Advocates work to end race-related disparity in health care for pregnant Black patients

WEEKS AFTER HER doctor told her she had miscarried, Terilynn Nash still felt pregnant. Unmoved, her doctor told her the symptoms she was describing would go away.

But Nash refused to leave the office without taking a pregnancy hormone test. “I felt like something was wrong,” she said.

The test revealed that Nash had indeed not miscarried. Although the pregnancy was ectopic and would not come to term, she was still carrying a fetus.

While Nash had heard stories about health care providers neglecting Black women in their pregnancies, it was the first time she felt the weight of this problem firsthand.

“My first time dealing with a pregnancy and seeing the unfairness or just mistreatment, that’s when I really was like ‘yeah, I feel it, I really feel it,’” Nash said.

It is a matter of life and death. We have to just be brave enough to say ‘you know what, we might have to throw all these other ways we’ve been doing care out the window. We might have to do it totally differently.’ Jyesha Wren, BElovedBIRTH Black Centering co-founder and program director

Experiences like Nash’s are not uncommon for Black women and birthing people in the U.S. In fact, they contribute to an ongoing crisis of Black maternal and infant mortality in this country.

According to data from The Commonwealth Fund, a nonprofit that rates health care systems, the U.S. has the highest infant and maternal mortality rates among high-income countries. Black people bear the brunt of these statistics with Black women dying from pregnancy at three times the rate as their white peers, CDC data shows; black infants are 2.4 times more likely to die than their white counterparts.

But with a high percentage of Black health care providers and strong support for anti-racist programs, the Bay Area has been leading the nation in its efforts to reduce racial pregnancy-related disparities.

The region has made use of statewide funding from programs like California’s Perinatal Equity Initiative; launched its own novel approaches to addressing the crisis like the Abundant Birth Project (a supplemental income program for pregnant Black and Pacific Islander San Franciscans) and fostered regional doula networks.

In Oakland, activists have launched BElovedBIRTH Black Centering, a program staffed by an all-Black team of health care providers that reimagines treatment for pregnant Black people with its midwifery-led group perinatal care model.

Nearly three years since its launch, the program has produced promising clinical outcomes and experiences that might serve as a model for addressing the national crisis.

Co-founder and Program Director Jyesha Wren insists that the nation has a moral obligation to address this crisis.

“It is a matter of life and death. We have to just be brave enough to say ‘you know what, we might have to throw all these other ways we’ve been doing care out the window. We might have to do it totally differently,’” said Wren, who is also a midwife with the program.

Inside BEloved 

On an early Thursday morning, pregnant mothers trickle into a room that, in many ways, feels like an oasis amid the stoic offices and pharmacies of a wellness center in East Oakland.

The room, which hosts the BEloved program, has walls adorned with an assortment of pregnancy glamor shots and pregnancy-themed paintings, like one of a baby floating in outer space, anchored by its umbilical cord to a placenta moon.

A self-service coffee station has offerings like “Milky Mama Lactation Tea.”

As Afrobeats play softly from a speaker in the corner, the expectant mothers settle in their chairs, each of them holding a different brown-hued baby doll.

They cover a lot of ground in the two-hour session. They read affirmations to unpack the pressure they put on themselves, as Black women, to be perfect; how, even in the third trimesters of their pregnancies, they are resistant to accept help.

What follows is a session dedicated to lactation. A lactation consultant with the program steps in to explain the benefits of breastmilk, passing around a model of colostrum (the first milk) for the mothers to inspect. She dispels the notion of a one-size-fits-all approach when it comes to breastfeeding, inviting the mothers to share their fears and concerns.

Towards the end of the session, Jyesha Wren steps out from behind the curtain where she has been conducting prenatal check-ins for the women.

Dimming the lights, Wren leads a stretching activity, the women laughing as they try to contort their bodies around their swollen bellies.

For most of her life, if you had asked Wren if she saw herself going into health care, she would have told you no.

While she grew up surrounded by the lore of her own home birth and hearing her mom preach the gospel of midwifery, she was not particularly compelled to pursue a birth-related career.

In college, knowing that she wanted to do some type of racial justice work, she studied sociology. But it was also in college that she came to understand the horrors and statistics around the Black maternal and infant health crisis. She says she became radicalized around birth.

From her work, she knew midwifery, particularly Black midwifery, was part of the solution.

“I figured that was the best way that I could apply myself and it really got me fired up and ready to go that this was a strategic role that I could play in the movement,” Wren said.

