The Dose - Uncared For: America the Outlier

Episode Date: December 16, 2022

The maternal mortality rate in the United States is more than double that of our peers – and it’s especially high among Black birthing people. Why? The Commonwealth Fund collaborated with Lemonada Media to create Uncared For, a six-part podcast series, hosted by award-winning journalist SuChin Pak (Add to Cart, MTV News) to take a personal and wide-ranging look at maternal health care around the globe to find the answer.  On today’s episode of The Dose, we’re sharing the first episode of Uncared For. SuChin Pak talks to Brandi Jordan, a doula who was an essential support for Pak’s own childbirth. Even though Jordan has decades of childbirth experience, when it came time for her own pregnancies, she was repeatedly ignored and neglected by her doctors. Unfortunately, Jordan is not alone in experiencing a system that disproportionately fails Black birthing people. The first episode of Uncared For examines some of the factors that contribute to the systemic racism that Black birthing people face in the United States and unpacks the historical roots of these inequities. Over the course of the series, the show explores health care systems in Germany, the Netherlands, and Costa Rica to find solutions for a health care system that’s safer for all birthing people. All six episodes of Uncared For are now available wherever you get your podcasts.

The Dose is a production of the Commonwealth Fund, a foundation dedicated to healthcare for everyone. Hi there, Dose listeners. This is Sujin Park. Now, you may be wondering what I'm doing here. Well, I wanted to share a new show from the Commonwealth Fund and Lemonada Media. It's called Uncared For, and it looks at pregnancy and childbirth in the U.S. and abroad.

Have you ever wondered why a country that spends over $4 trillion on health care every year has the highest rate of maternal mortality of any high-income nation? Or why the U.S. doesn't involve midwives in pregnancy care like our peer countries do. On this season of Uncared For, we'll unpack the roots of our maternal health crisis, delving into everything from housing discrimination to abortion restrictions.

We'll visit other countries to learn what they're doing to improve maternal outcomes, both during and after pregnancy. And we'll answer the question, what would it take to build a maternal health system that centers dignity, autonomy, and love in the delivery of care here at home? So here's the first episode of the series. If you enjoy it and want to hear more, all six parts are available now wherever you get your podcasts. I woke up in a completely black room and I jolted up out of my sleep and it felt like there was something sitting on my chest. I was gasping for air. My husband was next to me, but I couldn't even speak to him.

I was trying to wrap my head around what was happening to my body, and I thought I was dying. I thought that was it. That's Dr. Whitney Polk. She's a lecturer in counseling and mental health at the University of Pennsylvania. Just after giving birth to her first child four years ago, she realized that something was really off. I was trying to walk my daughter from her changing table to her crib, which was probably like a three to four feet distance, and I could barely do it. She went to see multiple doctors, but none of them seemed to take her concerns seriously. They told her it was anxiety, maybe even heartburn.

Yeah, heartburn. Whitney was experiencing a kind of chest pain that would wake her up in her sleep. That's not heartburn. It just felt wholly dismissive that I was not being listened to in any real way. And I'm having crushing chest pain and I didn't want to die. This fear of dying is something Whitney kept coming back to month after month. She wanted to feel strong enough to take care of her newborn daughter. Whitney is lucky to be here today.

Because the reality is in the U.S., Black birthing people like Whitney are dying. In fact, they're almost three times more likely to die during pregnancy and childbirth than their white counterparts. What is going on here? Black women are the most educated women in the United States. We have the most degrees. That does not save us. He says, look, you're a female, Black. You probably have high blood pressure in your family.

You should ask someone. The risk isn't being Black, it's living within a racist system. I can think about a patient in particular who asked me, if you're not there when I deliver my baby, am I going to die? I'm Sujan Pak. I'm a journalist and a mom of two. You may recognize my voice from my podcast, Add to Cart, or from my early days as an MTV News correspondent. Breaking news. Hi, I'm Sujan Pak with MTV News, and I'm standing here in front of one of the American Red Cross centers here in New York City.

