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Episode 17 – ‘Just’ BirthsReproductive Justice and Black and Indigenous Maternal Health Equity

Learning Objectives
1. Understand the magnitude of disparities faced by Black and Indigenous birthing persons and how forces of structural racism created and perpetuate these inequities
2. Define Reproductive Justice and understand how clinicians can promote reproductive justice during pregnancy and birth
3. Appreciate the importance of cultural reflexivity, community-centered initiatives, and midwifery and doula care in facilitating reproductive justice
4. Recognize the impacts of climate and land injustices on Black and Indigenous communities and know that climate justice, reproductive justice, and racial justice are all connected
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The Clinical Problem Solvers Antiracism in Medicine Podcast Series aims to equip listeners with the consciousness and tools to practice antiracism in their health professions careers. Learn more.

Audio Transcript

Naomi Fields: [00:10] [music] Hey y'all. This is Naomi Fields. Welcome back to another episode of The Anti-Racism in Medicine Series of the Clinical Problem Solvers Podcast. As always, our goal in this podcast is to equip our listeners, at all levels of training, with the consciousness and tools to practice anti-racism in their health professions careers. This episode is entitled Just Births, Reproductive Justice, and Black and Indigenous Maternal Health Equity. Today we're focusing on the roles of anti-racist action and reproductive justice and rectifying inequities experienced by Black and Indigenous birthing persons. I am so thrilled to be hosting this episode with our team members Chioma Onuoha and Victor Carmen. Chioma and Victor, can I have each of you introduce our phenomenal guests?

Chioma Onuoha: [00:54] Hey, Naomi. I am so excited to be here having this conversation. And to introduce our first guest, Dr Joia Crear-Perry, a physician, policy expert, thought leader, and advocate for transformational justice. As the founder and president of the National Birth Equity Collaborative, she identifies and challenges racism as a root cause of health inequities. She is a highly sought-after birth equity and racial health disparities expert and speaker, and has received numerous awards for her work as a health advocate exploring racial disparities in the industry. Dr Crear-Perry has addressed the United Nations Office of the High Commissioner for Human Rights multiple times to elevate the cause of gender diversity and urge a human rights framework towards addressing maternal mortality. Previously, she served as the Executive Director of the Birthing Project, Director of Women's and Children's Services at Jefferson Community Healthcare Center, and as the Director of Clinical Services for the City of New Orleans Health Department. Dr Crear-Perry currently serves as a Principal at Health Equity Cypher and on the Board of Trustees for Black Mamas Matter Alliance, Community Catalyst, the National Clinical Training Center for Family Planning, and the UCSF Preterm Birth initiative. She is an Adjunct Professor at Tulane School of Public Health as well. After completing undergraduate studies at Princeton University and Xavier University, Dr Crear-Perry received her MD from Louisiana State University and completed her residency in Obstetrics and Gynecology at Tulane School of Medicine. Welcome, Dr Crear-Perry.

Joia Crear-Perry: [02:17] You can just call me Joia or Dr Joia is fine.

Victor Carmen: [02:20] All right. Next up we have Dr Katy Kozhimannil. She's a distinguished McKnight University professor in the Division of Health Policy and Management at the University of Minnesota where she directs the Rural Health Research Center and the Rural Health Program. She conducts research to inform the development, implementation, and evaluation of health policy that impacts healthcare delivery, quality, and outcomes during critical times in the life course, including pregnancy and childbirth. Her scholarly work aims to contribute to the evidence base for clinical and policy strategies to advance racial, gender, geographic equity, and to collaborate with stakeholders in making policy changes to address social determinants and structural injustice in order to facilitate improved health and well-being. Dr Kozhimannil's research has been widely cited and has generated dialogue, interest, and policy at local, state, and national levels. In addition to conducting research, Dr Kozhimannil works extensively with community organizations and state and federal policymakers on efforts to improve the health and well-being of individuals, families, and communities, starting at birth. She holds a bachelor's in Spanish and International Relations from the University of Minnesota, and her MPA is from Princeton University, and her PhD in Health Policy is from Harvard University. Thank you so much for being with us today.

Katy Kozhimannil: [03:51] Thank you so much, Victor. Chi-miigwech. I'm super happy to be here.

Fields: [03:56] Fabulous. So jumping right into our key questions, we want to center this conversation on liberation-oriented solutions. But for our listeners who may be unaware can you each start by briefly describing the magnitude of the maternal health disparities for black and indigenous birthing persons?

Crear-Perry: [04:15] Sure. I can go first. So we know that for black and brown and indigenous folks the likelihood of dying in childbirth is somewhere between three times, seven times, up to 13 times depending on the locale that you're in. And the change is not because black folks are doing so much better or indigenous folks are doing so much better in some of those other places. The gap between how people are doing depends upon the lack of investment in the communities in general. Racism harms everybody. It just harms the people who it's intending to more directly. And so you'll see that places New York City will have 8 to 12 times the rate for black and brown people. But places like where I'm from in the Deep South it's only two to three times. And that's just because we don't do things like invest in childcare, paid leave, equal pay, or things that allow for us to thrive. So anyway, the point is the idea of a hierarchy of human value based upon race, religion, skin color, gender, the codification of that into policy and law has been killing us for generations. And you see that play out in the racialized health and equities in maternal health.

