MetroDoctors Spring 2021: Improving Outcomes for Black Birthing Mothers

Spring 2021

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Improving Outcomes of Black Birthing Mothers

In This Issue: • • • •

Why the Birthing Disparities in Black Women?

What’s New with Birthing Centers Father’s Role in Maternal/Child Health Listening to BIPOC Community Leaders

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CONTENTS VOLUME 23, NO. 1 SPRING 2021

3

Co-create a Better Future

By Thomas E. Kottke, MD

4

PRESIDENT’S MESSAGE

Envisioning and Embracing a New Day

By Sarah Traxler, MD

5

Page 6

IN THIS ISSUE

TCMS IN ACTION

By Ruth Parriott, MSW, MPH, CEO

6

IMPROVING BLACK BIRTH OUTCOMES

• Colleague Interview:

A Conversation with Lisa Saul, MD, MBA

9 • Structural Racism as the Cause of Racial & Ethnic Inequities in Birth Outcomes

By Brigette A. Davis, MPH and Rachel R. Hardeman, PhD, MPH 12

• Better Together Hennepin: Working Together to Reduce Teen Pregnancy

By Katie Miller, Emily Scribner-O’Pray and Lisa Turnham

14 • Minnesota Maternal Mortality and Morbidity: Impact on Generations

By Alina Kraynak DNP, RN, PHNA-BC

Page 12

16 • Building a Better Birth Center

By Rochelle Johnson, MBA, MSN, RN 18 • Doula Dads: Black Men in the Birthing Space

By Integrated Care for High Risk Pregnancies 20

• Improving the Birthing Experience for Black Families

22

• Tackling Poor Birth Outcomes Among

African American Families

By Integrated Care for High Risk Pregnancies Page 5

24

THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

How Trill Moms is shifting the way society listens to and cares for Black mothers.

By Brittany L. Wright

Career Opportunities

28

MetroDoctors

Doctors Metro MetroDoctors

Improving Outcomes of Black Birthing Mothers

• A Case for Holistic Maternal Care

27 • Environmental Health— Another Reason Why Transit is Important

By Richard Adair, MD

Page 18

Spring 2021

New brand campaign reflects changes at The Mother Baby Center

By Tracy Pfiefer

Community Conversations—Beginning by Listening

By Annie Krapek, MPH

29

In Memoriam

The Journal of the Twin Cities Medical Society

In This Issue: • Why the Birthing Disparities in Black Women?

• What’s New with Birthing Centers • Father’s Role in Maternal/Child Health • Listening to BIPOC Community Leaders

This issue focuses on the birth disparities in Americanborn Black women. Read what community efforts are underway to address the problems. Articles begin on page 6.

Spring 2021

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Richard R. Sturgeon, MD Medical Student Co-editor Zineb Alfath Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published quarterly by the Twin Cities Medical Society, Broadway Place East, Minnesota Medical Joint Services Organization, 3433 Broadway Street NE, Suite 187, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113.

E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

Spring Index to Advertisers TCMS Officers

President: Sarah Traxler, MD President-Elect: Zeke McKinney, MD, MHI, MPH Secretary: Cora Walsh, MD Treasurer: Alex Feng, MD Past President: Ryan Greiner, MD At-large: Matthew A. Hunt, MD

Crutchfield Dermatology......................................

Inside Front Cover

TCMS Executive Staff

HealthPartners................... Outside Back Cover

Annie Krapek, MPH, Interim CEO (612) 362-3715; akrapek@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Kerry Hjelmgren, Executive Director, Honoring Choices Minnesota (612) 362-3704; khjelmgren@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

COPIC.................................................................... 8

Lakeview Clinic..................................................27 MedCraft..............................................................26 Minnesota Community Care.........................11 Philando Castile

Community Peace Garden..................25 Physicians Wellness Collaborative.................26

Amber Kerrigan, Program Coordinator (612) 362-3706; akerrigan@metrodoctors.com

Superior Wealth Management Group........... 2

Kate Feuling Porter, MPH, Program Manager

The Mother Baby Center................................21

(612) 362-3724; kfeuling@metrodoctors.com

You. We only have one thing on our mind.

GJ Lempe – Steve Powers – John Soukup (952) 885-5605 Securities Offered Through LPL Financial, member FINRA / SIPC

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Spring 2021

MetroDoctors

The Journal of the Twin Cities Medical Society

IN THIS ISSUE...

Co-create a Better Future

When the MetroDoctors editorial board decided that Black birthing would be the theme of the Spring 2021 issue, I immediately asked Dr. Lisa Saul, President of the Mother Baby Clinical Service Line for Allina Health, to be my co-editor.

Lucky me. She said, “Yes.” Read more about her amazing life’s journey in our Colleague Interview. We are fortunate to have her leadership.

This issue is full of experts talking about Black maternal health and describing the exceptionally poor outcomes that Black families experience before, during and after birthing, why this happens, and what the community is doing to improve the situation. You’ll miss the Luminary. After a decade of serving as a physician editor, writing 60 Luminary vignettes, our colleague, Dr. Marvin S. Segal, has retired.

We thank him heartily and wish him well. In its place we welcome a medical student column.

When you finish reading this issue of MetroDoctors, I have four books I want you to read: Daniel Kahneman’s, Thinking, Fast and Slow; Isabel Wilkerson’s, Caste; Ibram X. Kendi’s, How to Be an Antiracist; and Robin DiAngelo’s, White Fragility. These books provide meaningful context to contributory factors of societal disparities — unconscious bias and racism — and present the “how” of antiracism, a solution to remedy these disparities.

In his book, Kahneman describes the evidence for system 1 and system 2 thinking. System 1 is our intuitive brain that is always running in the background and, because it equates difference with potential danger, it tends to generate racist thinking. System 2, our forebrain, is lazy and tends to accept without question the signals it gets from System 1.

The take-home is that we need to consciously and consistently challenge our System 1 thoughts if we are to avoid racist thoughts and racist acts.

If your reaction to Caste is the same as mine, it will be, “OMG! This is terrible. They never told me this in high

school history class.” Just one example: Wilkerson documents that the Nazis, when looking to set up their anti-Semitic regime, turned to Jim Crow laws as their model. Even more shocking, they initially concluded that they could never get away with Jim Crow in Germany.

Unfortunately, they did and much worse. I’ll bet you never learned that in history class, either.

In the third book, How to Be an Antiracist, Kendi describes his journey from growing up racist in Brooklyn (yes, Blacks can be racists, too) to his current position as Director of the Center for Antiracist Research at Boston University.

Concluding his book, he tells the reader that there is no neutral ground. There is racism and there is antiracism; sustaining antiracism requires policy change — education and awareness will never be enough. I think he’s right.

A few weeks ago, as I was reading a National Academies of Sciences publication, I came across a study (https://bit. ly/SAGEjournal) of more than 3 million Swedish infants.

Adjusted for covariates, preconception stress of the mother increased the risk of infant mortality by 53%, preterm birth by 19% and small for gestational age by 14%. As I imagine the experience of Black women and the daily microaggressions and microtraumas that they experience, I conclude that, in addition to improving obstetrical care, all of us — OBs or not — have an opportunity to improve birth outcomes by improving the experience of Black daily life. In the fourth book, White Fragility, Robin DiAngelo suggests we do it by becoming allies. So, seek out your opportunities and ask, “How would you like me to help you?” In doing so, you will be co-creating a better future for everyone.

By Thomas E. Kottke, MD Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

Spring 2021

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President’s Message

Envisioning and Embracing a New Day SARAH TRAXLER, MD

As I anticipate this year as your TCMS president, I am, of course, compelled to look behind me and reckon with the last year — a year that not only heralded a pandemic that is ravaging communities, but a year that brought to the fore reminders of blatant disregard for Black and Brown bodies. We watched the video of George Floyd’s murder, and countless others, as he became yet another example of the devaluation of certain members of our community because of long-standing systemic racist oppression.

But while George Floyd’s murder was a grotesque, graphic representation of that disregard for the bodily autonomy of a Black man, we must acknowledge that devaluation of Black and Brown bodies has been playing out in subtle and obvious ways for several centuries. His tragic death is a culmination of that systemic devaluation, and we cannot deny that the medical establishment has played its own role in perpetuating it. We see it demonstrated in how the COVID-19 pandemic disproportionately impacts Black and Brown communities, how Black maternal mortality is significantly higher than White maternal mortality, and how race-based medicine is still taught in medical schools across the country.