In this series, we're going to be talking about our healthcare system and why it fails so many of us. And by the way, this isn't just a story to me. My partner has an autoimmune disease that can sometimes leave him completely debilitated. And for years, we would go to the doctor looking for a diagnosis, and they would just brush him off saying, well, it's probably just anxiety. And the kicker is that we're actually the lucky ones in this country, because we have the most expensive insurance policy we can afford, which doesn't even cover all the costs. And then on the other hand, my aging parents, who by the way, speak very little English, rely only on Medicare. And it is a full-time job just to manage basic things like their appointments. So there's not much time left over to ask fundamental, important questions like,

are they getting the right care? Are they getting the right diagnosis? So what do we do when the institution that's supposed to help us live does just the opposite? The harsh reality is that it's expensive to stay alive in this country. Many Americans are one medical emergency away from financial ruin. This despite the fact that we spend nearly twice as much money on health care as other equivalent countries. And we still have the worst health outcomes. When it comes to developed countries,

we have the highest infant mortality rate in the world. The average life expectancy for Americans fell sharply again last year in 2021, marking the largest two-year decline in nearly 100 years. The United States still has more preventable deaths than any other rich nation in the world. It is an undeniable truth. The U.S. has a full-blown health care crisis on its hands. Our country has the highest rate of pregnancy and childbirth-related deaths in the developed world.

The highest. What are we doing wrong? And what can our high maternal mortality rate tell us about the American healthcare system as a whole? In this series, we're going to try to understand how the system is failing and how it can be improved. Over the next six episodes, our team will visit Germany, the Netherlands, and Costa Rica, where we'll talk to parents, midwives and community health workers to learn how everyone can be well cared for. We're spending so much time on building a relationship that people just feel safe.

In the end, you have the feeling that you didn't have a midwife, but you actually had a friend who coached you through this whole situation. The community sense is strong because people know each other. And I said, well, I should care for my neighbor. This is Uncared For. I'm your host, Sujin Pak. I just quickly wanted to show you your babies because you haven't seen them since they were babies. This is my daughter, Zoe. She's so big and beautiful.

Yeah. And then this is our first baby, Kai. Oh, my Kai. That's Brandy Jordan. Who is Brandy? Well, on paper, she's a newborn care specialist, a pediatric sleep specialist, and my postpartum doula. But in real life, when I gave birth to my first child 10 years ago, she was my safety net. The one person that made me feel like I could do this. When I see you and your face, I have these like crazy emotions. gels us together in a way that you get up close and personal really quick. Like how many people

were you around when you were topless and hormonal besides me and your partner? Just right up on my nip. You know what I mean? Just like, okay, let's point your nipple. You're like, I'm sorry, your name was? Though, of course, I had heard of doulas, I had really no concept of what one was and why you would need one. When I hear doula, I think of crystals and women with flower crowns giving birth at home. That is just not me. Nope. When I was pregnant, I just knew that my partner and I would be doing this alone, without family nearby, that neither one of us had even remembered the last time we had held a baby. So I knew we were going to need help.

It's only after having had the Brandy experience that I understand what a doula does. And even still, I can only say how she changed our parenting experience. So I'll let Brandy explain more clearly what doulas mean and the difference between the two types, a birth doula and a postpartum doula. So with birth doula, you are someone who's going to be there with them prenatally. You're basically educating them about the birth process, getting them to like just ponder those questions about like, do they want that epidural the moment they get there? So they have these conversations, they can help you to create your birth plan. And then they're obviously with you during your active labor until you have the baby. I started off as a birth doula and then quickly made the change to postpartum. A postpartum doula usually is going to arrive when

you come home from the hospital during that day or night. And they're really there to educate you in those days and weeks post baby. But our goal really is to be that extra pair of hands to really care for the whole family and ensure that you have what you need, that the village is actually doing the things that allow you to simply connect to your baby and heal. Okay, I got to jump in here because to say Brandy was an extra pair of hands doesn't even begin to describe how important she was to our family. I was the kind of mom that never slept because of terrible anxiety. I was the kind of mom who was scared to be alone with my baby. It was a really dark time, but Brandy was there guiding me every step of the way.