Kozhimannil: [05:23] That's really well-said, Doctor Joia. And I agree. And I appreciate that you brought us into a broad context right away. So often we hear the statistic of black and indigenous folks being three to four times more likely to die around the time of childbirth as others. And I think we've almost gotten used to hearing that and it— we need to take a moment and [also] zoom into the personal level of that. If we lose seven to nine hundred mothers every year, birthing people, that is a child growing up without a parent. That is a family who loses a beloved family member. And the fact that that disproportionately happens in some communities versus is not an accident. And it also affects generations. It changes a life trajectory of an individual but also of a community. And I think it's really important when we think about the maternal death statistics that we think broadly about that. I also think it's important that when we're talking about maternal health and maternal health and equities that we're not just talking about did you not die? Maternal mortality is an absolute something we should never see happening. Infant mortalities, it's just an absolute tragedy. We need to be thinking more broadly about how can birth be as beautiful and empowering and set people off on the right step, on the right foot as much as possible. So I really appreciate the context that you laid there.

Crear-Perry: [06:51] No. I mean, but honestly, the reason I do that to your point is because we have so many black infants that die. And nobody flinches anymore. So I used to say that talking point all the time. 23 000 black babies die every year and nobody cared. And so I realized that the reason that people are finally starting to listen to the maternal health crisis because the statistic is so high they're like, “Oh, of course, you all die twice as much. You have twice as much diabetes, twice as much hypertension. You're twice as dangerous.” That framing of deficit is so baked into how we talk about black, brown, and indigenous people. So I have to then say, “No. No. No. It depends on where you are and is also racialized to kill white people, too. So don't just think you can write us off anymore. It's actually coming for you, too.”

Kozhimannil: [07:31] Absolutely. I've often heard it— so I want to say two other things about that. One is that when we think about the variation across place— I was on Minnesota's Maternal Mortality Review Committee for years. And the inequities that we saw here in Minnesota were— we saw a black maternal mortality rate that was twice that of white folks. And we saw an indigenous Native American mortality— maternal mortality rate that was 7 to 10 times as high compared with white folks here in Minnesota. And this was a contextual— to speak to your point, context matters for structural disinvestment in different types of communities. And when there was discussion around, “How do we talk about this,” there was worry on the part of white folks that, “Oh, we can't talk about this because it's going to be hurtful. It's going to re traumatize the community.” No, the thing that traumatizes a community is losing their mother. It's like the trauma is happening, and not paying attention to it and not saying it out loud does not change anything. We have to pay attention to that. It is so, so important.

Crear-Perry: [08:39] [crosstalk].

Kozhimannil: [08:42] Yes. Yeah.

Crear-Perry: [08:42] Whose trauma?

Kozhimannil: [08:43] Whose trauma? Whose trauma? Absolutely. And I know I said I was going to make another point. And I cannot remember what that was.

Crear-Perry: [08:50] Well, whose trauma is a good one. That's the main one that we're in right now.

Carmen: [08:57] Thank you so much for that. It was just incredibly powerful to hear everything that came out of that question. And I really love what you said about context. And as a Dakota— I'm from the Dakota tribe from— my people are from Minnesota, “Minneshota” as we say. I appreciate you saying that because I have a lot of relatives down there as well. And I'll be able to provide that context to them when I go back and to talk to them about it openly, like you said, because that's what needs to be done. We also wanted to talk about academia and your work, kind of to dive deeper, more into it. And we know that academia and medical training, they can sometimes promote this distance between researchers and participants, between clinicians and patients. And sometimes it's nearly impossible to maintain that distance when you have personally experienced or borne witness to the issues that you tackle in your work and the issues that you just brought up. So we wanted to ask you, how do you define reproductive justice? And how do your identities and experiences shape your approach and your goals in this work?

Kozhimannil: [10:16] Thank you so much for that question. It is essential to who I am. At the beginning, when you introduced me, Victor, I have a lot of fancy titles now. And I've worked really hard to get the credentials behind my name and the expertise that I have to be able to do the work that I do, but I fundamentally do it because the intergenerational traumatic effects of losing a mother have affected my family and have affected my people in ways that are not always captured by the folks that have been traditional knowledge creators. And the fact that academic and medical institutions and standards are built on a foundation of structural racism, of not believing the people that are closest to the harm, has gotten us in this situation. The racial disparities in maternal and infant mortality haven't changed in more than a century. In fact, they've gotten worse as we've developed some of the technologies that we have and the, quote, knowledge to address it.

[11:30] I think who I am, as a person, growing up and being from a rural place, having relatives and family on tribal lands, knowing who my people are, is exactly why I do the work that I do. And I think it is essential, and I have worked to imbue the credibility of my lived knowledge into the credibility that I now receive as a “fancy person” with a Ph.D., and a professor — I'm even a “Distinguished” one! If that “Distinguished” can help certain people hear me, people with power to hear me, and to change the way that they allocate power, resources, opportunities, that is something that I aim to do in my work, and I wouldn't know that without the voices around me, the experiences, the experiences of my ancestors, those who've come before me. My grandmother passed at the of end of 2017, and when she did, her last words were of her sister who she lost in childbirth, and that was the last thing that we talked about. And that was what she wanted was to be reunited with her sister and her sisters' babies and the people that have gone before. It will always affect us.

Crear-Perry: [12:51] Was that question for me, too? I don't think so, right.

Carmen: [12:53] Yeah. Thanks so much.

Crear-Perry: [12:54] [inaudible].

Carmen: [12:56] Yeah. Dr Joia, you can go ahead if you want to answer that as well. We'd love to hear what you have to say.