As a gynecologist, I cannot ignore that J. Marion Simms, the father of gynecology who has a statue erected in his name in New York’s Central Park, gained his notoriety and knowledge through experimenting on enslaved African women without anesthesia, perfecting his techniques and then moving on to White women to be operated on with anesthesia. Moreover, it must be acknowledged that the birth control pill, a revolutionary innovation, but with roots in the eugenics movement, was developed and perfected during experiments on Black and Brown women prior to its release to the American, mostly White, public. And these two examples are a mere sampling of the countless ways in which communities of color have been exposed to injustices and used to advance science without consent, without regard for autonomy.

I’m not recounting these stories to be self-righteous, but to help expose the legacy of the medical establishment that has bred distrust and doubt among our patients of color and to remind us that we have deep work ahead of us that is necessary in order to undo a legacy of exploitation. At a time when we most need our communities to trust us and rely on the facts of science, we’ve needed to develop presentations, engage outreach groups, and form coalitions to do community engagement and negotiate around COVID vaccine hesitancy, a hesitancy that is a direct result of the multiple past injustices committed against marginalized communities by the medical establishment and the government. A change is certainly needed.

Sometimes it’s impossible not to feel burdened by the vast work ahead of us. In preparation for this inaugural address, however, I was reminded of our immediate past president’s message. Dr. Greiner’s final words remind us, “The story is still being written, our story, one that we can choose to write together or allow to be written for us.”

While the work ahead seems daunting, our story is still being written and we have the power and capability to pen a new narrative — one of active listening and centering new voices. I am confident that we, the TCMS membership, have the collective capacity to shape a new legacy of the medical establishment. I believe in our ability to dismantle oppression, advance equity, and promote trust. We can do this work by engaging community partners, stepping back, centering the voices of Black and Brown leaders, and working to hear what communities need from us.

As we look to a new year, I feel great responsibility taking the helm of TCMS at a time when such reform is so needed. There is, no doubt, more work to be done. And given the foundational work behind us, the depth of work ahead of us, and the incredible commitment of our physician leaders and advocates, I am confident that we can drive forward on issues that serve to make our communities more equitable, healthier and safer.

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The Journal of the Twin Cities Medical Society

TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO

Racism as a Public Health Crisis

Twin Cities Medical Society is proud to have lent our support to the City of Bloomington’s recent resolution declaring Racism as a Public Health Crisis.

The resolution includes a small appropriation to hire a consultant to recommend concrete local policies to combat the crisis. Bloomington has long been a leader in public health policy, including being the first city in Minnesota to assure clean air in outdoor dining spaces. We look forward to continuing to support their efforts as they explore municipal actions to impact health inequities.

Pilot Program for Resident Physician Wellness

The new wellness arm of Physicians Serving Physicians, Physician Wellness Collaborative, is launching a pilot program with four residency programs across the state to seamlessly and confidentially connect residents with support from physician mentors through a mobile app. The application, PeerConnect, has been in use by other professions, such as firefighters and EMTs. If the pilot is successful, PWC hopes to expand its reach to a broader physician community. If you are interested in volunteering as a peer mentor, please contact pwc-mn.org/peerconnect.

MetroDoctors

advance care planning training and advocacy, and collaborates to produce effective messaging and tools.

New Leader in 2021

Annual Legislative Training for Medical Student Advocates

Each January, the Dr. Pete Dehnel medical student Public Health Advocacy Fellowship hosts a workshop to discuss legislative actions to advance advocacy initiatives. Despite the tripling of the class size and a new virtual format, the session was quite interactive, including a legislative “Chutes and Ladders” game to illustrate the path a bill must traverse to become a law. The session concluded with an inspiring message from a health-professional-turned-elected-official, Sen. Erin Murphy of St. Paul.

For the third year, Sen. Murphy offered herself as a resource and the “first person to ask you to run for office.”

Honoring Choices Expands National Network

Honoring Choices Minnesota welcomes Georgia as the twelfth state program to join its national network. Through the network, Honoring Choices ensures timely sharing of best practices in

The Journal of the Twin Cities Medical Society

Twin Cities Medical Society CEO Ruth Parriott announced her decision to retire from TCMS in early 2021. The Board of Directors is pleased to appoint Annie Krapek, MPH as Interim CEO during the transition period. Ms. Krapek leads TCMS’s advocacy programs, most notably the public health initiatives and the medical student Public Health Advocacy Fellowship. She manages relationships with many of our most active members and external funders. Ms. Krapek joined TCMS five years ago and during her tenure completed a Masters program in Public Health while advancing from Program Coordinator to Senior Manager. Annie’s professional background includes working as nonpartisan staff for the Minnesota House of Representatives, and as program manager for the Minnesota Physical Therapy Association and Propel Nonprofits. She resides with her husband as a proud Nordeaster, animal lover, and enthusiastic home gardener.

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Improving Black Birth Outcomes

Colleague Interview: A Conversation with Lisa Saul, MD, MBA

L

isa Saul, MD, MBA is the President of the Mother Baby Clinical Service Line at Allina Health. She leads quality improvement, facilitated care model improvements for those patients at highest risk, and program/service developments that improve the health of our community and address care disparities. In addition to her role as president, Dr. Saul has worked as a perinatologist with Minnesota Perinatal Physicians for the last 15 years.

Dr. Saul is a California native who received her undergraduate degree from the University of California, Berkeley in Molecular and Cell Biology. She completed her residency in Obstetrics and Gynecology at the University of California, San Diego, and her OB/ GYN Residency at Morehouse School of Medicine in Atlanta. A fellowship in Maternal Fetal Medicine at the University of California, Irvine completed her medical training. Dr. Saul received her MBA in 2017 from the Kelley School of Business at Indiana University.

At what age did you realize that you wanted to become a physician?

I did not grow up in close proximity to physicians and had no real idea of what it took to become one. The first time I considered medicine as a potential career path was when my younger brother was born.

I am the oldest child in my family. Twelve long years separate my brother and me. When I found out I was finally going to have a sibling, I was elated. My mother had a less than ideal birth experience with me, mostly due to receiving high doses of pain medications that made her feel disconnected from the birth. At the time she became pregnant with my brother, hospitals were changing their approaches to birth, creating natural birthing environments that included family members. I was included in the birth planning, watched birth videos, and had one-on-one time with the obstetrician. He was so kind to me, and at the time of the birth, created a respectful, welcoming, safe environment for my family. The experience left a huge impression on me — because not only did I finally have a sibling, it was the first time I contemplated a future in medicine.

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What drew you to Perinatology?

Early in my medical education, sitting in lecture after lecture, it became clear to me that Black people are at highest risk for many illnesses: diabetes, hypertension, asthma, renal disease, obesity, certain cancers, drug addiction. There was never an explanation of why it was, just that it was. Clinical rotations did not paint a better picture.

Once I decided to pursue a career in Ob/Gyn, I selected a residency at Morehouse School of Medicine, with the knowledge that mostly African American physicians would teach me, and the residency would provide me the opportunity to care for women of color. One of my attending physicians, Roland Pattillo, was a key researcher of the HeLa cell line — the cells taken from Henrietta Lacks in 1951 during her treatment for cervical cancer. During my residency, I became intrigued by the complexities of high-risk obstetrics, and by the opportunity to explore the “whys” behind pregnancy outcomes for women of color. A fellowship in maternal fetal medicine provided a natural next step and allowed me dedicated time to spend researching my personal areas of interest.

My thesis focused on cervical length ultrasound, an important tool in the assessment of preterm labor risks.

MetroDoctors

The Journal of the Twin Cities Medical Society

What do physicians need to do at a clinical level to erase the disparity in birth outcomes?

The primary feedback I hear from patients of all races who have unsatisfactory experiences with care is twofold: they felt no one was listening to them and that the care team made assumptions about them that affected their care. Often, this causes patients to stop advocating for themselves even when they feel something is not quite right. Once trust is broken in this manner, the opportunity for poor outcomes widens.

As humans, we are biased. As physicians, we need to acknowledge these biases and leave preconceived notions at the door. It is important to our patients that we approach every interaction with curiosity, the sincere desire to hear what our patients are telling us, followed by a demonstration that we listened.

As a medical community, we tend to follow protocols, guidelines, and order sets pretty well. Our patients expect that we will provide excellent clinical care. In order to erase disparities in birth outcomes, we must couple the objectivity of clinical protocols and guidelines with the very subjective nature of human interaction.

Respectful interactions build trust. Assumptions erode trust. If we can prove we are listening — and that we care — we will earn our patients’ trust.

What impact does physical location (neighborhood), homelessness, being uninsured have on birth outcomes?