And I'm very aware that that is a privilege very few people have. For me, the only mantra that I had was, it's okay, Brandy will be there. But the blank slate of bringing home a baby, it's a kind of abyss that is so vast. Nobody told me what that was going to be like. I was so focused on taking my vitamins and making sure I was doing all the right things to have a healthy baby. But I didn't imagine bringing this baby home. And it was an utter shock to me that they just handed you a baby. You put it in a car seat, and you

come home with it with, like, no instructions. It wasn't always like this. There was a time when Americans who just gave birth stayed in the hospital for up to two weeks, depending on whether they could afford it. A picture of young Mr. and Mrs. America on their way home after mother's exciting days at the hospital. This postpartum period was used to monitor the birthing person during their recovery and slowly ease them back into their daily lives.

But then there was a baby boom and an economic meltdown thanks to World War II, and a shortage in hospital staff and beds eventually resulted in the birth and release model we know today. One to two days in the hospital for most births and one checkup after six weeks. I can't underscore the level for me of complete isolation and what I thought motherhood was going to be like,

that it was going to be instinctual, that it was going to be automatic, that it was going to be some kind of like spirit from a phoenix above where like an ancestor calls and I become Mother Earth. How's that working out? I lost it. Brandy gave us the full unedited course on newborn babies. She taught me how to breastfeed, swaddle an infant, help me find the right formula, examined rashes, bumps, and weird patches on baby skin. She put our child in a good sleep routine,

gave us the right ointments and creams. The list goes on and on. But the things that are still with me today are the moments in the middle of the night, exhausted and overwhelmed, where she guided me to trust myself enough that I was already loving and good enough for my baby. I feel like my work really is for people to see that they actually have their intuition,

they just don't trust it. And like before you realize it, I'm able to see like the person who was here when I came that first day no longer exists. You've actually crossed over the threshold to this new level of your parenting and connection with your baby. And that's when you fired me. Yeah, basically. Still hurts a little.

I do joke all the time that Brandy fired me because it was really hard to let go of that relationship. She knew even before me that I was ready to move on. But Brandy has her own story, one that I haven't talked to her about until now. Brandy had trouble getting pregnant with her second child, so she and her husband were relieved to finally see a positive pregnancy test. And like the good doula she is, Brandy immediately got started on a birth plan. So I called, you know, where I was going to be delivering and they were like, oh, you should come and do a blood test at the clinic. So I did that. And the next day, the midwife

called me and said, oh, I have bad news. You're going to have a miscarriage. Your ACG numbers are supposed to like double and yours didn't double. So you're going to have a miscarriage. HCG is a hormone that the body produces during pregnancy. These hormone levels rise after conception. So it's a common way to double check that someone is pregnant. But even though she had a positive pregnancy test, Brandy's HCG numbers were low. And this didn't make sense to her. And I was like, oh, well, I feel really pregnant.

Like, you know what I mean? And she's like, yeah, your body doesn't know yet that you're going to have a miscarriage, but you're going to have one. Like they were just basically telling me to wait to miscarry. Brandy and her husband, Michael, were devastated. But after three weeks of waiting, nothing had happened. Brandy's doctor brought her in for an intravaginal ultrasound to examine the tissue in her uterus. And they were like, oh, we see it, but your body's going to get rid of that. And I was like, okay. And they were like, you know, you can have a DNC if you'd like. Oh my God. A DNC, or dilation and curatage, is a surgical procedure to clear the uterus after a miscarriage. It

effectively removes any signs of pregnancy. Brandy's doctors recommended she follow through with the procedure. But she and her husband felt this was extreme. At this point, we're just, you know, I'm like obviously hysterical. Michael's still like, this doesn't make sense to me. Like if we see the baby there, like what are they talking about? And so we waited till eight weeks. Voila, there was a heartbeat. All was well. But they had recommended for me to have a DNC.

Okay. You work in the business. Yes. You know. I know. Anybody knows, you know. And so someone is telling you, an expert. An expert. Is telling you that this is going to happen. Yes.