Crear-Perry: [13:01] Thank you so much. First I want to honor sharing that. That was beautiful. I can see your grandmother. I've been thinking about my grandmother a lot lately and so many memories, so it's a good time to remember things that we've forgotten about ourselves. And also, it's a joke in the black community, we all got Indian in us but a lot of us do. [laughter] So when I think about it, though, especially in Louisianna. I have entire family members who were Cherokee, who were— oh, shoot. What is it? I'm going to mess this up…Piscataway! So we have in DC, there's both Anacostia and— I don't want to mess up the wrong name. But the point I want to make is that we were all treated poorly and I knew that there is no way that indigenous birth outcomes are better than black birth outcomes. It just makes no logical sense because of the level of harm, of total decimation, of being moved from your lands to others, [a]cross [the] country. So to say that you have your rights and values are being valued equally, just makes no logical sense. So whenever people give me data, I also question — that doesn't make any sense. Clearly, for peoples who have been harmed since the founding of this nation and decimated, there's no way that indigenous birthing people's rates are not really, really bad. So thank you for even sharing that.

Crear-Perry: [14:23] The data have been so missing and it's been such a fight. And the fight becomes circular, right. It's like, “Oh well, the Indian Health Services will get — we don't have money for that,” and it just keeps going and going. I say, “Okay. Well—.” I learned from our sisters. You say, “Hey, we have the data. We actually are epidemiologists ourselves. We can tell you what it is and it's bad.” But the problem is, just like for us— so the reason why I'm in academia, so often we say things like that and we get pushed out, kicked out, told we're crazy, told that you're not right because the fear of having us speak truth, the fear of acknowledging how bad the outcomes are for people who have been not centered for so long. I mean, as an OBGYN training, I was taught in medical school, in the late 1990s, which was not that long ago in my mind, that there were three biological races and the person said it so casually. We were talking about— it was my embryology class. A section was named, human prenatal development. So that's also signaling to you by the naming of the course, right. “It's a human being at conception” is what we were supposed to get from that and they would show videos of fetuses feeling pain, right, so— and that same professor, that same person— had NIH funding to do this lab around this fetus, to make fetus videos, he would also talk about how there were three types of skin. “Mongoloid, Caucasoid and Negroid.”

[15:46] So the codification of eugenics, of race-based medicine has been deep inside of our health care system for a long time. Although, I have spent the 20 years trying to unlearn what I was taught, think about how many people who were in my class still believe that, who still are teaching that who are still are running around taking care of people in rural Louisiana because most people stay where they train, and I trained at a state medical school in Louisiana so guess what? Same thing in rural everywhere else, Minnesota rural— so the people who were working— and we export this around the world. I was talking to my brother in Nigeria. Guess who teaches Nigerian doctors? US trained physicians. Guess what we teach them? Eugenics, race based medicine. Horrible stuff. I was taught that there's a gynecoid pelvis for white women, android pelvis, which is like male, for Black women, and a anthropoid pelvis for Asian women as if our bones are shaped differently. Every part of bodies has been taken apart and utilized for harm inside of this racist healthcare system. So we're not surprised at the outcomes we have are awful because we devalued human beings and then codified that into our policies and our practices for so long.

[16:54] And then the intergenerational trauma you're talking about is real because— and I will say this. I hold both the trauma of the slave owner and the person who's enslaved, right? And so I understand the fear that's happening right now. So many people, if you actually start telling the truth, what does that mean about their family members? What does that mean about having to acknowledge that their family members raped, sold, murdered, generations of human beings? But we can no longer afford to have that lie continue because they're afraid to have to feel. We all have to feel— if I have to feel my slave owning ancestor's trauma, guess what? You got to feel it, too. Everybody is coming so acknowledging it, forgiveness. Forgiveness, right? Because if we all keep fighting each other, an eye for an eye, nobody has an eye left so forgiveness, and we just got to let it go and move forward, right? That's how we got here, so.

Kozhimannil: [17:43] Joia, that is beautiful. Thank you. I resonate with that as well. I'm a mixed-race person. My babies are mixed race children and the codification that you spoke of, that is what the institutions of medicine and science and academia have perpetuated and that is a cycle that it's important to break and difficult to do so in a country that was founded on genocide, on the theft of land and labor, and on family separation particularly focused on Black and Indigenous families. Those forces that caused that, that founded this country are the forces that have been upheld through academia through medicine and those are the forces that continue to cause harm in our communities, and it is difficult to be academician, or a scientist or a healthcare or public health practitioner in this time. And, Joia, you and I have talked about this— how we will sometimes be brought in as the keynote speakers at these conferences to address racism and when we submit our work through the normal process of abstracts, they don't get selected because they're not seen as being the most urgent and important if you go through the typical channels. And that's the mantle we have to lift as we move forward when we do this work. When we see spaces where we do have privilege, we need to act and elevate the voices that are missing when we go through the typical process.

Crear-Perry: [19:07] But I also say we have to acknowledge the harm. It is purposeful that we can not get things put into journals. It is purposeful. The same people who were alive who were throwing things at my grandparents..they're in charge. They're running the corporations, and they are not happy when we say it's racism. They're like, “Oh, no. Wait, wait, wait.” I can tell you one of my favorite moments. I'm good about being honest about names, and I love Paula Braveman. She's an amazing researcher, and so is Nancy Krieger. We have huge fights. I fight them both because I would say, “How many more times you need to do a study answering the question if racism causes harm? What's the point? Can you just say it does so we can have your validation? Because what the world needs is for you to open your mouth and say it. You need to say it.” If I keep saying it, [it's] like, “Oh, it's the Black woman complaining.” I need the white people who do the research to say, "It's racism. I don't need another grant, I don't need NIH to give me any more money. I don't need to prove it.