Insecurity, whether based upon food, shelter, health care or all three creates stress on an expectant mother that has direct links to poor birth outcomes. Women who do not have a reliable place to live or access to healthy food are at higher risk for outcomes such as growth restriction, unhealthy weight gain, and preterm labor — all risk factors for preterm delivery. Redlining and other forms of housing discrimination places some at higher risk of exposure to environmental toxins. Lead-contaminated drinking water in Flint, Michigan is an example of how housing disparities can influence health outcomes. Finding food and shelter meets an immediate need — one not met by attending a prenatal care appointment.

Many women have to choose between attending to their health and other more urgent needs. Others are unaware of the health coverage resources available to them because of their pregnancy.

Thus, care begins quite late — if at all — limiting opportunities for early and ongoing intervention related to clinical issues.

What needs to happen at a societal level for Minnesota to erase the disparity in birth outcomes?

At a community level, we need to improve access to care by expanding office hours, prioritizing pregnant and postpartum women for temporary housing programs, and strengthening MetroDoctors

The Journal of the Twin Cities Medical Society

systems to link our patients to affordable transportation. Ride share platforms like Uber and Lyft are activating in this space.

Furthermore, ensuring appropriate levels of care and the associated transport to higher levels of care addresses geographic disparities.

At a health system level, clinically-based interventions are a priority. As a state, we need increased access to substance abuse and mental health services. Standardized care within hospital systems is necessary, and standardization between hospital systems for high risk issues ideal. There are several organizations and committees in our state working to that end.

At a site of service level, we need to continue to leverage telemedicine and virtual visits. Our experience at the start of the COVID-19 pandemic accelerated this work. Robust case and peer review committees ensure practice standards aligned with available evidence.

Providers can, in addition to enhancing listening skills, work to improve communication between teams and team members.

This will ensure transfer of important information to the team members responsible for care.

Patients and families should be educated on when to seek care once they identify warning signs of clinical concern in pregnancy.

What advice would you give to physicians who want to practice anti-racism?

To be an antiracist, one must be willing to confront racial inequities. To confront racial inequities, one must be able to see that they exist. Structural racism is so pervasive in our lives that it is possible to miss it completely. We need to see where it exists as a barrier to patient care as well as in our working environments.

Physicians, as life-long learners, should take the time to learn about different people and cultures. They should expand their social circle to include people from various backgrounds and nationalities and seek to understand similarities and differences.

Physicians should actively discourage rounding practices and hallway conversations that disparage the race or language of a patient or team member or tacitly endorse stereotypes. Lastly, all physicians should review guidelines, protocols and policies that influence their care and determine if modifications are in order to remove language that supports racism or disparate care.

To what extent do other minority populations experience poor birth outcomes?

We see statistics that are alarming in many communities of color.

In Minnesota, African Americans represent 15% of maternal deaths despite making up 11% of the births in the state. Native

(Continued on page 8)

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Improving Black Birth Outcomes Colleague Interview (Continued from page 7)

American Indian mothers, 2% of the births in the state, are 12% of the maternal deaths. In many states, these numbers look similar for Latinx patients. These numbers do not account for maternal morbidity, which occurs far more frequently than maternal death in our community. In order to account for birth outcomes in Minnesota accurately, and make meaningful steps toward improvements, we must be able to track both morbidity and mortality in the pregnant population. Representative Ruth Richardson is working to put forward a bill that will expand our current reporting system to include maternal morbidity.

What advice would you give to young women of color who want to follow in your footsteps?

Your background, your heritage, is your strongest currency. Remember the lessons that your parents, grandparents, aunts, uncles, and others instilled in you about who you are and who you can become. In your loneliest moments, know that you have a village of cheerleaders who believe with all their might that you can do anything you put your mind to. Because you can. And you will.

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Black professionals are fleeing the state for the South. Why is this happening and what can we change in Minnesota to make the state more attractive to people of color?

When I was growing up in the southern California (LA area), our cul-de-sac was filled with families from the Philippines, Asia, Mexico, and a Mormon family. We heard different languages, tasted different foods, and had multicultural experiences everywhere.

We had reservations about moving to Minnesota.

What I have found is that although Minnesota does not come with the baggage of the South, it is still a very segregated community. Not only for Blacks, but for all people of color, and over time you feel the isolation in all your environments, e.g. work, grocery stores, restaurants, at the theater, etc.

“Minnesota Nice” also plays a role. I spent four years in Atlanta where racial discrimination is overt; whereas here, it is very covert and shrouded in “Minnesota Nice.” It makes you want to be with your tribe and to contemplate moving to get back to your family. Many people come to Minnesota for employment, growth opportunities; some get what they can and then leave for a warmer BIPOC climate.

These comments and experiences are very personal; I can only speak for myself.

MetroDoctors

The Journal of the Twin Cities Medical Society

Structural Racism as the Cause of Racial & Ethnic Inequities in Birth Outcomes

R

acial inequities in pregnancy — and birth-related outcomes — are well known among clinicians and epidemiologists, with a growing awareness among the general public. From devastatingly large disparities in maternal mortality,1 to persistent gaps in preterm birth, small for gestational age, fetal death2 and infant mortality, we consistently find that the average birthing experience for Black, Indigenous, and other People of Color (BIPOC) in the United States is barely comparable to that of their white counterparts. These outcomes serve as key indicators of population health, precisely because advancements in knowledge and technology around the pregnancy and parturition periods have drastically improved the likelihood of both parent and child emerging in good health. Nevertheless, the stubborn disparities across racial and ethnic groups highlight the inequities in access to salubrious resources, and the increased risk of exposure to harm, that BIPOC birthing people face.

As researchers continue to examine the causes of disparities in birth outcomes, particularly for BIPOC communities, it is clear that differences in socioeconomic status and individual comorbidities cannot explain the size nor persistence of these disparities. In fact, it is likely that no single risk factor can explain these inequities but rather structural racism, defined by Gee & Ford (2011) as “the macrolevel systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among

By Brigette A. Davis, MPH and Rachel R. Hardeman, PhD, MPH MetroDoctors

Brigette A. Davis, MPH

Rachel R. Hardeman, PhD, MPH

racial and ethnic groups,” is the cause we should examine.3 Structural racism, not race, is responsible for the persistent racial disparities in birth outcomes, such as preterm birth, small for gestational age, and infant mortality.4 Unequal exposure to psychosocial stressors and trauma, unjust exposure to chemicals, environmental toxins, and teratogenic agents, as well as structural barriers to quality, and respect-centered prenatal care are all driven by the complex interplay between institutions that create and reinforce a racial hierarchy that protects white individuals over Black, Indigenous, Latinx, Pacific Islander, Asian, and other individuals of color. Understanding how these systems influence and maintain disparities in birthing outcomes, and how to dismantle these systems, must remain at the center of all work aiming to address racial and ethnic health disparities in birth outcomes.

Stress,5-7 distress, depression,8 and trauma7 during pregnancy are well-documented risks for adverse birth outcomes, particularly preterm birth and intrauterine growth restriction impacting birthweight at delivery.5 The biological mechanisms

which likely explain this relationship, include the complex neuroendocrinal and immunologic changes induced by stress, which influence pregnancy, fetal development, and parturition physiology,9 though the precise biological mechanisms are still being examined. For instance, the relationship between stress and the increase in cortisol is associated with the precipitous increase in cortisol releasing hormone (CRH) which signals the initiation of labor. Studies have found that increases in cortisol in pregnancy are associated with preterm birth5,10,11 and low birthweight.12 Similarly, increased blood pressure and other indicators of sympathetic nervous system activation — caused by acute and chronic stress — precede low birth weight, small for gestational age, and other developmental indicators associated with intrauterine growth restriction. A review of the literature has found that maternal stress can even cause epigenetic changes influencing both fetal and neonatal physiology — influencing preterm birth and future growth and regulation in children.13 Exposure to stressors is more prevalent among BIPOC, precisely because many of

The Journal of the Twin Cities Medical Society

(Continued on page 10)

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Improving Black Birth Outcomes Structural Racism (Continued from page 9)

these stressors are driven by structural racism. Studies suggest that both cumulative life stressors and the severity of stressors is greatest among Black and U.S. born Latinx populations compared to whites.14 The proliferation of stressors in Black and Brown communities is driven by systemic factors which deny BIPOC access to opportunity and resources by constraining access to jobs to precarious and low-wage work — often limiting health insurance, reducing access to quality education that supports economic mobility, and restricting access to housing to poorer neighborhoods with worse housing stock.15 These patterns are sometimes driven by interpersonal discrimination, yet more insidiously, though seemingly race- and class- neutral polices such as source-of-income discrimination, credit scores, and linking school funding to tax revenue. These stressors are compounded by the existential threats of discrimination by law and immigration enforcement, and mass incarceration16,17 which simultaneously removes social and financial support from households, and all of which influence birth outcomes.

