Birthing With Your Full Self

J’Mag Karbeah at the University of Minnesota Twin Cities campus Photo Sarah Whiting

I am at the age when my friends and I have regular conversations around starting and growing our families. For some people, this is a topic that brings up a plethora of emotions: excitement, nervousness, apprehension, and even fear. But for me, a Black woman living in Minnesota, the feeling I often encounter is one of distress and worry. In Minnesota, Black babies are twice as likely to die in their first years as white babies. That statistic does not get much better when you zoom out to national data. According to the CDC, Black and Indigenous women are two to three times more likely to die from pregnancy- related causes than white women.

Every time I hear these statistics, I get chills thinking about what might lie ahead for me and the other Black women and babies in my community. There are people actively researching, advocating, teaching, and challenging these dire outcomes. One of those people is J’Mag Karbeah, a predoctoral trainee at the University of Minnesota’s School of Public Health who, along with Dr. Rachel Hardeman and a partnership with Roots Community Birth Center in North Minneapolis, studied how community-centered and culturally relevant care result in positive outcomes. Karbeah and I had the chance to chat about this research, the work at Roots, and what remains to be done.

What are you currently focusing on in your research, and how did you become interested in your field?

I am trained as a health services researcher. I am finishing up my doctoral training at the University of Minnesota School of Public Health, and my research focuses on naming and addressing the impacts of structural racism in maternal and child health.

A lot of the work I wanted to do was inspired by the fact that I grew up in Milwaukee learning about the crisis of teen pregnancy — and I heard how rooted in anti-Black racism the language about pregnant Black teens was.

When I got my master’s, I was met with rhetoric that Black moms do worse and Black babies do worse as if it were an education problem rather than a social problem. It was intuitive for a professor to say, “Black people have worse outcomes,” without interrogating why that is, and how the health care system itself is complicit in adverse health outcomes.

Our health care system often creates inhospitable environments for Black people and other people of color. Black birthing people have perinatal experiences and prenatal appointments that are so dehumanizing that they stop going to these appointments.

Serena Williams had previously experienced pulmonary embolisms, and knew her body well enough to say “I feel unwell after having my child.” It took fierce advocacy from the world’s best athlete, an extremely wealthy person, to receive the health care that possibly prevented her death. It is important for us to take a step back and think about what happens to Black people who are not wealthy.

Dr. Laura Attanasio and Dr. Rachel Hardeman (director of Center for Antiracism Research for Health Equity at the University of Minnesota) wrote a paper showing that often when Black women voice concerns to their providers, they are recorded as declining care and being uncooperative. When you talk to women about these experiences, it is not like they did not want medical care. They had a question and their provider could not answer the question, or did not think the question was important.

A Stanford University study [came to the same conclusion, finding] that Black people, and specifically Black women, are often regarded as being uncooperative in their medical records. Cultural narratives about Black women and their perceived aggressiveness informs their care experiences.

Rebecca Polston, owner of Roots Community Birth Center, is intentional about not seeing Black identity or non-white identity as a detriment.

As a risk factor, basically.

Right. Instead of seeing a Black woman and saying, “Oh no, this is going to be difficult,” how do we see Black birthing people and say, “This person has a cultural identity and history that can be a real asset. Maybe they have strong community bonds — how can we include that in their care? How can we make sure that their larger community feels connected?”

What we heard from Roots clients, but also the folks that provide care at Roots, is that it is transformative when someone is allowed to bring their full [authentic] selves into a prenatal visit, their pregnancy, and their birth process. People feel empowered and more connected to their care team, and it often means a safer, healthier birth for everyone involved.

The model [that Roots uses] is based on the birth center model, which is more relationship oriented than what we usually see in a hospital setting. What happens when we spend an hour at an intake visit and 30 minutes at each prenatal visit, rather than 15 minutes, as in a traditional hospital setting? Roots understands that this is really important for people of color. Everyone should have access to this [level] of care.

People have known about the benefits of community-centered care for a long time, but there is a pushback from the general medical community. How can we get them to understand this model around birth and pre- and post-natal care? How can it infiltrate how we think about pregnancy and Blackness?

For over a decade, the Vaginal Birth After Cesarean (VBAC) has calculated the risk of an individual having a vaginal birth after c-section, and included correction for being Black. So, Black race was considered a risk factor — Black women were more at risk having a vaginal birth after c-sections with no reasoning other than the idea that their racial identity was a risk factor [because of data on disparities that are caused by societal factors]. The American College of Gynecology has recently chosen to remove this risk factor from the VBAC, but that has taken years of fierce advocacy from mostly Black providers.

[Medicine has been] treating Black identity as if it is a biological thing rather than a social construction. This is harming women’s ability to have the births that they desire.

It is a deeper issue than I think we realize. White providers show less empathy towards Black patients. We live in a society that continually devalues Black people, and so it is not surprising that providers have these views about Black people. When medical training programs simply state Black people have health problems without explaining that this is because of systems that have disadvantaged them, [that is a huge problem].

This all compiles into this idea that it is harder for folks to identify with people outside of their racial group. It is harder for providers to see that this Black person is me, that this Black child could be my child. I think it is reasonable to say it is ridiculous, right? As a Black person, it is hard for me to see how you cannot see a Black child as your child, because a child is a child.

I have talked about Roots at different conferences, and I remember one provider who said, “I do not have the ability to spend this much time with patients as the Roots folks. That does not mean that I am racist.” That is a faulty argument because, to me, the decision is how do we change our system? If having more time with patients allows you to be a better provider, how do we create better payment and compensation models?

Recent legislation expanded postpartum Medicaid coverage [in Minnesota from 60 to 365 days] because birthing people are vulnerable for that whole year after birth. We also need to create payment models that allow people to seek care more frequently.

Sometimes it makes me sad that we have to talk about things as “benefitting everybody” when they will have a larger benefit to Black folks. To be able to get a bit of the care we need, we also need to advocate for folks who do not necessarily advocate for us. Reproductive care can impact other chronic illnesses we see in our communities.

Do you have any words for somebody who is pregnant and nervous about racism within health care impacting their birthing outcomes?

It is a very disheartening situation, but Minnesota has fierce advocates for Black women, whether it is Representative Ruth Richardson or Dr. Rachel Hardeman. The Dignity in Pregnancy and Childbirth Act [passed in Minnesota in 2021] is a great example of the work that is being done by legislators to address the Black maternal health crisis through effective policy. Change does not happen without policy, and it should be a light to Black and other birthing people in Minnesota that there are so many advocates who are putting in the work. There is a wonderful provider and scholar, Dr. Monica McLemore, who says this could all be different, and all we really need is for folks to listen to Black women who are already leading this charge.