[20:03] Now let's work on solutions; stop stalling for the solutions. When we started the Black Lives Matter Alliance, we were sitting there, and I had been working with Paula Braverman for I don't know how long about black infant mortality. And she would have on her list racism is one of the facts. She finally put it on a slide. And I said to her, “Ma'am, you are the epitome— you're the only person doing this research. I mean, you'd be able to say full-throated out of your mouth that racism is the reason black infants die because there's, 'racism created race'. There's nothing else.” So just this year, after the years, they released the March of Dimes report. I get this email from the American College of OB GYN and has a direct quote from Dr Paula Braverman. And she says, “And I couldn't believe it. We've run all the numbers, all the data, there is no other factor for black infant mortality that's being higher than racism.” I was like, “Finally, can the heavens open? Can we say, ”Ahaa, the queen has spoken." But that's really what we have to deal with. It's not just we're trying to get through the normal process. It is actively purposefully stopped because people are afraid to have to feel the injury of the harm of their ancestors. Right now, we're in the battle of our lives, but it's fine. We're going to win because we're on the right side, and it's internal. We understand that right now, the internal life, the feeling that emotions that having to feel we have to all this stuff. People around the covenant color— I mean, people around the world who are indigenous and of color have always— we have emotions. We have feelings. We understand. We're connected to the earth and the sky and the sun. And guess what? Now is time for America to have to have feelings and emotions, to feel the pain of its harm that it's done.

Kozhimannil: [21:39] One of the most powerful things about realizing the racism is man-made, which I think a lot of us can acknowledge, is that then, man can unmake it. And by man, I mean all of us, right?

Crear-Perry: [21:47] Yes, exactly.

Kozhimannil: [21:49] That's the empowering thing about understanding that people get so upset about racism, [inaudible] calling that a cause. In fact, it is not— I mean, let's take steps tomorrow; here are the things we can do. Racism is the unequal valuing of people based on the color of their skin and how they look and the allocation of resources that saps the strength of us all, as Kumar Jones says. And so we can stop doing that tomorrow. We do all have privilege and active power in this to engage that process. Now, that's mostly on the folks that are white. White supremacy is the underpinning of all of this, and proximity of the white acts as a part of it.

Crear-Perry: [22:32] That is [inaudible] the truth, truly. Honestly, white supremacy is internalized, so it's everywhere. So there are so many people like, “You can be black—.” Let's just think about Supreme Court, okay, Clarence Thomas. I would say his internalized whiteness is on fleek, right? He is codifying over and over and over. So, “No longer do I want to have a conversation about skin color. This is not about skin color. If your behaviors are that you harm, blame, shame, put people under their place you could look like all kinds of stuff.” I've got some some allies— not allies, I have some peers who have similar few appearances than I, whoops and a lot of energy trying to put me in my place and tell me that I'm wrong and I need to sit my behind down. So trust me, this is not the— so that's also the white lie. This was never about the type of melanin you produce. At this point, the work of undoing whiteness is every single one of us because all of us, for the last 400 years, have been living inside of this war hole.

[23:29] So all of us have been doing— my biggest thing that I'm working on lately is a sense of urgency. Whiteness always wants to be in a hurry. So I'm like, “You know me now,” I'm like, “Don't do all that. That will wear you out.” That's why we dice, or at least. So I get on a call when I get on a call, that makes people upset. That makes people mad. [laughter] But I'm working on it very much. So also really big one for me is I will replace things, onto the next, is what we would say in hip-hop; onto the next one, onto the next. And I learned this from an indigenous sister. We were in a room. It was all Black and Brown indigenous people. But our language was off. We were starting to fuss. And she said, “When did the White man show up?” I was like, “That's the word I've been looking for. When did the moment when the whole energy of the space changes to one of blame, shame, harm? I'm going to put you in your place.” That can be in a room full of Black folks, right. So we learned this. Now it's time to unlearn it. What does it look like to have - and I really mean this - a Black Feminist ethos? What does it look like to the people who're the most impacted? I'm sure there's some language in the indigenous community the same way. I'm just most familiar with Black feminist literature work. That's what we need, care, love, open, transformational justice because it's going to be harm. There're going to be people coming out of prisons. It's just a lot happening. We got to be more open to going slower, feeling out, all have good and bad, nobody's perfect, all of that. [laughter] Yeah.

Fields: [25:04] I love that, Dr Joia and Dr Fabian. Thank you so much. I am thinking as you're talking about how you're saying about how identity and experience are assets that basically imbue us with the power to do this work. The cultural reflexivity, excuse me, that we even have to do to undo that internal whiteness that can impact how we're navigating these spaces. And they're making me think about reproductive justice because as my understand is, it's a framework that is centered on— well, centered by the people who are actively being affected and it recuse that sort of back and forth in order to accomplish its goals. And, Dr Joia, I was wondering for the purposes of bringing our listeners into the fold if you could define what reproductive justice is.

Crear-Perry: [25:54] Sure. Sure. I would love to. Thank you. So reproductive justice is a term that was coined in 1994 by 12 Black women who were really working on the intersection of the people of African decent with the United Nations. So it comes from a global understanding of human rights framework. I mean if you're Black and you've been doing— and women who's been doing work in this country long enough, you realize this country is going to kill you if you just stayed here. So you got to get into the international space. You got to get bigger than just counting on a president to be nice to you.

[26:23] And so that's what they did back in 1994. They really went to the meeting. I want to say it's in Beijing, but I can't remember. Don't quote me on it, please. And they really came together and said, “Listen, we have basic tenets. One is we have the fundamental right to personal bodily autonomy.” So it starts from a human rights framework. The United States does not operationalize the human rights framework. We believe that people have to have civil rights. So everybody begs to be seen. Black folks are two-thirds human. White women have to have permission of their husbands to get access to contraceptions in the 1960s. So that means that they were not considered to be fully human. The LGBTQI is asking to be married.