Research even suggests that community-level trauma such as racialized law enforcement communities can vicariously influence the health of people unrelated to those directly targeted. One study has found a 24% increase in low birth weight among infants born to both U.S. born and foreign born Latinx people following a large immigration enforcement raid in Pottsville, Iowa,18 suggesting personal risk as well as potential community risk of detainment and deportation is costly for birthing people in that community.

Emerging research on the impact of exposure to police violence as trauma for Black communities examines how police encounters and extrajudicial violence serve another racialized community trauma of Black people.19 Based on research which shows widespread mental distress among Black people following police violence, adverse birth outcomes as police presence in community increases,20 as well as a potential increase in fetal demise following 10

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the Rodney King beatings,21 highlight the need to understand the community-level impact of police violence on Black birthing people.

Increased exposure to stressors as a driver of racial/ethnic health inequities aligns with Geronimus’ landmark Weathering Hypothesis,22 which posits that chronic exposure to disadvantage leads to accelerated aging, explaining earlier onset of many illnesses, particularly among African Americans. This was originally posited to explain the increased risk of low birthweight among older Black, but not white mothers, in comparison to their adolescent counterparts.23 A recent systematic review supports this hypothesis that as age and thus the lifetime risk of exposure increases, so does the risk of multiple adverse birth outcomes including preterm birth, lower birthweight, and intrauterine growth restriction.24 Indeed, even in Minnesota, among nulliparous, singleton births between 2014 and 2018, the rate of preterm birth for adolescents (15 – 19 years) compared to young adults (20 – 29 years) was 8.1% vs 7.0% for U.S. born non-Hispanic white individuals, and 8.7% vs. 10.5% among U.S. born non-Hispanic Black individuals.25 Unjust, inequitable exposure to environmental toxins such as air and noise pollution and chemical waste, are also structural mechanisms through which disparities in birth outcomes are created.26 Historically, federal and local governments chose low-income BIPOC neighborhoods as the location for infrastructural developments such as highways, the location of landfills, and the sites of chemical plants.27 Endocrine disrupting chemicals, air pollution impacting the heart and lungs, and even teratogenic pollutants influence the rates of preterm birth, birth defects and infant mortality in BIPOC communities.

Finally, the systemic discrimination BIPOC birthing people face during clinical interactions antenatally and during birth is critical and most amenable to action by those reading. Non-Hispanic Black and Latinx patients are less likely to report being treated with respect by their provider.28 Similarly, research on a large dataset of births over 20 years in

Florida suggests patient-physician racial concordance reduces the risk of infant mortality, particularly when faced with complications during birth.29 Together, these results suggest a more respectful, relationship-centered approach toward caring for BIPOC birthing people to improve the health and well-being for individuals and their offspring.30 Racism ranging from historic, state-sanctioned denial of education, jobs and housing, and their contemporary manifestations including state-sanctioned violence from law and immigration enforcement, mass incarceration, and housing discrimination, interact to design the sociocultural landscape in which all people in the United States reside. As scientists, clinicians, and others concerned about the persistently high risks for adverse birth outcomes in BIPOC communities, it is important that we understand and acknowledge the ordinariness of racism in their lives and the role it plays in perpetuating these inequities.30 A resounding commitment to dismantling structural conditions which deny BIPOC birthing people the resources, safety and respect necessary for a safe pregnancy experience, is necessary to achieve reproductive justice and birth equity.

Rachel R. Hardeman, PhD, MPH is an Associate Professor and Blue Cross Endowed Professor of Health and Racial Equity, Division of Health Policy and Management at the University of Minnesota School of Pubic Health. As a reproductive health equity researcher, her work leverages reproductive justice and critical race theory to build empirical evidence of racism’s impact on Black birthing people and their babies.

Dr. Hardeman has received funding from federal and philanthropic agencies, including as a Robert Wood Johnson Interdisciplinary Research Scholar. She is also the PI of the Measuring and Operationalization Racism to Achieve Health Equity (MORHE) Lab. Brigette A. Davis, MPH is a 4th year PhD Candidate at Harvard T.H. Chan School of Public Health, a Robert Wood Johnson Health Policy Research Scholar, and a member of Dr. Hardeman’s MORHE lab. Her research examines ways to operationalize and

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measure structural racism, and its impact on birth outcomes.

References 1. Petersen EE, Davis NL, Goodman D, et al.

Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. Morbidity and Mortality Weekly Report. 2019;68(35):762.

2.

Pruitt SM, Hoyert DL, Anderson KN, et al. Racial and ethnic disparities in fetal deaths—United States, 2015–2017. Morbidity and Mortality Weekly Report. 2020;69(37):1277.

3. Gee GC, Ford CL. Structural racism and health inequities: old issues, new directions. Du Bois review: social science research on race.

2011;8(1):115-132.

4.

Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. Journal of Women’s Health. 2020.

5. Dunkel Schetter C. Psychological science on pregnancy: stress processes, biopsychosocial models, and emerging research issues. Annual review of psychology. 2011;62:531-558.

6. Maric NP, Dunjic B, Stojiljkovic DJ, Britvic D, Jasovic-Gasic M. Prenatal stress during the 1999 bombing associated with lower birth weight—a study of 3,815 births from Belgrade. Archives of women’s mental health.

2010;13(1):83-89.

7. Shapiro GD, Fraser WD, Frasch MG, Séguin JR. Psychosocial stress in pregnancy and preterm birth: associations and mechanisms. Journal of perinatal medicine. 2013;41(6):631-645.

8. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Archives of general psychiatry. 2010;67(10):1012-1024.

9. Widmaier EP, Raff H, Strang KT, Vander AJ. Human Physiology: The Mechanisms of Body Function. NY: McGraw-Hill Higher Education; 2015.

10. Shaikh K, Premji S, Khowaja K, Tough S, Kazi A, Khowaj S. The relationship between prenatal stress, depression, cortisol and preterm birth: A review. Open Journal of Depression.

2013;2(3):24.

11. Giurgescu C. Are maternal cortisol levels related to preterm birth? Journal of Obstetric, Gynecologic & Neonatal Nursing.

2009;38(4):377-390.

12. Cherak SJ, Giesbrecht GF, Metcalfe A, Ronksley PE, Malebranche ME. The effect of gestational period on the association between maternal prenatal salivary cortisol and birth weight: a systematic review and meta-analysis. Psychoneuroendocrinology. 2018;94:49-62.

13. Nowak AL, Anderson CM, Mackos AR, Neiman E, Gillespie SL. Stress During Pregnancy and Epigenetic Modifications to Offspring DNA: A Systematic Review of Associations and Implications for Preterm Birth. The Journal of Perinatal & Neonatal Nursing. 2020;34(2):134145.

14. Sternthal MJ, Slopen N, Williams DR. RACIAL DISPARITIES IN HEALTH: How Much Does Stress Really Matter? 1. Du Bois review: social science research on race. 2011;8(1):95.

15. Williams DR, Lawrence JA, Davis BA. Racism and Health: Evidence and Needed Research.

Annual review of public health. 2019.

16. Dyer L, Hardeman R, Vilda D, Theall K, Wallace

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21.

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23.

M. Mass incarceration and public health: the association between Black jail incarceration and adverse birth outcomes among Black women in Louisiana. BMC Pregnancy and Childbirth. 2019;19(1):525.

Jahn JL, Chen JT, Agénor M, Krieger N. County-level jail incarceration and preterm birth among non-Hispanic Black and white US women, 1999–2015. Social Science & Medicine.

2020:112856.

Novak NL, Geronimus AT, Martinez-Cardoso AM. Change in birth outcomes among infants born to Latina mothers after a major immigration raid. International journal of epidemiology. 2017;46(3):839-849.

Bor J, Venkataramani AS, Williams DR, Tsai AC. Police killings and their spillover effects on the mental health of Black Americans: a population-based, quasi-experimental study.

The Lancet. 2018.

Hardeman R, Chantarat T, Karbeah J. Police Exposure As a Determinant of Structural Racism: An Exploration of the Association between Preterm Birth in Neighborhoods with High Police Exposure. Health Services Research.

2020;55:50-50.

Grech V. Terrorist attacks and the male-to-female ratio at birth: The Troubles in Northern Ireland, the Rodney King riots, and the Breivik and Sandy Hook shootings. Early human development. 2015;91(12):837-840.

Geronimus AT. The weathering hypothesis and the health of African-American women and infants: evidence and speculations. Ethnicity & disease. 1992;2(3):207-221.

Geronimus AT. Black/white differences in the relationship of maternal age to birthweight: a population-based test of the weather-

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ing hypothesis. Social science & medicine.

1996;42(4):589-597.