And you yourself are feeling what? I started to distrust my own body. I was like, I'm feeling really pregnant. Like, I'm feeling like I'm having a lot of symptoms. But I guess my body just hasn't figured out yet that we're about to have a miscarriage. But it ruined my entire pregnancy because I couldn't quite, like, connect. Because I was like, what if something, maybe they did see something that I don't understand and it's going to come at seven months or eight months like I can't really dig into this pregnancy until she's like in my arms. Brandy's daughter Nola was born at home

in just 52 minutes. It was a quick easy birth and Nola was perfectly healthy despite what the doctors had told Brandy. I was taught to trust doctors. And if they say this is a thing, they know more than I know. Like, I didn't go to medical school. And I feel like there's a lot of people who can resonate with that because we're often taught that all the time, like in pregnancy. Like, I don't feel good. Oh, you're just a worried new mom. Think about it. Have you ever brought up a concern with a doctor that was ultimately brushed off? Has your provider ever made you feel like you're just overthinking it? Finding nonjudgmental health care isn't easy. That's why with the birth of Brandy's third child, she made a conscious decision to deliver her baby somewhere familiar, with doctors she could trust, at the hospital where she'd been working. So I was watching Pixar Upper as we do, and my water broke. So we go to the hospital, and I'm like, okay, my water broke. It's my third baby. And the doctor says to my face,

it doesn't matter that you think you're in labor. It matters when I think that you're in labor. Okay. think you're in labor. It matters when I think that you're in labor. And I'm like, okay, not only that, but that I misunderstood and I actually peed myself is what he told me. And at this point, like I know what's about to happen. And so I'm like trying to hype myself up to just be able to deal with like the avalanche is about to hit me in like 10 or 15 minutes. Because right now they're like five minutes apart. Like I can talk, but my labors progress really quickly. With her first two children, Brandy had something called precipitous labor, meaning her babies came super fast after contractions began. So she knew the urgency of her situation. But because the doctor didn't believe Brandy was in labor, he refused to give her a hospital room. Instead, she had to wait in a small public

triage room, which was essentially a glorified closet. And within, you know, a good 10 minutes, like I'm in full blown labor, like I'm nine months pregnant, so I'm not comfortable being on this cot. So I literally got on my hands and knees on the hospital floor because there was nowhere else to go. What? Yeah. And I remember saying, can someone just give me a pillow because it's cold. And like, I remember being like, I'm expected like to bring a human into the world under these circumstances. Like, you've got to be kidding me. Why am I being subjected to this level of like inhumanity and indignity? I'm just a lady having a baby. Everyone's supposed to want to help me. While word got around that Brandy was an employee, hospital staff moved her to a private delivery room just in time. Her son Etienne was born just 40 minutes later. But to this day, Brandy is shocked

by the treatment she received. I worked in the labor and delivery and postpartum department. That was my department. But I didn't have on my fancy white coat that night. And some childless male resident thought he knew more about, you know, my body than I did. By the way, it's worth noting here that according to Brandy, the hospital was not especially busy the night Etienne was born. There were plenty of rooms available when Brandy arrived mid-labor, and still she was denied one. Nothing changed about the situation. It was really that previously I was just like some

Black lady on a Tuesday night who didn't really deserve to have a hospital room. I think about you in that situation and nope. Can not even imagine that my dear friend, the one that gave me so much strength, is on her knees laboring in a hospital. If I were to call you and tell you, Brandy, the craziest thing just happened. Yeah. And I told you this story. I'd be beside myself. Like, what? Who do we need to roll up on? Like, what's happening? Let me put my earrings on so I can take them off.

Yeah. I say to myself, though, if that had to happen to anyone, I'm glad it was me with 20 years of maternal child health experience. But I'm thinking about what happens when someone doesn't have your experience. Yeah. First child. They die is what happens. They die. We'll be right back.

My daughter was pretty heavy. She was a 10-pound baby. But it would hurt to rest her on my chest. And that's like one of the number one things that you're going to do when you have a newborn. So I had a lot of pain. I definitely felt like I was gasping for air. I never felt like I could get a full breath, like a full deep inhale, exhale. It was very shallow. That's Whitney Polk again. When we met her at the beginning of the episode, Whitney was experiencing these crushing chest pains that turned out to be so severe, they landed her in the ER twice after giving birth to her daughter Esme. But to really understand what happened, we need to I started to feel really uncared for.