A health crisis fueled by racism 

To understand the scope of the Black maternal and infant health crisis in the U.S, it is crucial to understand three key statistics: maternal mortality, infant mortality and maternal morbidity (the often-dangerous complications that arise in pregnancies and labor like C-sections and preeclampsia), said Rhonda McClinton-Brown, deputy director of strategy, policy and planning for the Santa Clara County Public Health Department.

According to the California Department of Public Health, Black birthing people in California are 3.1-3.6 times more likely to die from pregnancy-related causes, 1.3 times more likely to experience severe maternal morbidity, and their infants are 1.5 times more likely to die within a year of being born. Rates in the Bay Area generally mimic these disparities.

For Wren, the reason for these stark racial disparities boils down to racism. “The simple answer is, it’s racism. That’s the one-worder,” Wren said.

She identifies three main drivers behind the disparities: obstetric racism, systemic racism and weathering.

Obstetric racism, a term coined by anthropologist Dána-Ain Davis, is the implicit racial bias health care providers might harbor that may cause them to dismiss concerns Black people have regarding their health in their pregnancies.

Systemic racism, Wren explained, is the way in which racism impacts the social determinants of health — for example, zip code, income or education — that are responsible for pregnancy-related disparities. It’s the reason why in historically-redlined neighborhoods like East Oakland, in which many Black and Brown people reside, it becomes especially difficult to have a healthy pregnancy, Wren said.

While social determinants of health certainly factor into racial disparities in maternal and infant health, McClinton-Brown emphasized that all Black pregnant people, regardless of their education or income status, face these racial health disparities. 

A study from the National Bureau of Economic Research found that even the wealthiest Black families in California have worse maternal and infant health outcomes than the most low-income white families.

Lastly, the chronic stress of racism experienced over generations is responsible for cellular and biological changes to Black people’s physiology in a phenomenon known as weathering, Wren said.

While short bursts of stress are normal to have, the chronic stress triggered by racism that Black people experience physically wear down their bodies, leaving them vulnerable to conditions like hypertension and diabetes that complicate pregnancies.

Wren noted that weathering is not inherent to all those with African ancestry. Instead, it comes from a generational exposure to racism in one’s environment. She cited studies showing that African Americans have different rates of these weathering-related complications than do recent immigrants from Africa.

A different approach

With her degree in midwifery from UCSF and a new job as a midwife at Alameda Health System, the county’s public health care system of hospitals and wellness centers, Wren set out seven years ago to find a solution to these disparities.

“From my perspective it was like how can we not do this? I didn’t come to this profession to keep doing clinic like we’ve been doing. Because what’s going to happen then? Preventable morbidity and mortality, and our people are going to keep dying,” Wren said.

When she floated the idea of having a black-centered pregnancy program, there were a number of reasons the program could not happen immediately. For one, Alameda Health System did not have many Black health care providers.

She said there was also not enough political will at the time. The people she spoke to about the program had trouble imagining a solution to such a complex and lofty issue.

But as she kept pushing and with steadfast support from Black leadership at Alameda Health System (including CEO James Jackson and former Obstetrics, Midwifery, and Gynecology Department Chair Dr. Kevin Smith) and the Alameda County Public Health Department, AHS put their support behind the program.

In 2018, AHS received funding from the Perinatal Equity Initiative, a state program awarding funds to counties to reduce Black infant mortality, pushing the process forward.

What they created in the next few years was a program, the first of its kind, that, according to Wren, combined several strategies shown to reduce complications for Black folks in pregnancy.

Hoping to lower the risk of implicit racial bias and facilitate improved communication, the program would be staffed by an all-Black care team.

It would use a group perinatal care model called centering which allows for prolonged interactions with health care providers and empowerment for pregnant people around their pregnancy journeys.

Pregnant participants would join cohorts of 8-12 people, meeting 15 times throughout their pregnancies and post-partum. Rather than sitting in a waiting room for a brief prenatal check-in, they would get two-hour educational sessions to learn about their pregnancies and how to advocate for themselves in their journeys, while waiting for these check-ups.

Seeking to avoid the over-medicalization of pregnancy and building on Alameda Health System’s strong midwifery practice, the program would be midwife-led.

Each centering group would be facilitated by a midwife who would consult with physicians as needed, based on pregnancy complications outside of their scope.

Midwifery, Wren explained, is a discipline with a strong focus on listening to and centering people’s experiences. So, when it comes to ensuring Black people have empowered pregnancies where their health concerns are taken seriously midwifery becomes especially important.

Doulas, who are labor support professionals, play a complimentary role to midwives in this program, meeting a couple of times with participants before their due dates and helping them advocate for themselves.

The use of doulas and midwives in pregnancies has been shown to improve outcomes for pregnant people and infants, Wren said.