Forde AT, Crookes DM, Suglia SF, Demmer RT. The weathering hypothesis as an explanation for racial disparities in health: a systematic review. Annals of epidemiology. 2019;33:1-18. e13.

Birth Statistics Query: Single Preterm Birth Counts among U.S. Born, nulliparous mothers by maternal ethnicty, race, and age (20142018). Minnesota Department of Health; 2014-2018. https://mhsq.web.health.state. mn.us/birth/queryFrontPage.jsp?goTo=birthInterfaceSas.jsp&queryPage=birthInterfaceSas. jsp&startQuery=true. Accessed January 5, 2021.

Bekkar B, Pacheco S, Basu R, DeNicola N. Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US: a systematic review. JAMA network open. 2020;3(6):e208243-e208243.

Rothstein R. The color of law: A forgotten history of how our government segregated America. Liveright Publishing; 2017.

Blewett LA, Hardeman RR, Hest R, Winkelman TN. Patient Perspectives on the Cultural Competence of US Health Care Professionals. JAMA network open. 2019;2(11):e1916105-e1916105.

Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician–patient racial concordance and disparities in birthing mortality for newborns. Proceedings of the National Academy of Sciences. 2020;117(35):21194-21200.

Hardeman RR, Karbeah JM, Kozhimannil KB. Applying a critical race lens to relationship centered care in pregnancy and childbirth: An antidote to structural racism. Birth.

2020;47(1):3-7.

At Minnesota Community Care, we believe in health for all.

That’s why we provide comprehensive primary health services to everyone regardless of age, financial situation, access to insurance, language or immigration status. While our name has evolved, our purpose has remained the same over the past 50 years - to serve the health needs of our community.

Together, we are Minnesota Community Care.

mncare.org | 651.602.7500 11

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Improving Black Birth Outcomes

Better Together Hennepin: Working Together to Reduce Teen Pregnancy

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elping teenagers postpone parenthood improves health outcomes and makes good social and economic sense. Young people who wait to become parents are less likely to live in poverty and are better able to pursue their dreams. Additionally, young people who wait to become parents are less likely to experience pregnancy complications, and their children are at lower risk for infant death, childhood health problems, developmental delays, and school struggles.

Although teen birth rates across the U.S., Minnesota, and Hennepin County have reached record lows, the negative outcomes associated with teen pregnancy still exist. Due to racial disparities in teen birth rates, these negative outcomes disproportionately impact communities of color. For this reason, Hennepin County believes investing in teen pregnancy prevention is an upstream public health strategy for eliminating health disparities and ensuring healthy futures for young people.

To tackle teen pregnancy and address local disparities, Hennepin County has invested in a collective, community-driven approach titled: Better Together Hennepin: Healthy Communities — Healthy Youth (BTH). BTH launched in 2006 to address the county’s high rates of teen birth and disparities by race, ethnicity and geography. Housed within Hennepin County Public Health, BTH delivers four key supports proven to prevent teen pregnancy and promote adolescent health: connections to caring adults; healthy youth development opportunities; sexual

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health education; and adolescent-friendly health care. This approach includes a variety of innovative and evidence-based programs that are guided by community engagement.

Focus on Health Disparities

Although Hennepin County is typically highly ranked in Youth Leadership Council members and community overall health, there are critipartners at a past Better Together Hennepin event. cal health disparities by race, ethnicity, and lived experience such as inHennepin County Commissioner Irene volvement in corrections, foster care and Fernando. homelessness. Black, American Indian and Decline in Teen Birth Rates Latinx teens are inordinately impacted by Hennepin County has been successful in teen pregnancy, sexually transmitted infecits efforts to prevent teen pregnancy. Since tions, and related sexual health outcomes. the start of BTH, the birth rate among For example, in 2019 Hennepin County Hennepin County teens aged 15-19 years Black teen birth rates were 13 times higher decreased 66% with only 367 teens exthan white teens. Structural racism and periencing a birth in 2019 compared to historical trauma create the conditions that 1,122 in 2006. These declines mirror nalead to these health disparities. In order to tional teen birth rate trends, but Hennebest utilize resources, ensure equity and pin County outpaces the Minnesota and improve outcomes within communities U.S. teen birth rate reductions. National and populations, BTH focuses work withstudies suggest that the declines in teen in communities with the greatest health birth rates are attributable to declines in disparities among Hennepin County citsexual activity and increases in adolescent ies, neighborhoods, and populations of contraceptive use. Declines in teen birth young people. In order to maximize imrates among this population also include pacts, BTH works to identify and reinforce declines in abortion rates. systems that support adolescent health.

While disparities persist, since 2006 This approach is supported by Henall racial and ethnic groups in Hennenepin County leadership who, in June pin County have experienced teen birth 2020, passed a resolution declaring racism rate declines, with a 61% decline among a public health crisis. “I think that there is African American (Black) teens, 66% enough data and enough research through decline among Hispanic (Latinx) teens, our own public health department…that 81% decline among white teens, 85% dewe can unequivocally say that at the root cline among Asian teens, and 86% decline of our work to dismantle disparities is the among American Indian teens. need to dismantle systemic racism,” said MetroDoctors

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Engage With the Community

Better Together Hennepin achieved these results because of the commitment, expertise, and reliability of partners that are embedded in the community. Together with school districts, clinics, community stakeholders and youth, BTH developed a partnership model that addresses teen pregnancy prevention and adolescent sexual health. BTH partners are highly respected and trusted by professionals, parents and youth. This collaboration allows BTH to offer aligned and coordinated programming that is evidence-based, and at the same time, responsive to local concerns.

The BTH initiative supports communities with the highest teen birth rates, by providing funding for local agencies to implement the following activities: • Sexual health education in middle and high school classrooms • Parent/guardian education to support communication about sexual health • 1:1 youth education and support in school and clinic settings, including healthcare referrals • Community mobilization, capacity building and training in settings where youth are present • Youth leadership and peer education programming • Assessing, promoting, and building community capacity for adolescent-friendly clinics This layering of services by community partners, across communities with the

greatest needs, has been highly successful.

In addition to the outcomes in teen birth, over 80% of youth participants report that community educators understand them; over 80% report they learned a lot from the programs; and 85% report that talking with the educator and getting answers to questions was the best part of the program.

All this work happens with a shared commitment to health and racial equity between BTH and community partners. In addition to participant feedback, BTH is guided by community wisdom. BTH has a community advisory group made up of 24 professionals and community stakeholders, as well as five youth leadership councils, each consisting of 10-20 youth.

Working closely together, sharing power, creating mutual trust and constant communication have been key to BTH reaching its goals. As one school official noted, “BTH and community educators have gained the respect of the community because they are known as approachable, responsive and accountable. The security of these relationships has allowed for open, honest and responsive communication, which has been especially important when challenges arise.”

Look to the Future

BTH has been successful at reducing teen birth rates. However, this work must be sustained for new generations of young people. Hennepin County will continue to invest in adolescent health by prioritizing

Hennepin County Teen Birth Rates 2006-2019 births per 1,000 females ages 15-19 years by reported race/ethnicity 120.0

Hispanic Asian

100.0

Black American Indian

80.0

White 60.0 40.0 20.0 0.0

2006

2010

2015

2019

Based on geocoded birth certificate data provided by Minnesota Department of Health vital records. Analysis and reporting provided by Hennepin County, HSPH - Health Protection Assessment Team. The population figures (2000 - 2009) are based on US Census 2000 - 2010 straightline estimates; 2010 - 2018 are based on 2010 US Census counts

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access and education that is culturally relevant and meets the needs of those most impacted by health disparities. The partnership model and community engagement strategies will continue to guide this important work. BTH believes we truly are better together!

Learn More:

• •

https://www.hennepin.us/better together http://bit.ly/BTH2020report

Katie Miller, Emily Scribner-O’Pray and Lisa Turnham, champion the work of Better Together Hennepin as Hennepin County Public Health principal planning analysts. They each have over 25 years of experience in the fields of youth development and adolescent health. They have expertise in adolescent sexual health; evidence-based programs; youth and community engagement; community partnerships and collective impact; program development and evaluation; and adolescent-friendly clinic environments.

References: • Centers for Disease Control and Prevention: Reproductive Health, Teen Pregnancy, retrieved 1/14/21 https://www.cdc.gov/teenpregnancy/ about/index.htm.

• Hennepin County Resolution, News Release, 6/30/20 https://content.govdelivery.com/accounts/MNHENNE/bulletins/29366e5.

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Minnesota Maternal Mortality and Morbidity: Impact on Generations

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n December 2020, the U.S. Surgeon General and the U.S. Department of Health and Human Services released a call to action amplifying the need to transform maternal care in the United States. “Optimizing maternal care is critical to the well-being of future generations: improvement must extend beyond pregnancy and promote mental and physical health in young girls and adolescents, through reproductive years.”