A subchorionic hemorrhage is medical speak for bleeding inside the uterus. It often goes away on its own, but in rare cases, it can increase the risk of miscarriage or preterm labor. I was in the middle of teaching a class, and I just happened to just swipe gently my backside, and I noticed that I was bleeding. And so I had to leave class early and rush to the emergency room. And I think my husband and I were very concerned and thought that the staff would also be equally concerned. But we ended up waiting around for quite some time. And then once I did get into an exam room,

I just remember being in the stirrups for quite some time and nobody really telling me what's going on. Am I losing my child? And I think we were there for several hours and the physician came in and said, you've had a hemorrhage or a threatened miscarriage, I think is the technical term, which feels very intense. Whether a miscarriage is actual or threatened, the difference is insignificant to a pregnant person. You hear that word, miscarriage, and that's the only thing your brain latches onto. And let's face it, we've all been in the position where we're waiting hours to be seen by a doctor.

When it's a sore throat, not a huge deal. But when it's about the life or death of an unborn baby, the stakes feel so much higher. It just kind of felt like everything on paper was being checked off. Yeah. But the care and emotional support that I was looking for were missing. But things got worse as Whitney's pregnancy progressed. Soon after her threatened miscarriage, she was told that Esme would be born with Down syndrome. One genetic test later, that diagnosis turned out to be incorrect.

By the time labor and delivery came around, Whitney was pretty traumatized by her care. What was your emotional state even going into the delivery room? I will say I was pretty numb going into the experience. Like given all of the difficulty and the stress, I was just kind of like, well, my job now is to just get her here. And whatever happens to me is what happens to me. It was very life and death. I wrote a bunch of letters to everybody in case it didn't work out. And at the end of the day, I did my best to get her, my daughter, to this point.

And whatever will be, will be. Yeah. Hearing Whitney say that, whatever will be, will be, just really devastated me. That while she was preparing to give birth to her first child, she felt compelled to write goodbye letters to her family. It's so heavy to think about. But this constant internal questioning, am I going to survive this? Will my baby be born healthy? Is unfortunately nothing out of the ordinary for Black birthing people in the U.S. Here's a news story from NBC in 2018. Tennis great Serena Williams with baby

Alexis Olympia shares her harrowing ordeal. Serena had trouble breathing. She knew it was a sign of blood clots she had suffered before, so she guided her doctors on how to save her life. Not even fame and money are enough to secure better health outcomes if you're a Black birthing person in this country. What our research has shown is that Black women in particular report not feeling respected when they access the health care system, not feeling heard, not feeling as though they are the experts in their own bodies, which, you know, sounds pretty ridiculous when you think about it, because if anyone should know what they're feeling, it should be that person.

That's Dr. Rachel Hardiman, professor of health and racial equity at the University of Minnesota. Through her research, Dr. Hardiman zooms in on how the lived experiences of Black birthing people dictate the kind of medical care they receive. So they're bringing in sort of the social environment that they're living in and their day-to-day experiences of racism, and then accessing a healthcare system that was never designed to serve them well. And so, in my mind, that's sort of the perfect storm. A perfect storm. Imagine Whitney's painful experience with her providers replicated over and over again. It raises questions about who healthcare in the U.S. was designed for and who it chooses to neglect. And this neglect has very real consequences. Like we mentioned earlier, Black birthing people are almost three times more likely to die from a pregnancy-related cause than their white counterparts. And according to Dr. Hardiman, they're set up to fail because our systems are just, well, inherently racist. When we ask the question of sort of why is the Black maternal mortality rate rising or why is it so high, the narrative is often, well, Black women are less healthy.

They go into pregnancy, you know, overweight and they don't take care of themselves. They're not eating right or they're not getting prenatal care. And what our research and the research of many scholars out there has shown is that first and foremost, despite whether or not someone gets prenatal care actually doesn't dictate outcomes, but also it's really debunked this narrative that Black women aren't caring for themselves and has shown that because of structural racism, because of structural inequity, because of the weathering hypothesis, Black birthing people are coming into pregnancy at suboptimal health. So in addition to our inherently racist systems, there's the weathering hypothesis that Dr. Hardiman mentioned, which was put forth in