Moving through their pregnancies with a cohort of other pregnant people and health care providers would provide them with an extended village of support.

The program would serve Medi-Cal-insured people throughout Alameda County, helping Black patients who bore the brunt of the harmful impacts of social determinants of health.

The impact of the pandemic

In January 2020, Wren and her team presented their proposal, but budget constraints halted its progress.

The pandemic and George Floyd’s murder later that year led Wren to push even harder for the creation of the program; the pandemic increased pregnancy complications and dangerously isolated mothers and birthing people, post-partum. The stress of police violence with George Floyd’s murder was causing more Black pregnant people to come in with heart failure, hypertension and panic attacks.

They launched a telehealth adaptation of the program in October 2020 before their in-person launch September 2022.

Krista Hayes was part of the program’s first cohort.

When she discovered she was pregnant in June of 2020, the exact moment the country grappled with the murder of George Floyd, she felt overwhelmed.

“As a Black woman carrying Black life in, it was just a very intense experience,” Hayes explained.

Feeling alone as most of her family had moved out of the Bay due to high costs of living, Hayes found support she needed in the program.

It was through the program that she also learned to advocate for herself in her pregnancy, which became especially important when she faced complications during labor.

“I feel like it’s been a divine calling.” Krista Hayes, BElovedBIRTH Black Centering community coordinator and doula

After her pregnancy, when she saw a call out for the program’s alumni to join their doula apprenticeship program, she knew she had a responsibility to give back to the community that empowered her.

She is now a community coordinator and doula with the program.

“I feel like it’s been a divine calling,” she said of her time working with BEloved.

While Hayes affirms the realities of Black maternal and infant health disparities, she is tired of constantly feeling the disheartening weight of the crisis.

“There are still things that are happening that are joyful. That are loving,” Hayes said. “There are people out there who are still putting in beautiful work and I would love to see celebrations of groups and entities that are really putting forward the wonderful work to enrich our community.”

Coming to terms with healthy infants

This July, BEloved grew to welcome 12 cohorts per year. It is now enrolling its 20^th group since the program first started.

To understand its impact, BEloved, in collaboration with The Wallace Center, UC Berkeley’s research center for maternal, child and adolescent health, has been tracking the clinical outcomes of its patients, finding that its patients had modest but significantly better outcomes when it comes to preterm births and healthy infant birth weight, two key drivers of infant mortality.

Comparing results from BEloved patients and Black patients outside of the program, all of whom delivered at Alameda Health System’s Highland Hospital, the center found that from January 2021 until March 2023, 88.8 percent of BEloved patients had term births (babies that were not preterm). Meanwhile, non-BEloved patients had a rate of 86.5 percent.

The data showed that 89.4 percent of BEloved patients had infants with a healthy birth weight, while 85.9 percent of non-BEloved patients had babies with healthy birth weights.

While Wren emphasized the importance of tracking infant birthweight and preterm births, she says these metrics are only symptoms of the bigger problem fueling a crisis in Black maternal and infant health.

“If we know racism is the root cause of these disparities, I want to see that we’re reducing exposure to racism, I want to get at the root of things,” Wren said.

To assess the experiences of program participants, in collaboration with Project Evident, an outside consulting group, BEloved surveyed participants based on discussions from a focus group.

The survey found that 97 percent of BEloved participants reported feeling that their participation in the program led to improved care experiences, a reduction in racial bias from health care providers and respectful assistance from these providers in making decisions for their care.

To Wren, these survey results are especially important because they indicate that BEloved’s impact extends beyond the program, to the greater health care system — one of the program’s main goals.

While participants receive outpatient care through the program’s group sessions, they deliver their babies with a totally different care team, one that is not racially concordant.

The fact that participants are noticing different treatment when their health care providers know they belong to the BEloved program speaks to the program’s ability to create cultural shifts and set accountability measures in the health care system, Wren said.

“We are, through BEloved, able to help the Black women and birthing people in our program really set a new standard for ‘OK this is actually how I would like to be treated,’” Wren explained.

This experience has rung true for Terilynn Nash.

After her first misdiagnosed ectopic pregnancy, Nash suffered another before her midwife referred her to the BEloved program during her third pregnancy.

“Oh my goodness, their program was such a blessing,” Nash said, reflecting on her time with BEloved.

The program helped her know what to look for, what questions to ask, how to advocate for herself.

It also produced a happier result.

After attending the sessions, often with her husband Carl, she delivered her first child in August.

A baby girl named Nylah.

Note to readers: This story has been updated to add information about the role of Black leadership at Alameda Health System.