[27:01] All of us have been asking for civil rights in this country. And every other high-income nation just by virtue of your birth, you're fully human. So that we have not ever done in this country, what'd look like to have a diverse nation invest in every human being and believe that they're fully human. So that's step one. Because you have this human right, that means you have the right to personally bodily autonomy. So that means if the patient says, “No, I don't want to LARC [long acting reversible contraceptive].” You just can't say, “Well, you're only supposed to have 2.2 children.” The CDC does a replacement rate by race, which is also racist. And it says that each person should have 2.2 children. [laughter] And you have 5, so that's too many. We need to make sure that your birth spacing more, right. So that's on there.

[27:42] A second one is to be able to not have children. So my own state of Louisiana, you could not qualify for Medicaid if you had not been a child-bearing adult. So that means if you had not utilized your uterus to birth a human being, you could not qualify no matter how poor you were for generations. So that means if you're born without a uterus, you could not qualify for healthcare. The decision that you're only valuable to get health insurance or health coverage because you provide labor is a history and legacy of racism and slavery in this country. Jim Crowe continues, right. So when you see in states like Michigan, when they offer to have Medicaid expansion, they said, “If you're in urban Michigan, you have to have a job. If you are in rural Michigan, you don't have to have a job.” It's the continuation of you're only valuable if you're providing a service, providing a baby, providing something to us, not because you actually exist.

[28:34] And then this last one, as a mother of an 11-year-old-son, who I do not allow to play outside I have the toy gun. [inaudible] a racist mother, I do not want anyone to see my son is older and shoot him within 11 seconds, we would like to parent our children in safe and sustainable communities. So that means access to pay lead, equal pay, not mass incarceration, not police violence, having trees and walkways and parks, all the things that are invested in communities where you value human beings, we expect those things in our communities as well. And we actually demand those things at this point. I'm getting tired of just asking at this point. But those are the [inaudible]. The sad part is since 1984, it has become, reproductive justice means abortion. So that is why I want to be really clear that the intention of the original founders was the entire framework, including being fully human. So for black women, we've never been seen as fully human since [inaudible] woman speech at the beginning of time. So what does woman mean? What does it mean for black women to be seen as fully human in this country? That [inaudible] we're also debating at this point.

Onuoha: [29:40] Thank you so much for that. And I appreciate how you kind of brought in a bit of a global perspective. And I think that we're starting to recognize that respect and cultural communion have always been integral to traditional birth practices and to the work of doulas and midwives. And slowly it is becoming more widely acknowledged, in part due to both of you all's phenomena work that these are essential components of our journey towards black and indigenous maternal health equity. So I would love to hear, why do these things make such a difference? And what is something that can be done to improve birthing people's access to them?

Crear-Perry: [30:15] I'll go quickly because I'm an OBGYN. So I have probably the least to say about— I'll say this, that we were not— as an OBGYN, my field was started by J. Marion Sims and a whole bunch of people who did not value birthing the same way that [inaudible] are talking about. And so many times, I would get written up for acting like a midwife. Because the idea of managing a clock of medical birth is very different for OBGYNs. So I learned from my indigenous sisters, from doulas, from midwives. I really recognize that our training is inadequate in medical school. That idea that we don't even learn the bodies are powerful that they can do things on their own. We don't even go to a home birth—I mean, we are lacking in our understanding of the physiology of birth. When people say things like normal, physiologic birth, [inaudible] like what does that mean? And so if you think about who founded it, what their goals were, how they decimated black grand midwifery, the whole intention. When your intention is off, your outcomes are going to be off as well. So I'm sure Katie has a whole lot more to say about what actually happens.

Kozhimannil: [31:23] Oh, I appreciate that so much. And actually, I'm going to start from the reproductive justice framework that you laid out because I think that's what we need to start when we talk about birthing people— is in birth. And I think I would extend the reproductive justice framework even further to encompass beyond just health and the experience of kind of coming into pregnancy and childbirth and the communities that we're in, and then the policies that support parenting or parenthood or health or well being or access to services. And I would also extend that from an indigenous perspective to include the nonhuman relatives, our earth, the health of our planet, of the communities, and the plants, lands, and waters around us. We know that there's an effect. That connection between our earth and our ability or our life cycles, and there's an integral connection there and the traditional ways in which people cared for one another to bring humans into the world beyond a medical or clinical context, to celebrate the cultural change, the family growth, the arrival of a new human among us the precious new person that we get to know. And get to—that we give to, and we receive from.

[32:47] A new little teacher comes to this world. And that little teacher arrives in an environment where we facilitate that. And I think that's the philosophies of midwifery, of doula support. These are ancient traditions that have been known by people for years and years, and every cultural context, the words that we use here have been— are not always used by everyone. And midwifery and doula care have been professionalized to be integrated into the clinical medical care, healthcare system that we have. And I understand why that is, because if you're a health insurance company, your job is to pay for healthcare, and that's— there's a limit to what we can ask health insurance to do. But certainly, facilitating financial access to care is a huge barrier for many people. I think about this with both doula and midwifery, and birth center services. There are multiple barriers to accessing these things that we know work. And by we know they work, I mean, there are many, many randomized control trials over many years and many populations to show that this works. Although if you just asked people again, closest to this experience, they would tell you that it works. And there ought to be a place in our world of science to incorporate lived experience and traditional knowledge as well. I think we would do well in birth with that. And I think that's sort of the beauty of the practice of midwifery and doula care. So yes, we need to think about financial barriers to access and what is the role of health insurance? Yes, we have to think about policies, leave access, and those types of things.