the early 90s by a public health researcher named Dr. Arlene Geronimus. She found that for Black birthing people in particular, chronic disadvantage through one's life in a bunch of different ways, whether it's at your job, at school, and other, you know, just going into the grocery store, going to the mall and being followed for no reason. All of those micro and macro aggressions throughout one's life are going to wear and tear at the body, causing things like higher blood pressure and other things that we know can be concerning during pregnancy. Basically, weathering is this idea that stress is cumulative and impacts Black birthing people's health over a lifetime. Which brings us back to Whitney Polk, who has actually studied and experienced racial stress. A little over a month after becoming a new mom, the symptoms that Whitney

felt during the end of her pregnancy were just getting worse. Her blood pressure was fluctuating, her liver numbers were high, and she was fainting often. So she demanded to be seen by a cardiologist. I was pretty persistent. I kept asking, you know, it's interfering with my ability to take care of my daughter. I'm having crushing chest pain and I's interfering with my ability to take care of my daughter. I'm having crushing chest pain and I go to the ER and they tell me that I have heartburn. So I take Zantac. But nothing is really helping what's going on with me. At this point, Whitney had enough. So she decided to call her cardiologist to get some clarity. I had sent him a pretty detailed email and he had only responded to about two questions

and they were very short. It was very clear that he didn't really engage with anything that I asked. And I'm relaying all of this to him and he says, look, you're a female, Black, you probably have high blood pressure in your family, you should ask someone. And I just felt very dismissed. And also, it was a bit racist, that interaction.

As someone who studies race, and specifically racial stress, that was a very racially stressful moment for me to be dismissed by essentially this person who has my life in their hands. Put yourself in Whitney's shoes for a moment. She knew something was wrong with her body, so she advocated for herself time and again, but it was never enough. Whitney was worried that if she didn't find a solution soon, she might not see Esme grow up. But she wasn't ready to give up, and neither was her family.

I should mention that my mother is a nurse. My mother-in-law is a respiratory therapist. So everyone was kind of watching me or concerned about, like, health issues. And my grandmother, who had a history of heart issues, had been Googling and asked me to ask about peripartum cardiomyopathy. Peripartum cardiomyopathy is a rare type of pregnancy-induced heart failure, and the symptoms seem to perfectly line up with hers. So Whitney asked her cardiologist to look into it. I asked about it and I was told,

no, that can't be a possibility. You're fine to go home and be discharged. He would say to me over and over anytime that I brought up cardiomyopathy, you're too young for that. But of course, when I go into your office, I'm the only Black person there and I'm the only person who's under the age of 65. You only see white people of a certain age. Your sense of how heart issues functions is limited to the population that you see. By now, Whitney had done this so many times with her medical providers. So she decided to do a little investigating of her own. I just had a bee in my bonnet about peripartum cardiomyopathy. And so I went online and I found a Facebook group. This Facebook group called Save the Mommies had over 3,000 members,

one of whom was a doctor named James Fett, who specialized in peripartum cardiomyopathy. And this Facebook group was so helpful in that you didn't have to have a diagnosis yet. You could just ask people questions. You could post your labs and people would respond. I asked questions and Dr. Fett would respond and give his suggestions. I spent like hours just reading paragraphs and paragraphs of what's been going on to them. And they were so much like my own story. They knew something was wrong. They told their doctor. They weren't believed. And the next thing you know, they end up in the hospital. And I remember at one point telling my story and asking, does anyone have recommendations for a cardiologist in the Boston area who understands this?

After months of not being heard, it took one Facebook post for Whitney to be given a name and a number of a doctor at Harvard, the same university where she was getting her PhD. So even though it's the week between Christmas and New Year's I'm going to email this person from my Harvard email address I'm going to tell them my entire story and keep my fingers crossed and within maybe three or four hours I got a response and I had an appointment to see this doctor within a couple of weeks and I felt like there was a light at the end of the tunnel that I might actually be around for my daughter, that somebody was going to take me seriously, that I could get on like the right medication if necessary, but that someone would investigate further. So Whitney went to see this doctor. And this time he took Whitney seriously. He listened to her and he did investigate further.

