHANOOR SEERVAI: The U.S. has one of the highest maternal mortality rates in the developed world. This crisis gets much worse when you account for race. Black birthing people are three times more likely to die from pregnancy-related causes than their white counterparts. These disparities are stark and well known, but then why does racism continue to impact the reproductive health outcomes of Black people?

I’m Shanoor Seervai, and on today’s episode of The Dose, we’re going to talk about what it will take to dismantle structural racism in health care, particularly for Black birthing people and their babies. My guest, Rachel Hardeman, is a tenured associate professor at the University of Minnesota School of Public Health.

She also has the Measuring and Operationalizing Racism to Achieve Health Equity Lab, and partners with one of five Black-owned freestanding birth centers in the United States. We’re going to talk about new ways to measure structural racism, the capacity of health care providers to do better, and how looking at the problem differently would help to prioritize equity in reproductive health.

Rachel, thank you for joining me today on The Dose.

RACHEL HARDEMAN: Thank you so much for having me. I’m excited to be here.

SHANOOR SEERVAI: So let’s talk for a minute about how you decided to focus on your area of work.

RACHEL HARDEMAN: I’ve always focused on health equity and really thinking about what it will take to achieve health equity and ensure that everyone in our communities and our country has the opportunity for optimal health.

I got really interested in the birthing space when I was pregnant, and I had a actually phenomenal experience during my pregnancy and childbirth and in the postpartum period. But what I knew was that not everyone has access and opportunity to have and receive the type of care that I did.

And so that was always sort of in the back of my mind, you know, how can we achieve this level of care for everyone, right? Because everyone deserves that. And so I started digging more into both the persistent and long-standing disparities we see in preterm births in our country for Black infants and then, you know, really started digging into the maternal mortality and morbidity rates, knowing that someone like me, with a Ph.D., you know, my spouse is a physician — we have a lot of privilege in this space. And we saw that there were people with just as much privilege as we had who were actually suffering from adverse outcomes because of the way our system has been designed.

And so, my work from that point forward has really focused on both thinking about why that’s the case and understanding the historical context behind it, but also really developing research innovation that allows us to dismantle the systems that have created those inequities and sort of embedded them in our society.

SHANOOR SEERVAI: And can you just talk a little bit more about why, you know, you said people like you are still having adverse birth outcomes in contrast with what you said was a phenomenal experience for you.

RACHEL HARDEMAN: Yeah. So, what we also know is that Black birthing people who are high socioeconomic status, highly educated, are at greater risk than their white counterparts of experiencing adverse birth outcomes, maternal mortality, or morbidity. Which means that this issue transcends what we typically in public health talk about as sort of the great divider, right, which is socioeconomic status, which suggests that the issues are much deeper than that. Which is what led me really to dig into the role that racism plays in contributing to these outcomes.

SHANOOR SEERVAI: Can you briefly explain for me why we’re using the term birthing people today? Because a lot of the studies, you know, have referred to women for a long time.

RACHEL HARDEMAN: Yes. So I use the term birthing people to recognize that not everyone who gives birth or has the capacity to give birth identifies as a woman. And so by using the term birthing people we are including folks who are transgender or may have a whole different identity, but also are pregnant or giving birth.

SHANOOR SEERVAI: There’s a lot of data available demonstrating the disparities in outcomes for Black birthing people. It’s clear and irrefutable, but why has that data seemingly not been used to change those outcomes?

RACHEL HARDEMAN: Because we have amassed a great deal of data describing health disparities generally, disparities and birth outcomes, and maternal and infant health outcomes. But what we haven’t had, one, is political will to be able to make the large-scale changes that are needed. But also, I think when we think about the broad evidence base, we have, you know, many brilliant scholars who have documented disparities, but we also haven’t been able to measure and really get at the fundamental cause, which is racism, right?

So there’s been some great theoretical work that has very clearly identified racism as a fundamental cause of health inequities and as a fundamental cause of maternal and infant health outcomes. And some great attempts as well at measuring that and capturing that in the evidence base. But I think we still have a long ways to go in really developing rigorous and sound measures that explain what’s happening.

And to be clear, I don’t believe that we have to have those measures, right, to be able to make the changes. I think if we wanted to, right now, we could make those changes without those measures, but also given sort of how our world works, we sort of need that empirical evidence base.

And one of the goals of my research lab, of my research center, and my program of research generally, is to be a leader in that space of pushing sort of the methodological boundaries of how we capture the role that structural and institutional racism plays in health care delivery and in the lives of birthing people.

SHANOOR SEERVAI: Okay. And that’s exactly what I was going to ask you next, which is what are the new ways of collecting data that you’re looking into and what methodological changes do you suggest?