[34:28] And yes, we also need to think about cultural access. And support. And the cultural and family and personal practice of pregnancy and birthing. And what it means to have people who share your experience or your culture, or who center your culture in supporting you through that process. We have a mismatch in our OBGYN, and midwifery workforces that are predominantly white when more than half of all birthing people in this country are not white people. And so, I think that that's where other types of supportive practices can come into play to bring that culture. But we also need to not turn away from the workforce diversity in the fields of obstetrics and other types of medicine as well.

Carmen: [35:15] Thank you so much, both of you, for laying that out. You know, both of you talked about the policies that have an impact on this. You mentioned also, Mother Earth as well, and the health of the planet, and the climate, and how that's impacting birthing people as well. And we wanted to kind of ask you about climate and land injustice, from the framework both of colonization, but also, the enslavement of people. And how that looks like today in terms of you can talk about climate change, the impacts in terms of land injustice, the stolen land, but also things like the— redlining, that's land injustice as well. And how are these climate and land injustice issues, how are they impacting maternal health equity for Black and Indigenous birthing people and why must our vision of maternal health equity incorporate climate and land justice?

Crear-Perry: [36:20] Once again, I feel like Katy is going to be more robust, so I'm going to start. So when we started, we really were talking about redlining. It's a concrete thing that people did not learn in school. So that was mindblowing for folks. So we would say we could run the numbers and show that Black babies who were born in these communities were more likely to die. And that it wasn't that their moms didn't have an education or income, so we can show concretely for people social determinants of health. So this was like, wooh, big ta-dah. Now fast forward seven years. Man, as a person who grew up in the deep South, in New Orleans, Hurricane Katrina, had to do health fairs outside after— because all the hospitals were flooded, was called a refugee, was not able to— we have patients who were dying from heatstroke. I realize, climate was always we me. I just was not putting in the same frame that we should have been. We are aware that heat causes premature birth. We are aware that the places that have higher rates of pollution, which is a climate issue as well.

[37:18] So when we developed this whole article because when we were talking about reproductive justice, what that means is the places that are using population control, which is an entire field of population-held, population medicine development who then blamed and shamed people around the world for climate, right? So they say the reason that we have poor climate was because mommas in India have too many babies, right? [inaudible] make some policy that decreased to do eugenics, to codify eugenics, right? So we would write articles, once again going back to the gatekeepers showing that this has always been a lie. But there's never been a tie between the production—the uterus' of poor indigenous people around the world that caused climate injustice. It was always the pharaohs, then the people owned the land, that's Ceasar's. The folks who were stealing and robbing across the continent of Africa, across the United States. All of the people who— we just finished trying to decolonize Kenya not that long ago, right? So all of this hoarding, all of this hoarding is what's causing climate injustice. The region where the Congo is, that's intentional. That's coming from white supremacy and policy so that impacts maternal health in a transnational way. So you have to tie the two things. We just look at, oh, we're going to get some more midwives and doulas, which is important. It's important. And you don't also talk about the impact of climate injustice, of large corporations hoarding, stealing, robbing from [inaudible]. And this is where I'm teeing it off to Katy because [inaudible] going to do a much better job talking about the earth.

Kozhimannil: [38:54] Oh, [inaudible]. Thank you so much. I'm so grateful for this question because I think the strength that we get in our lives are relationships with our land and with one another. That is how we engage in the world. And there's a strong indigenous philosophy of seven generations where you think seven generations above and seven generations behind and you work to be a good ancestor to those that come after you and honor the ancestors that came before you. And that's not just about human beings but also all of our beings. I think that the climate crisis that is happening is an indication of the rip, the tear, the disintegration between us and our earth, and that is a space of violence. And there are extractive qualities to that are political, that are economic. And I think the same happens between us and our people. If we have that, sometimes, again that's done to us when we're separated from other people like us and then to compete, I think it's been happening for centuries with Black and indigenous people in this country, and I think that's an important aspect to acknowledge and I also think that the— so as climate justice and reproductive justice and racial justice are completely the same thing because of that tearing that happens between us and our earth, our land, our mother and us, and one another.

[40:39] And the way a forward is to reconnect those things. And the most powerful way to reconnect those things is through a good birth, a good birth when we are on our land, and we are connected to the land that has knowledge. And that we are connected to that and not— and we eat the foods that are from our land and we know that. And when we are with our people who love us and are able to— and when those things are not there— this is why I work on birth because I believe it has such transformative power, and it happens every day. Every day, there are miracles happening all over the place, and folks that are in medicine and that get to witness births and be a part of that is such a— what an honor, what a gift, and what a space for transformative change. It can absolutely change someone's life, how they give birth. And so there are opportunities all the time to influence that. And I know you have so many folks that listen that are adjacent to this that have a chance to be a part of shaping the environment in which someone gives birth, whether that's taking care of the earth or your community around you, or taking care of a patient in a clinic or in a hospital.

Crear-Perry: [41:51] That was beautiful. Thank you.

Fields: [41:54] So Dr Katie, I love how— and Dr Joia, I love how— I think what both of you are kind of been talking about, at least what's coming up in my mind, is how birth is one of these things where we talk about the art and the science of medicine. And I think it sounds like some of what you're saying is that we have gone far too far into the quote-unquote, “Science direction.” And we are really neglecting the fact that if you want to put this under the art umbrella, this really is an act of community. This is an act of people coming together and our current policies really just don't allow space for that. And I'm talking about policies at the— policy with a big P and also policy with a little P when it comes to healthcare systems levels. I think another area in which policy, probably more so with a big P, is really sort of curtailing people's ability to really have reproductive justice is in terms of access to family planning. And so I know you've both worked with communities that have limited access either by physical location or overly restrictive legislation.