And so even after the first appointment, he said, well, you don't exactly fit the criteria based on these previous labs, but I think we might need to do a cardiac MRI. Doing the cardiac MRI is what actually showed that I did fit the criteria for peripartum cardiomyopathy. And as soon as those results came back, I was put on the correct medication regimen for this particular kind of cardiomyopathy that happens post-pregnancy. And I started to feel better. I mean, I didn't feel amazing right away, but within a year, my numbers were back up into normal range. What was it like to receive that proper diagnosis? What was that moment? I feel like I was very lucky. I feel like I worry about women who don't have Harvard email addresses and don't have the resources to keep fighting. I felt supported. I felt cared for. I felt listened to. You know, he would ask me about my doctoral

program. He remembered my daughter's name. And so I just felt vindicated. I felt like, okay, someone has a plan and I don't have to fight so hard anymore. And this meant that Whitney could see Esme grow into the beautiful four-year-old she is today. She is so kind and thoughtful, but she's very emotionally expressive. So if something hurts her feelings or she needs a hug, like she's the first one to tell you. And I love that about her and I hope that she keeps it because she's advocating for herself. And I love it. No matter how shocking Brandy and Whitney's stories are, they were still lucky in some ways because they're still here. And so many other Black birthing people in the U.S. aren't.

There are about 700 pregnancy-related deaths each year in the U.S. So, how can we prevent more pregnant people from becoming statistics? Well, we know one thing. The entire system needs to change. We need access to affordable health care before, during, and after pregnancy. We need trusted primary care and a maternal care system that prioritizes the mother and family's needs. But for many, it actually starts long before pregnancy. It starts with where you're born and what neighborhood you live in. When I describe the social determinants of health, I always think about it as a tree. And then off of every branch, you have a different determinant of health.

So health care and health access, economics, the built environment, the community, all of those things, education. That's Dr. Veronica Gillespie-Bell, an OBGYN at Ochsner Health in New Orleans, Louisiana. She's also the medical director of the state's Maternal Mortality Review Committee. And the reason I like to think about the social determinants of health like a tree is because it matters where your tree is planted. So if your tree is planted in a minority neighborhood, then your determinants of health are not going to be the same as a predominantly white neighborhood. So when we look at those minority neighborhoods, we see increased tobacco ads.

We have higher rates of crime. There's less access to green space, more likely to be near a dumping ground or near an environmental challenge. Let's think about it like this. The trees in higher-income neighborhoods have all the sun, water, and nutrients they could ever want to survive and flourish, while the trees in lower- income neighborhoods have less access to these basic needs, which means they're already starting off at a disadvantage. So Black women, brown women are not predispositioned to have a higher maternal mortality rate or a higher morbidity rate.

It is the social conditions that we have put them in that's leading to these outcomes, which is also important because that means we can change them. Remember earlier when Dr. Rachel Hardiman talked about the perfect storm of factors leading to our country's dismal health outcomes for Black birthing people? Well, social determinants are a huge factor impacting those outcomes. Here's Dr. Hardiman again. So what we're seeing in our research is that structural racism is at the root of why the social determinants matter for health, meaning that it's structural racism that has contributed to where people are able to, for example, get housing. This system is by design.

Let's take a city like Minneapolis, where Dr. Hardiman is from. Since the early 1900s until 1948, racially restrictive housing covenants prevented Black people and other minorities from buying homes in white neighborhoods. These racist practices were reinforced in the 30s with countrywide redlining, which dictated who qualified for a mortgage or home loan. Only in 1968, when the Fair Housing Act was passed, was housing discrimination finally prohibited. But the damage had already been done. Black people were segregated into communities with less access to good schools, public transit, green space, and healthy food options. And the effects of these racist policies are still very much felt today. We have people living in these communities who decide that they're going to start a family

and become pregnant and need to access health care. And they're accessing health care systems that have not grappled with all of the things that they need to do to make sure that they're providing equitable care. So we know that there's racism that's deeply embedded in our healthcare delivery systems. I usually go through a whole history lesson for folks around sort of what that means. So let's get into it, cliff note style. While social determinants like racist housing policies play a big role in health outcomes, it's the healthcare system itself, and the racism inherent in it, that feels like the elephant in the room. To better understand where this medical racism originated, we have to go all the way back to 1845 in Montgomery, Alabama,