In the United States, maternal mortality doubled between 2000 and 2015 and disproportionally affects African American/Black, American Indian and Hispanic women. The magnitude of the maternal health crisis occurring in the United States directly affects individuals, children, families and communities, for generations to come.

Maternal morbidity is defined as severe pregnancy and postpartum complications and maternal mortality is the death of a mother during pregnancy or within one year after giving birth or end of a pregnancy from any cause. Maternal morbidity and mortality are viewed internationally as indicators of the overall health status of a country, state or community.

Preliminary data from the Minnesota Office of Vital Records shows that each year in Minnesota during pregnancy, labor/delivery, or the year postpartum approximately 20-35 women die and approximately 3,000 women experience morbidities.

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Incidence and Cause In the United States, the leading cause of preventable pregnancy-related deaths among mothers is hemorrhage followed by chronic medical conditions, preeclampsia, and infection, some of which can be prevented or mitigated with early diagnosis and appropriate intervention.

The Centers for Disease Control and Prevention (CDC) found that approximately 60% of pregnancy-related deaths from 13 states occurring in 2011-2015 were preventable, which did not vary by race/ethnicity or by timing of death.

Deaths can be prevented by identifying contributing factors and implementing prevention strategies at the community, healthcare facility and system levels.

These strategies can include improving access, quality and coordination of care across multiple healthcare providers and non-health related services.

Preliminary data from Minnesota Vital Records shows the leading causes of maternal mortality from 2011-2017 are obstetric complications, unintentional poisoning, violence, non-obstetric complications, motor vehicle crashes, and suicide. Obstetric complications include, but are not limited to, obstetric hemorrhage, unanticipated complications of obstetric management, hypertensive disorders in pregnancy, and pregnancy-related infections. Approximately one-third of the preliminary determined maternal deaths in Minnesota resulted from suicide, unintentional poisoning (drug overdose) or violence. Assessing the timing of maternal deaths in

Minnesota’s birthing persons indicates that 43.6% of maternal deaths occur between 43 days and one year post-delivery, followed by during pregnancy (24.5%) and within 42 days of delivery (21.3%). In evaluation of the state’s preliminary data, collective action is needed to better serve new mothers and families in the extended post-partum period (43 days to one year).

Maternal morbidity has increased by 75% in the United States in the past decade. According to Firoz et al. (2019), “For every woman who dies of pregnancy-related causes, 20 or 30 others experience acute or chronic morbidity, often with permanent sequelae that undermine their normal functioning”.

Maternal morbidity includes complications in pregnancy, childbirth or postpartum, and can range in severity from non-life-threatening urinary incontinence to exacerbation of previously diagnosed medical conditions, chronic pain, or potentially fatal strokes. Health conditions related to maternal morbidity can be temporary or can last for the rest of a mother’s life resulting in poor health outcomes or permanent disabilities.

Focus on Health Equity In Minnesota, there are significant disparities in maternal mortality rates across different race and ethnicity groups. Preliminary data from Minnesota Vital Records, 2011-2017 shows that African American/Black women are 1.5 times more likely (including those born in the U.S. and in other countries) and

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American Indian mothers are 7.8 times more likely to die during pregnancy, delivery, or the year post-delivery than non-Hispanic white women. When breaking down the African American/ Black population further, this preliminary data shows that African American women born in the United States are 2.8 times more likely to die during pregnancy, delivery, or the year post-delivery than non-Hispanic white women in Minnesota. Another way to look at the disparity data is to compare the proportion of births to the proportion of deaths (see Figure 1).

Unfortunately, similar trends are occurring across the nation emphasizing the urgency to address the true inequities and structures of discrimination existing in maternal health. The CDC convened a working group of health equity researchers and practitioners, including University of Minnesota’s Associate Professor and Minnesota Maternal Mortality Review Co-Chair Dr. Rachel Hardeman to identify how bias occurs in maternal deaths. The goal of this work is to design a consistent approach for states to document bias and contributing factors to maternal deaths including discrimination, interpersonal racism and structural racism. This approach will magnify the forms of bias that contribute

to maternal health outcomes, whether being intentional, or systematically applied in practice.

Strategies in Action CDC’s Office of Reproductive Health works with states to form and convene maternal mortality review committees — a panel of experts representing organizations and specialties in holistic maternal health to review identified maternal deaths. The Minnesota Maternal Mortality Review Committee reconvened in 2019 to continue this integral work. The goal of this committee is to determine if the death was preventable, assess contributing factors and make recommendations to address maternal deaths. These recommendations range from a variety of population health strategies to integration or changes in state policy. Examples of strategies include providing tools to pregnant people and their support persons necessary to voice concerns and ask questions during and after the birth process, such as the CDC’s Hear Her Campaign. For providers and health systems, integrating specific trainings such as bias trainings or health systems implementing protocols and policies for swift identification of acute obstetrical issues. Expansion of postpartum care or paid family leave

Figure 1.

Comparing the Proportion of Minnesota Maternal Deaths to the Proportion of Minnesota Births by Race/Ethnicity, 2011-2017

Data Source: Minnesota Department of Health Resident Maternal Mortality File

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are examples of state policy changes that positively impact maternal health.

Using this type of surveillance and monitoring of maternal mortality, the committee identifies contributing factors, and partner with agencies to create meaningful change. Organizations such as task forces, state hospital associations and agencies (departments of health and human services), professional health and community led organizations, and Perinatal Quality Collaboratives are integral components in translating the recommendations from review committees to action.

Addressing maternal mortality and morbidity is multifaceted, and tangible investments need to be prioritized to improve birthing outcomes for all people. By improving and increasing funding opportunities for community-led programming, family-centered birthing opportunities, and investment into diversifying the healthcare workforce, Minnesota can create a future of equitable care. Connecting with pregnant persons frequently during and after birth, providing tools to contact their provider or a trusted health partner, and allowing one to be heard during this time is critical. Building opportunities to meet birthing persons at their readiness, and integrating support throughout and after pregnancy, can lead to a more equitable delivery of care for all and healthier families in Minnesota.

The Minnesota Department of Health is the state health agency whose mission is to protect, maintain, and improve health of all Minnesotans. The department’s Child and Family Health Division champions this work, within the Title V Maternal and Child Health (MCH) Block Grant Program to promote and improve the health and well-being of the nation’s mothers, children, including children with special needs, and their families.

Submitted by Alina Kraynak DNP, RN, PHNA-BC; Women’s Health Consultant– Maternal and Child Health Section.

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Improving Black Birth Outcomes

Building a Better Birth Center

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e’re all painfully aware of the statistics: African American and Native American women are three times more likely to die of pregnancy-related causes than white women; Black women are 48% more likely than whites to deliver prematurely; Black mothers are more likely to suffer a loss of pregnancy, and more likely to lose their baby within the first year of life.

When planning for the new Regions Hospital Birth Center, we knew the facts. We wanted to create a place that would help reverse the trends and close the gaps.

We started with a clear vision: To create a space that matched our goals for family-centered care, had high reliability and embodied health equity. Most birth centers focus on the first two, but we added health equity because of our patient population.

Sixty percent of the patients who deliver at Regions are people of color; 25% need an interpreter and 50% rely on government supported health insurance.

What’s the first step toward health equity? We started with data because we needed to see where we had disparities.

Most hospitals collect quality data, but don’t take it down to race, ethnicity, language and payer. We were able to zoom in on unique patient populations and focus accordingly.

We also wanted to know our patient feedback. We found that we had

big disparities in response rates from our patients of color.

So we gathered the data and took steps for our other important goal, building relationships with our community partners. Because while we weren’t seeing much variation from a quality data

perspective, we did see huge gaps in our patient experience.

We were receiving very little feedback from our African American patients, who make up 35% of our patients. How were more than a third of our patients feeling when they came to the Birth Center? Why weren’t we hearing from them?

We made the patient experience surveys much shorter and much easier to respond to. And we began working on relationships with our community partners, to help us build trust.

To name just a few: • We changed our prenatal education partnership to an organization, Everyday Miracles, who offers classes in multiple languages, and at a reduced rate to people who have government supported insurance.

By Rochelle Johnson, MBA, MSN, RN

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• We worked with Minnesota Community Care’s D.I.V.A. Moms program, which helps African American mothers navigate their pregnancy while providing physical, emotional and culturally-aligned support.

• We asked the Hmong Health Care Professionals Coalition for insight into after-delivery nutrition that aligns with cultural traditions.

Asking patients what they need and strengthening our community partnerships meant looking outward — but we also needed to look in, at ourselves. Staff development was crucial.