RACHEL HARDEMAN: Um, man, we could talk about this for hours because I think there’s much to be said in this space. There’s some great work that’s been done over the past few years, really operationalizing structural racism in particular, and using population health–level data. So data from the American Community Survey or Census data to describe inequity in education and employment and incarceration rates and things like that, and understanding their impact sort of at a societal level and in a given county or state. That work has been phenomenal in moving the field forward.

Some of the work that I’m really excited about that we’re doing in my lab and then my research center is really thinking about the multidimensionality of structural racism and the fact that structural racism is, it’s the water we swim in, it’s the air we breathe. It’s embedded in all the ways that we exist and go about our day-to-day life. It’s embedded in the ways that we make policy decisions. And we have relied sort of on these unidimensional measures to understand what’s happening. And what we miss then is how these unidimensional measures of structural racism are actually interacting with one another, right? Dr. Maeve Wallace has done some really great work in this space of showing how each of these dimensions of structural racism are contributing to poor outcomes in the maternal child health space.

Whereas what we also know is that someone who is struggling with unemployment perhaps also may have a criminal justice involvement, right? Or there might be an intersection there, or we know that, you know, sort of inextricable link between education and employment, for instance. And so being able to think about the multidimensionality and the ways that these manifestations of structural racism are intersecting with one another. It allows us to tell, I think, a more complex story about what’s happening in a given community but also I think it allows us to think differently about the policy behind it, right? So the goal of our work is really to inform policy, whether that’s policy at a health care delivery system level or big P policy at a federal level. If we’re going to create this new legislation that is going to ideally impact housing insecurity, but we’re not addressing employment or criminal justice involvement within that, are we missing something, A; or B, are we actually exacerbating structural racism in a different way because we haven’t thought about the ways that these dimensions are intersecting.

SHANOOR SEERVAI: So when it comes to reproductive health, what would this even look like?

RACHEL HARDEMAN: It could look a lot of different ways. So one of the things I think a lot about is that what we know right now about the role that racism plays in maternal health and maternal health care delivery is two things. One, that birthing people are coming into pregnancy and accessing prenatal care at a disadvantage when they’re Black or a person of color because of the toll that structural racism has played in their life and across the life course, right? So we know that the weathering hypothesis from Geronimus which tells us that chronic disadvantage over the life course is going to add chronic wear and tear to the body. So Black working people are at a greater risk of entering into pregnancy, sort of less healthy than we would like them to be.

And then they’re entering into a health care system that’s steeped in structural and institutional racism. And that’s when we have to bring in the historical context, right? So the fact that we are operating within and caring for patients within a hospital system or health care system, that hasn’t reconciled all of the historical atrocities in the way that Black bodies have been researched upon or mistreated.

There’s so many examples of that, you know, in our history. And also right now, you know, it’s not just our history, it’s still happening in our day to day. And so we also have the clinical encounter and the way that our clinicians have been trained or not trained to understand the issues of institutional structural racism. So we know from my research that racial concordance matters, right? So when a physician is Black and caring for a Black infant, their likelihood of mortality in those first few days after being born drop significantly. Whereas when a white physician is caring for a Black infant, the mortality penalty is quite a bit higher. And we looked at data across a 20-year period, 1.8 million births, right, and continued to see this pattern. That’s not to suggest, right, that a single physician is seeking to harm an infant, right? That is not the case at all. But I think what it suggests is that we are still grappling with the ways that structural and institutional racism are embedded in both the way that care is delivered, the way that hospital policy, health care policy has been created, the way our clinicians are trained. And so we have, all of those intersections as well to grapple with, right, to be able to really get at the heart of what’s happening and make some changes.

SHANOOR SEERVAI: And so once we start talking about what happens at the clinical level, we’re talking about, as you describe, the system that has bias baked into it for decades, for centuries, even. You raised one example, which was lower infant health if the physician is white, but can you provide other examples of the racism that pregnant people confront and how this could be dismantled by health care professionals?

RACHEL HARDEMAN: Yeah. So I think in our research, two of the things that come up often, particularly in the qualitative work we do is, mistreatment related to pain, and there’s a lot of great studies out there around pain and who gets treated for pain. But when it comes to childbirth, the data show that Black and Hispanic birthing people are less likely to receive pain medicine, even when they report higher levels of pain.

You know, they may report pain on a 1-to-10 scale at a 7, but are less likely to receive any sort of treatment for that pain. The other thing we hear a lot in our research is around respect and being heard. And so Black birthing people in particular are more likely to report not being listened to, not being heard by their doctor, not being respected, and feeling as though they are not treated as the experts of their own bodies and their own needs.