at a white doctor's surgical practice. You know, I think James Marion Sims is the sort of most well-known example of how historically racism has been perpetuated on Black bodies and Black female bodies in particular. Sims was known as the father of modern gynecology. And, you know, during chattel slavery, what he did was use Black women's bodies to test all of his techniques. Dr. Sims experimented for four years on Black enslaved women who are mostly unknown except for three women named Anarka, Lucy, and Betsy. These women had to undergo the painful operations without any sort of anesthesia, even though it was available to Dr. Sims. And remember, they couldn't actually refuse these procedures because they were enslaved. And so we have to be thinking about that example, but many, many others and how our healthcare

delivery systems have been created, how medical education has been created and built, right, on the backs of Black bodies. And that's based on, you know, racist ideas around Black inferiority, right? So then we're sending people into these healthcare systems that have not actually addressed these issues. So while they may not be as explicit as they used to be, right, they're still there. They're sort of still, you know, part of the foundation of healthcare delivery. Dr. Hardiman is actively working to address these biases through anti-racist trainings for providers. But these types of

trainings require practice and patience, which require time. And as we know from stories like Whitney's, when you're Black, pregnant, and experiencing complications, you don't have the luxury of time. So what then? According to Dr. Hardiman, it's crucial to ask the hard question directly and upfront. How will you keep me as a Black woman safe during my pregnancy, during my childbirth? And if your clinician doesn't know why you're asking that question, doesn't know what you mean by that question, or doesn't answer it adequately, then it's also okay to find someone else.

You know, yes, our system is complex and we've made it unnecessarily hard to do a lot of these things that you still, you have the autonomy and the ability to seek out care that you are comfortable with. A large part of this equation involves advocating for yourself and speaking up when you feel like something isn't right. But that's easier said than done, especially if you're pregnant for the first time and you're anxious to just get through the laundry list of routine questions about your health and your baby's health. That's where having an advocate like Brandy can really help. My approach in working with families of color is to really think about what makes you feel safe. Who are the people that make you feel safe? Let's do that. Like, I focus on the joy of pregnancy. I focus on the strength. I focus on allowing us to be vulnerable

in ways that we're generally not allowed to be and not focusing on this idea that they can die at any moment. Doulas like Brandy aren't just there to support you in your advocacy by taking notes and asking the right questions, doulas offer emotional and physical support too. And the data backs their impact. Birthing people with doulas tend to have decreased rates of preterm birth, C-sections, and postpartum depression. Simply put, they lead to better outcomes. And that's something that every birthing person should be able to access. We deserve to be able to birth in the way that everyone else does. And that means it's being a really joyous occasion.

And we're going to have a doula because we're fabulous and we deserve it. And it's amazing. Not because we're at threat of death at any moment. Brandy is absolutely right. Birth should be a joyous, sacred occasion. Not one where you write goodbye letters to your family and friends. But the unfortunate reality of being Black and pregnant in the U.S. means having to question if and how you'll be kept safe

by the people who are supposed to be trained in doing exactly that. It means having to advocate extra hard for yourself because you know that you might not be heard the first or second or third time you mention crushing chest pain. It means understanding that despite your medical know-how, you might just be left to labor in a triage room. That is a heartbreaking, difficult pill to swallow. But in the same breath, there is an important point to keep in mind. While maternal mortality is horrible, it is rare, right? And so I don't want people to go into pregnancy just completely terrified because that leads down that stress pathway that we're trying to avoid. You know, we can build something where dignity,

where autonomy, support and love are at the center of how care is delivered. So what is so unique about the U.S. that makes things so abysmal? And are we outliers? Or is it like this everywhere? Well, that's exactly what we're going to find out. Next week and throughout this series, we'll look at some of the biggest gaps in health care,

like access to care, workforce challenges, and social determinants, and explore how we can make Dr. Hardiman's vision for maternal care a reality for everyone. But first, what's still standing in our way? The first thing I did was I called my sister, and I was sobbing. And I was telling her, I was like, I think I'm pregnant. And did you just see the news? Audio Engineer. Isauda Aceves is our Associate Producer. Mix Help from Kristen Muller. Music is by Andrea, Kristen's daughter. Jackie Danziger is our VP of Narrative Content. Our Story Consultant is Kaya Henderson. Fact Checking by Naomi Barr. Executive Producers

are Jessica Cordova-Kramer and Stephanie Whittles-Wax. This season of Uncared For Thank you.