Department leaders took a year-long equity training. Providers of all kinds got together to learn about biases and health equity principles that impact care. We challenged ourselves to translate what we learned into practice by creating policies and procedures for the new building that MetroDoctors

help disrupt some of the barriers that impact disparities.

Take the universal drug screening test. A young Black woman might be sensitive to the questions she’s being asked. We make sure our teams are able to talk through the policies, in a culturally sensitive way, and verbalize why we do the test and why it is supportive of all pregnant women.

Being able to have these conversations around our policies really makes an impact on the patient. If our staff can’t speak to the reasons they’re asking these screening questions, patients are not going to trust them.

The Regions Hospital Birth Center has been open since last July. It’s easy to say you want to meet patients where they are at, but it takes a lot of thoughtful planning, training and implementation to begin to close the gaps and create a

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bright, welcoming environment that celebrates each family who walks through its doors. I think we’re on our way.

Rochelle Johnson, MBA, MSN, RN is the Director of Nursing for the Regions Hospital Birth Center in St. Paul, MN. As director, Rochelle has worked to create an open line of communication with community partners in order to impact maternal and infant health. With a focus on health equity, Rochelle has a passion for addressing the disparities that exist for people of color, especially maternal and fetal health outcomes, so she works to create meaningful community partnerships in order to address social determinant of health both before and after delivery.

Rochelle is a registered nurse with a Master of Science in Nursing Leadership and a Master of Business Administration.

She can be reached at: Rochelle.l.johnson@ healthpartners.com; (651) 495-3050.

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Improving Black Birth Outcomes

Doula Dads: Black Men in the Birthing Space Integrated Care for High-Risk Pregnancies (ICHRP)

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hen fathers are involved in maternal and child health, mothers are more likely to seek prenatal care and refrain from unhealthy behaviors, and fathers are more likely to have close bonds with their children. Yet, despite these findings, most maternal healthcare systems are not designed for fathers’ involvement. According to researchers, stereotyped messages depicting that a father’s role in the family is to provide financial support tends to limit their involvement in the birth process and their children’s lives.1,2,3 William Moore is one of the first African American male doulas in Minnesota and a founding member of Doula Dads, an organization founded to help African American fathers understand the birth process and their significant role in it. In an interview with Cinna Cullens, he stated the stereotypes that Black fathers are not involved in childcare, do not spend significant time with their children, and are unimportant in their children’s development are belied by a 2013 Center for Disease Control study that showed that Black men are “more involved with their children in day-to-day activities” than fathers of other races, but are “just least likely to be married to the mother of our children.”4 Doulas are paraprofessionals who are trained to support a mother and family during pregnancy, labor and birth by coaching fathers, providing care to mothers, and sharing information about maternal health. Doula Dads was founded to

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challenge societal stereotypes by preparing Black men to play active roles during pregnancy and delivery and in the lives of their children. According to Moore, their goal is to help African American families understand that “birth work is not women’s work, it’s family work.” This coaching, he noted, requires some paradigm shifts related to gender norms, such as abandoning the perception that a father’s role begins only after the baby’s birth.

The National Institute for Children’s

Health Quality (NICHQ) has called for an end to excluding fathers from maternal and child health programs and for engaging fathers as allies in efforts to improve maternal and child wellbeing. This call has been embraced by the African American Integrated Care for High Risk Pregnancies (ICHRP) collaborative, a public-private partnership serving Ramsey and Hennepin Counties that advocates for prenatal and postpartum African American maternal and child health, and Ramsey

William Moore, Health Educator, Saint Paul-Ramsey County Public Health, Doula Dads, and one of the first men in Minnesota to be certified as a birth attendant and breastfeeding educator in 2019.

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County Birth Equity Community Council (BECC), a community-engaged collaborative that meshes racial healing activities and public health strategies to reduce inequities in birth outcomes.

One way in which these organizations have supported greater involvement of African American fathers in maternal and child health is encouraging men to become doulas. During the COVID-19 epidemic, according to Moore, Doula Dads have shifted to virtual methods to support families. Andi Mack, another founding member of Doula Dads interviewed by Cullens, is a staff member at Black Family Blueprint, which provides coaching and consulting to strengthen parenting and intimate relationships. He reported having been inspired by a woman doula to enter the field and investigate the importance of fathers’ participation in maternal and child health processes. As he “started to imagine why it was important for me to be present while my wife was giving birth and the value of certain comfort and relaxation techniques that I could provide to assist the birth,” he recalled, “it became very clear that I have to work with ‘brothers’ on their path to fatherhood.” He was further inspired by learning more about the historical practice of midwifery in the Black community and how men had been removed from the birthing process due to the “medicalization of birthing.”

Chief among the reasons that fathers need to be involved in maternal and child health, according to Moore, are to counter stereotypes about gender roles and become familiar with resources available to parents that even “some case workers do not know about.” For instance, “A lot of men and a lot of case workers don’t know that male parents can use WIC,” the federal Special Supplemental Nutrition Program for Women, Infants and Children. He strives to help Black fathers understand what they and their partners may experience during the process, including such biological factors as prenatal mood changes and post-partum depression among both men and women.

In Mack’s doula practice, he coaches new fathers on what fatherhood and MetroDoctors

From Left: Paige Anderson Bowen, MPH, Chief Advancement Officer, Minnesota Community Care (MCC); Diane Banigo, DNP, APRN, CNM, D.I.V.A. Moms; Shauntae Thompson, Perinatal Care Navigator, MCC; Tee McClenty, Project Manager, CPPM, ICHRP NorthPoint; Sameerah Bilal-Roby, African American Babies Coalition + Projects; Sonja Batalden, Director Perinatal Care, MCC at ICHRP Spring Into Action Conference in 2018.

manhood entail and current fathers on how to become more directly engaged with their children. He sees his role as involving Black fathers in the entire maternal and child health process, “not just showing up and taking pictures at the end.”

Ways in which men can assist the birth experiences of African American women include: offering culturally reflective care; promoting breastfeeding; and supporting mothers’ nutritional health during pregnancy. He believes it is important for Black fathers to know what pregnancy looks like through all its stages, to understand the meaning of terminology used by medical providers, and to be engaged in the process from packing Black Buddy Bags for the birth experience to supporting mother and baby at birth and beyond. From his experience, “There’s no way a Black father with a healthy mind could detach after witnessing the birth of his child regardless of the relationship with the mother. There is a deeper level of love, respect and value of the children and an increased value of that mother after observing birth.”

Through their work, Doula Dads are helping strengthen African American households and communities. They are also committed to helping maternal and childcare professionals better understand the concept of co-parenting as understood in the African American community. As an example, Moore stated that providers often refer to people who are coparenting as single parents and clarifying this

The Journal of the Twin Cities Medical Society

misunderstanding “is not only important in understanding African American families but also essential to providers in connecting with the families they serve.”

The doula training program for Black males in Minnesota that led to the formation of Doula Dads was a collaboration between Ramsey County Public Health, ICHRP, and the Cultural Wellness Center, a transformative space intended to incubate culturally-based solutions to real-world problems. Despite the challenges, the Doula Dads are encouraged by the progress they have witnessed. According to Mack, “To hear ‘brothers’ share how they understood and were able to apply a technique to support the mother is a reward that speaks volumes to the work that I am doing and that I am trying to get better at doing.”

References: 1.

National Institute for Children’s Health Quality (NICHQ), “Making Fathers Visible in Maternal and Child Health” Insights, 2019, https://www. nichq.org/insight/making-fathers-visible-maternal-and-child-health.

2.

NICHQ, “Fathers: Powerful Allies for Maternal and Child Health,” Insights, 2019, https://www. nichq.org/insight/fathers-powerful-allies-maternal-and-child-health.

3. Ave Mulhern, The Father Factor: Before the Baby Involving Dads in Maternal and Child Health, National Fatherhood Initiative, 2019, https://www.fatherhood.org/fatherhood/ before-the-baby-involving-dads-in-maternalchild-health.

4. Jo Jones, Ph.D., and William D. Mosher, Ph.D., Division of Vital Statistics “Fathers’ Involvement With Their Children: United States, 2006–2010,” National Health Statistics Reports, Number 71, December 20, 2013, https://www. cdc.gov/nchs/data/nhsr/nhsr071.pdf.

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Improving Black Birth Outcomes

Improving the Birthing Experience for Black Families New brand campaign reflects changes at The Mother Baby Center

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he U.S. spends more on health care than any other country globally, yet we still lead the developed world in pregnancy-related deaths. Sadly, up to half of these deaths are due to preventable causes — things we can address with proper prenatal and postnatal care.

When we dig a bit deeper, we find that Black women experience pregnancy-related deaths at a rate three times higher than white women.