We have wonderful scholars across the country who are thinking about this and doing this work, and measuring, you know, creating patient reported measures of obstetric racism. So Dr. Karen Scott’s work has been really phenomenal in that space, to be able to then turn to our providers, our clinicians, our hospital leaders to say here’s what’s happening in these clinical encounters, here’s what’s happening during the childbirth experience. And then also, you know, here are the next steps.

I think the other way to capture some of that experience in that data is through the maternal mortality review committees in each state. So as a review committee is reviewing a maternal death, being able to identify if racism was a contributing factor, and if so, how, has been incredibly important and powerful to this work.

And we have a long ways to go and sort of really figuring out how to identify that because it’s not easy. But it’s another, I think critical data point or measurement point as we develop the evidence-base in this space.

SHANOOR SEERVAI: I want to go back to what you said about respect and being listened to, because it seems that right now it’s the job of the person giving birth to advocate for themselves. But how do you advocate for respect? Like, what does that even look like?

RACHEL HARDEMAN: You know, this is a question that I grapple with all the time. People ask me all the time, what would you tell birthing people, particularly Black birthing people as they’re getting ready to access the health care system for a pregnancy? And I struggle because they shouldn’t have to do anything but show up and be themselves and talk about what they need, right? We shouldn’t be asking them to do anything else, but we also know that while we’re working to fix the system or dismantle it and create a new one, right, that we have to also work simultaneously to keep people safe.

And so I think, you know, from the respect piece, there’s some great work that was done by like Dr. Michelle van Ryn and other folks years ago, that shows that the work that people do, particularly Black people and low-income people do, to show up in health care settings in ways that are deemed acceptable to the providers, which is again putting, you know, the onus on the birthing person. And so when I think about sort of what needs to happen or what, you know, how folks can do that right now, it’s both having, creating a support team, right, to come along, whether it’s having . . . you know, not everyone has a partner and that’s fine, but having someone with you, that cares about you, that cares about your well-being. Having a doula present can be incredibly important and, and powerful in those spaces as well. And really being clear about what your needs are, what you expect. But also being willing to move on and find a different provider, which again puts the burden on the birthing person. But I think so many of us feel like we are stuck, right, with whoever we choose and start the process with, and that’s actually not the case. And so finding someone that feels good and feels right for you is incredibly important.

SHANOOR SEERVAI: And to the extent that most providers are well-intentioned, what are the near-term changes that they could make?

RACHEL HARDEMAN: I have a couple of friends who are pregnant recently and have said to their providers: “Here’s what I know about the data for Black birthing people. What are your plans to keep me safe?” And if your provider can’t answer that question then that’s a red flag. But I think most once prompted can answer that question and can answer it honestly. I also think that, and I don’t mean to suggest that like training is like the end all be all answer. But I think it is important in the sort of near term to really ensure that our clinicians, our providers, our nurse managers, even our hospital leadership, our C-suite folks, that they understand these issues as much as possible, right? So one of the things we’re doing within my research center right now, based on legislation that was passed here in Minnesota is, creating antiracism training for perinatal care providers in the state of Minnesota. So now they’re all mandated to go through at least a one-hour training on the role that racism plays both in the lives of birthing people but also in how it shows up in the health care delivery system. And also offering them some skills around how to navigate that, how to show up, how to display empathy, how to honor the lived experience.

I mean, a lot of it feels like basic things that we do as, you know, should be doing as human beings. But what we see has happened in health care settings is because there’s time limitations, right? If you only have 10 minutes in an encounter, how do you actually get to know someone? And so we’re thinking about ways to kind of intervene in those little ways along the pathway towards kind of working on this larger institutional change.

SHANOOR SEERVAI: So I want to come back a little to the work you do around collecting qualitative data and recording stories, like using the lived experiences of people to inform your work. How does that then inform the antiracism trainings that clinicians could undergo?

RACHEL HARDEMAN: Stories are incredibly important for this work and being able to share the lived experience. And also to say to clinicians, “This is a story from your institution,” is incredibly important because it’s so easy to say, “Well, that doesn’t happen here,” or “I’ve never seen that happen.” And so in the work we did in California to create a training there, we leveraged — anonymously — stories from birthing people all over California to help inform the scenarios that we embedded in the training.

And we’ll do the same in Minnesota where we ask folks to share because it is so important to be able to lift up those stories. And also I think on the part of the person sharing, it feels like what they went through wasn’t in vain, right? Because hopefully it will be helping to change systems and change ideology in this space. And so, I think the qualitative work around experiences of racism in pregnancy and childbirth has been instrumental and moving the field forward and leveraging the attention of policymakers, of journalists. You know, when I think a few years back when the ProPublica story on maternal mortality first broke and the power of using Shalon Irving’s name and her story and other birthing people’s stories in that space — it’s what really drew people in. And I think because of it, we’re in a space now where there’s more attention being paid to these issues and more resources being put behind them.