Fields: [43:06] And I think that regardless of one's political leanings, family planning is a health equity conversation. And as much as the lack of access to safe and reliable services actually amplifies a context for unsafe abortions, at the same time, we're working with populations that have suffered atrocities related to family planning, such as forced sterilizations in our black and indigenous folks, unethical contraceptive trials in Puerto Rican folks. And I think the idea exists in popular discourse that reproductive justice and birth equity compared with access to family planning services are the terminally opposed. And so I'm super curious to know, from your vantage points as advocates, to what extent does family planning figure into a vision for reproductive justice, for black and indigenous communities? And also sort of what of your experience is showing you about how to invoke these conversations in communities and populations that have suffered these atrocities?

Crear-Perry: [44:06] That was a long question, Naomi… [laughter],

Kozhimannil: [44:11] That was a big important question.

Crear-Perry: [44:13] Yeah. I'll get through this, that family planning is a gaslighting word. I have planned to do lots of things. So family planning comes from— and under the last administration, under the Trump administration, they were really clear here, family planning explicitly by law excludes abortion. So when you all conflate the two things, you're also participating in the gaslighting of white supremacy. Oh, that's what happened. You said the art and science of medicine. So that's another thing that our healthcare system loves to do is say things like that. So yes, truthfully it is. That's a beautiful language that we use in Black Indigenous cultures around the world. And guess what? When you're telling a woman to get up on that bed, and follow this clock? There's no art to that. That is all bodily control, body shaming. So we're trying to move away from even using the word family planning. In fact, a lot of the larger organizations are no longer using that term. Because it comes from a population control that comes from eugenics. And especially, Black and Indigenous folks should not be interested in ever talking about a plan. We do want to have reproductive and sexual well-being, we do want to have the ability to be invested in no matter what our income or education is. No matter what our cultural beliefs are, our desire is for you to see us as fully human and to invest in us. Not to tell us how to plan, or what our life course should be, or what our reproductive life'sl plan should be. Most of my friends who are well off? My Black friends who are— who have income, and resource, and power? Their families had it for seven generations. It was not because they had some plan. They stole, and they got resources from other people. So this is not about planning, this us about being invested in a team that's [inaudible]. I'm sorry, it was a lot. I'm trying to get to [inaudible].

Fields: [45:45] You don't need to apologize. And I love the language correction, that is so important to know the source and the actual ramifications of the language that we—

Crear-Perry: [45:52] We have a whole lecture we give on it. And in fact, even the family planning societies are really re-looking at that name, why do we even say that? What would be the point of the federal government— it used to be called Office of— all these organizations say Population. Because they took the world Control off and replaced it with Affairs. As if they didn't change how they operate, what they do. So any organization that has the word Population in it, I question their history, I question their reason why I question all of them. Around the world. All of them even today. I'm curious, if you want me to plan, then what's your plan to ensure that everybody has access? So, haven't seen that yet.

Kozhimannil: [46:31] I have a—I so appreciate this conversation, and I'm very grateful to you, Joia, for educating us. I think that's something we need to do more. Thank you for demonstrating how we can talk about language and stop and say, “You might not know.” And I think it's especially true in science and medicine. So much of our language has become what we are taught as trainees, is scientific language, or the words we're supposed to use to be believed and understood. When we are in fact, then participating in that. So, I think I love this question because it comes down to who are you asking? Who's being centered here? To what end? And I think often, I've done a lot of work on rural maternity care. And on access to being able to have a place to give birth when you live in a rural community. And that work, I'm so privileged to have been able to be in a position to do that work. It was exactly the right work, and it has resonated across this country. People know now that more than half of rural counties have no hospital where you can give birth. And they know that because of my research.

Kozhimannil: [47:46] And my research happened because there were five grannies in rural Alabama, in a Black community, whose daughters were— they had no place to give birth. And as their daughters were having babies, they were taking care of grandbabies, because their daughters were driving all over the place to have a baby. And they went to their legislator, Representative Terri Sewell, who's a Black woman, and I think it matters that she's a Black woman. And they asked her, “Is this happening? Why are all the hospitals closing their birth units? Is that just happening here? Is it happening all over the place?” And representative Sewell's staff got on the phone with the National Rural Health Association, and they called me because I had been doing rural maternity care work. And they asked, and I said, “I do not know, but that is an excellent question, and I know how to do that study.” And we got the resources to change what we were doing, to answer the right question from the people who know the right question. And not only did they ask, “Is this happening more often in our communities? What is the consequence of that for our mamas here,” we found that those grannies in Alabama were exactly right, as Alabama grannies often are, and they were correct that communities like theirs were more likely to lose hospital-based obstetric services, rural communities with a higher proportion of black residents, those in states with less generous Medicaid programs.

[49:07] Those were the places that were— and with fewer OB/GYNs, fewer family physicians, fewer births, more remote rural places. But fundamentally, the fact that rural communities with a higher proportion of black residents, holding constant all those other factors, were more likely to lose hospital-based obstetric care— that, to me, is such a clear example of systemic racism, of structural racism, of structural disinvestment. And I don't think that was hospitals saying, “Let's go close the OB unit in the black community.” It's because Medicaid pays for a higher proportion of births for black folks and for rural folks and it pays less than private health insurance. And so people were making financial decisions, but they were racist because we have a racist financial system that underpins financing of healthcare.