SHANOOR SEERVAI: And I want to touch on policy before we wrap up. Do you think that the American health care system is better positioned today to address structural racism than it was 10 years ago?

RACHEL HARDEMAN: I think it’s not a cut and dry answer, right? It’s a yes and no to me. I think yes in the sense that the COVID-19 pandemic has shown us how the health care system can respond quickly and can respond with innovation and make changes and, you know, to be able to accommodate a changing society.

We saw it, we saw that quick shift to telehealth. We saw payment reform. We saw payment changes and reimbursement changes with respect to telehealth very, very quickly early on in the pandemic. And so to me that suggests that when there’s will, there can be innovation very quickly.

But I think we still lack, even amidst this sort of racial reawakening in our country, I think we still lack a lot of the will to dismantle structural racism because it means dismantling power structures that people are very, very attached to for all of the reasons that we, you know, that humans are attached to power, right? And so I think that it makes it really hard to do that work and to do it efficiently or quickly.

But on the other hand, you know, we have seen progress, right? So I’m in the school of public health. And I wrote a paper probably about six or seven years ago where we looked at the top 50 public health journals to see how many of them were naming racism — structural racism, systemic racism, or some other similar term — in the journals. I’m describing simplistically the systematic review, but it was a rigorous systematic review. And what we found is that, over a 12-year period in the top 50 public health journals, there were only 25 articles out of thousands, right, that named racism.

And so I think we’ve come a long ways from there, you know? Nancy Krieger and Rhea Boyd and colleagues just published a piece in Health Affairs where they looked at if racism was named in the top four medical journals in the past year, right? So amidst this racial reawakening in our country, certainly things have shifted quite a bit in the aftermath of George Floyd’s murder. I’m sitting in my home office a few miles from where he was murdered, right? And as someone who’s from this community, I was often asked, you know, are we in a moment or is this a movement? That was what, over a year ago. And my response was the jury still out and I’m not sure yet. And I feel like that’s still my response, right? I’m not sure yet. I think we’ve maintained some momentum, but I think we still have a long ways to go to really see the changes that we need to see.

SHANOOR SEERVAI: And if we look at this idea of seeing change, really making this a movement and not a moment, what are your top priorities right now, as you’re looking ahead to reproductive health care in 2022 and making it better?

RACHEL HARDEMAN: I think ensuring that people have access to the type of experience that they want and need. You know, you mentioned early on my work with a freestanding community birth center. What we saw in our research there is that they can create an incredible empowering experience for birthing people and also their outcomes are phenomenal, right? So they’re not seeing low birth weight babies and preterm birth babies.

But what we also know is that not everyone has access to that care, both from a payment perspective, right, so we have a lot of work to do in the health policy space there, but also, there’s a risk factor, right? So if you’re high risk, you know, you risk out of that experience.

And so, figuring out what parts of that model can be used or leveraged in other spaces to make sure that birthing people, regardless of the setting they’re birthing in, have access to culturally centered maternity care I think is a huge priority. I think we have a lot of work to do also in the postpartum space of thinking about not just offering access, which I think has been on the policy agenda and it’s moving forward and expanding access for birthing people on Medicaid for that first year postpartum, which is wonderful. But we also have to be thinking about what does that look like? Because we’re expecting people who may have had a pretty terrible experience during the prenatal period or during childbirth then to just magically decide to access postpartum care for 12 months because they have access to it without thinking about how do we create something that makes them want to do that?

I think the third thing we’re thinking a lot about in 2022 is in the measurement space and really making sure that we have what we need to quantify the role that racism plays in impacting maternal outcomes.

SHANOOR SEERVAI: I do want to point out, you know, you’ve talked about the experience that people have and then giving them the experience that they want. And I think there’s a lot of pressure in our society for joy to be a big part of childbirth and motherhood. And here we are talking about racism. So how can we turn this experience that has been and can be traumatic for so many people into something that is joyful?

RACHEL HARDEMAN: That’s such an important question. And I worry about that because even with the way that we produce our headlines or the way that even I pose research questions, it’s often from this sort of deficit place of “Why are Black birthing people dying in childbirth?” And so I think we have an important responsibility to reframe that narrative in a way that is supportive and elicits joy. If they want to have joy, you know, because some people may not want to, right, but intentionally focusing on that is both important but also it can be a powerful way to sort of enter into systems that feel not welcoming or aren’t offering you what you need.

SHANOOR SEERVAI: Rachel Hardeman, thank you so much for joining me on The Dose today.

RACHEL HARDEMAN: Thank you so much for having me. It was great to talk with you.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Karl T. Wright, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thanks for listening.