[49:59] Anyway, I'm going to bring this all back to the discussion around reproductive justice broadly, which is that, as we have talked about and people have really, I think, understood the salience of going into labor and having to travel really far to give birth and how difficult that is to not have a place nearby to give birth, there's been some empathy that's developed for rural birthing people, rural pregnant people, rural families. But a lot of that narrative and the narrative of rural America is very whitewashed. We have an idea of rural places being these agricultural, white, aging places, farm families that are white. No. One in five rural residents is black, indigenous, or a person of color. We have rural tribal communities and rural black communities that have been around and have been underinvested in for such a long time. And those communities are the least likely to have obstetric services. It's the places where you can give birth at the furthest away, and it is also the places where is hard to get access to— it's the places where people have experienced forced sterilization and coercive infertility, and it is also places where people don't have access to choice about their contraception, their sexuality. It's not a place where you can contracept if you want to very easily. It's not a place where you have anonymity as a teenager or any privacy to get— it's not a place where you can ask questions. It's also not a place— so it's not a place where you can prevent a pregnancy if you don't want to get pregnant, get information about sex if you want to have a healthy sex life. And if you can't prevent pregnancy and you become pregnant in this community where that is incredibly stigmatized, where there are no resources and you can't terminate your pregnancy and there's no place to give birth, what the hell are moms supposed to do? What the hell are families supposed to do?

Crear-Perry: [51:53] Disappear. Go back.

Kozhimannil: [51:55] Right? Oh my God.

Crear-Perry: [51:55] Go back. Haven't you heard that on TV? They love saying that, “Go back. Disappear.”

Kozhimannil: [52:00] It's just—

Crear-Perry: [52:00] It's a whole thing. But the truth is— the last time that I testified—

Kozhimannil: [52:03] It's inhumane. Right?

Crear-Perry: [52:04] –a senator from West Virginia—he said out loud that his entire town—in Joe Manchin's state, his entire town depends upon Medicaid, that their number one employer in rural white America usually is the hospital. And so it's not by accident. I just want us to no longer act as if this is not purposeful. Black hospital's more likely to close because the people who have power to decide who closes are usually the state legislature. Hospital deeds, bonds come from who gets—so we [gerrymander] who gets elected to office. Then we see entire towns that need Medicaid dollars because their entire infrastructure is required for the hospital. I grew up in these kind of towns. My mother is a pharmacist in these kind of towns, rural America's full of small towns that have hospitals, just like they have small towns that have prisons. The prison industrial complex, the small rural hospital complex is the same thing. And it's used to ensure that people who are racialized as white have resource, people who have power and wealth have resource. So when you go to places and you say, “Hey, the disconnect from the senator saying, I want to shut down.” I don't know about us in expanding Medicaid, but in his town who need Medicaid to survive. That is called cognitive dissidence. The hospitals need to know in West Virginia that people are dying. In rural white America, they're dying from racism. Me and Katie clearly can talk for hours if y'all can see. [laughter]

Onuoha: [53:36] And we wish we had many more hours to speak with you both, but unfortunately we know we are all super busy. But to kind of close us off, we have a question that we ask all of our guests, and that is, for our listeners who are heading back into the clinical world, what is one key takeaway that they can put into practice tomorrow? And what would you recommend to reproductive health practitioners in particular?

Crear-Perry: [53:58] Yeah, well, I would say for me, the one key takeaways, we're all tied to each other and so the next work is really going to be you unlearning whatever harmful things you have, unlearning the hierarchy and belief of a human value in yourself because you've grown up, wherever you grew up around the world, it might not look the same way as it did for me growing up in rural Louisiana. But wherever you grew up there, it was some binaries, some hierarchies, some things that you need to let go of because the future is no borders, no walls, no hierarchies, no binaries. So we have to unlearn that ourselves.

Kozhimannil: [54:31] I thank you for that. That's such a beautiful vision. I think I'm going to start with the sort of twin values that, when I feel kind of the earth shaking under me and I feel lost and overwhelmed, I try to think about what can I do to be kind, what can I do to promote justice. And people who are in clinical settings, where they are caring for pregnant and birthing people, any anybody that you're caring for in a clinical setting, look them in the eyes and see them as a human being who is like worthy of your time and attention and care, and listen to them about their experience. If you are with someone who is giving birth that day, that what a miracle, their whole life is changing, and you'll get to be there and be a part of it honor that, honor that with just, if all you can do is lock eyes with them and say in your mind, “I see you, I honor you bringing birth into this world, bringing a baby into this world today.” I think that is what a gift that our healers have, that you all have people that I don't get that chance to interact with folks every day. And I think it's a tremendous honor, and I think it's something that you can use. You can use the power of that, of your presence in that space to see someone's full humanity and their full empowerment in a moment of giving birth.

Crear-Perry: [55:58[] I love that.

Fields: [56:01] I absolutely love that. Let's say I had tears well up in my eyes, as I was thinking about being in those situations and what a miracle it really is. And I think sometimes that's the starting point, being present in that moment and also being present with oneself. Like you said, Dr Joia, to do that cultural reflexivity of what do I need to unlearn to better support this person in this miracle that they're going through? I'm so grateful, endlessly grateful for the conversation that we've had here today. And I want to thank you both for your candor and for the work that you do and taking the time to equip us and our listeners to be better advocates. I know I will be returning to this conversation often.

Onuoha: [56:44] Thank you. Thank you all.

Kozhimannil: [56:46] Thank you so much.

Crear-Perry: [56:52] Currently they're getting money for NIH grants to do study black kidneys. And I tell you that there's no such thing as a black kidney. Guess what you do when I say that, you fight me every time I say. [laughter] You send me little nasty tweets but you know they talked about Jesus and I ain't Jesus, so I can take it.

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If applicable, all relevant financial relationships have been mitigated.

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