It’s been nearly two decades since a Michigan-based public health researcher introduced us to the term “weathering.”

This word describes how the health of Black women begins deteriorating in early adulthood not as a result of race, but because of the effects of stress associated with cumulative experiences and socioeconomic disadvantages.

So, what does this tell us?

It tells us that pregnancy outcomes might be affected by certain “preexisting conditions” not within the DNA of Black women themselves but in our communities and the larger health system.

It tells us that Black women need early access to good health care. They need providers they can trust who will identify risk factors and look carefully for symptoms suggestive of pregnancy-related complications.

It tells us that we can do better.

Changes at The Mother Baby Center

At The Mother Baby Center, a partnership between Allina Health and Children’s Minnesota, we believe improved health

By Tracy Pfiefer

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outcomes for Black women can only come through better healthcare experiences.

With this in mind, we’re taking multiple steps to improve the birthing experience for Black women and their families.

Recently, we launched a brand campaign to better reflect the diversity of our community. By changing something as simple as the images we use to tell our story, we believe we can help create a more welcoming environment where people from diverse backgrounds feel more comfortable turning to us for their health.

With illustrations by Minneapolis artist Kprecia Ambers, our new campaign is designed to help people see themselves not just in the faces of other patients at The Mother Baby Center but also in our diverse group of providers.

The work we’re doing is backed by research. Many studies have shown that patients are more comfortable with providers who look like them or have a shared understanding of their racial, ethnic and cultural differences.

While our new campaign creates a more inclusive presence across our website and throughout our advertising, we know it’s just a start. In truth, our rebranding goes much deeper than our exterior. We’re also making important changes within.

To support our brand promise and create a more respectful environment at The Mother Baby Center, we’ve launched a parallel Diversity, Equity and Inclusion (DEI) initiative. Through our DEI work, we’ve developed training opportunities to support the individual journeys of our providers and staff.

The DEI training program addresses several concepts, including:

• • • •

Culturally responsive pregnancy care Unconscious bias in the workplace Unconscious bias in patient care Practical ways to address macroaggressions, microaggressions and unconscious bias in practice We’re also developing a “train-thetrainer” module to equip leaders and staff with tools to lead meaningful dialogue and encourage ongoing learning, reflection and growth.

Personalized Care for Unique Stories, Diverse Backgrounds

Since opening in 2013, The Mother Baby Center has grown to three locations. Our providers deliver more than 10,000 babies each year. We know that every family we meet has a unique story. Our job is to be a trusted partner with each of them in their personal journey from conception to pregnancy to parenting.

Learn more about the work we are doing by visiting themotherbabycenter. org.

Tracy Pfiefer, Vice President of Operations, Mother Baby Clinical Service Line.

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The Journal of the Twin Cities Medical Society

What you conceive of, we deliver.

Expert guidance and support.

Latest safety protocols.

On-site neonatal ICU.

At The Mother Baby Center, we believe that every mother deserves to be heard, every baby deserves the best care, and every family deserves support.

Learn More at themotherbabycenter.org.

W H AT YO U D E S E R V E , D E L I V E R E D.

Improving Black Birth Outcomes

Tackling Poor Birth Outcomes Among African American Families Integrated Care for High-Risk Pregnancies (ICHRP)

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he healthcare establishment has recently become increasingly conscious of poor birth outcomes among many U.S. families. In particular, they have recognized that African American and Indigenous families represent a disproportionately high percentage of the estimated half a million maternal deaths, four million neonatal deaths, and six million child deaths annually. Such deaths have become so common and alarming that it is not unusual to see maternal complications leading to death in televised medical dramas and widely discussed in news media. In response, at least six states and the District of Columbia have enacted special legislation to address poor birth outcomes, with varying degrees of success.

In 2015, the Minnesota legislature directed the Department of Human Services (DHS) to implement a pilot program to improve birth outcomes for African American and Indigenous families, resulting in the Integrated Care for High-Risk Pregnancies (ICHRP) Initiative. Based on research showing that a community-driven approach would have the greatest impact, DHS staff members Dr. Jeffrey Schiff and Fritz Ohnsorg launched ICHRP with a community-centered design that resulted in both African American- and Indigenous-led ICHRP collaboratives. This article describes the approach to tackling poor birth outcomes developed by African American ICHRP, a public-private partnership serving Ramsey and Hennepin Counties.

By Integrated Care for High Risk Pregnancies

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From Left: Paige Anderson Bowen, MPH, Chief Advancement Officer, Minnesota Community Care (MCC); Diane Banigo, DNP, APRN, CNM, D.I.V.A. Moms; Shauntae Thompson, Perinatal Care Navigator, MCC; Tee McClenty, Project Manager, CPPM, ICHRP NorthPoint; Sameerah Bilal-Roby, African American Babies Coalition + Projects; Sonja Batalden, Director Perinatal Care, MCC at ICHRP Spring Into Action Conference in 2018.

The African American ICHRP is a culturally responsive service provider and advocate for prenatal and postpartum maternal and child health that offers screenings, referrals to health and social services, education for healthy pregnancies and babies, and peer support for expectant families. It also engages in community engagement, health professional training, and technical assistance to inform the community, launch other initiatives, and advance existing healthcare organizations.

Employing a collaborative care model that focuses on early prenatal identification of families with elevated psychosocial risk levels, its primary goal is to stabilize risk factors that have been shown to impact birth outcomes. After identifying a family’s needs and risks, a collaborative care team puts together a comprehensive care plan to connect them to support and services, including prenatal care. These teams and their collective partners consist of paraprofessionals and practitioners such as

behavioral health practitioners, care navigators, chemical health treatment practitioners, child protection practitioners, community birth practitioners, community health workers, doulas, peer support specialists, prenatal care clinicians, public health nursing staff, and social service practitioners.

The African American ICHRP’s primary service hubs are the Ramsey Prenatal Clinical Collaborative, made up of Open Cities Health Center and Minnesota Community Care, and NorthPoint Health & Wellness Center, a multi-specialty agency in north Minneapolis. They receive support from the Amherst H. Wilder Foundation’s African American Babies Coalition + Projects, which is known for fostering the healthy brain development of babies and provides additional communication, outreach, and training to healthcare professionals and the broader community. The collaborative is overseen by a 15 member advisory council within

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The Journal of the Twin Cities Medical Society

a decentralized and egalitarian operating structure. In 2019, the African American ICHRP served more than 10,000 moms and families through individual services, in-person educational sessions, and the Internet. It also reached more than 1,500 community members and healthcare professionals through print media messages, webinars and radio programming.

The collaborative’s community-centered approach is based on three key pillars: mobilizing assets within Minnesota’s African American communities to promote maternal health equity and increase families’ control over their health and lives; building on existing research and practices related to high-risk African American pregnancies in Minnesota and around the country; and highlighting the contributions of community engagement, social connections, and patients’ voices to families’ health and wellbeing. Together, these pillars support efforts to build control and resilience that help buffer families against stressors associated with high-risk pregnancies, health-related behavior, and management of health conditions.

The African American ICHRP collaborative has brought Black-centered design thinking to each stage of their work. During the inspiration phase, collaborative members immersed themselves in participatory community research with African American moms to identify their maternal needs, barriers they experienced in health care, and aspirations for successful birth outcomes. After learning that many African American women believe

that healthcare workers are dismissive of their concerns, especially if they have limited incomes, health problems, or already have several children, and often feel rushed through healthcare processes and treated in disrespectful ways, the collaborative became committed to creating a better continuum of care that is attentive to the cultural needs of families.

In the ideation stage, collaborative members deeply considered how they could effectively respond to maternal needs and expectations in Black cultural contexts. These ideas were incorporated into service formats and tested with varying mothers and their families to evaluate what worked best. Peer support meetings were found to be especially successful in helping families talk through maternity concerns and barriers encountered during visits with healthcare professionals and to gain resources to aid healthy pregnancy outcomes. As an example of its willingness to experiment and innovate, when the ICHRP name did not immediately resonate with expectant families in Ramsey County, the names D.I.V.A. Moms (Dynamic, Involved, Valued African-American Moms), Drop-In D.I.V.A., and Nu’D.I.V.A.s were found to lure more expectant families.

During the implementation stage, the collaborative has delivered programming and services from 2018 through today.

Based on that experience, it strongly believes that integrated care can reduce maternal, neonatal and child deaths. An especially important part of the ICHRP

Tee McClenty, Project Manager, CPPM, ICHRP NorthPoint (center) with Doula class participants Meleshia Williams and Rose Gbadamassi in 2019.

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The Journal of the Twin Cities Medical Society

model is including paraprofessionals on the care teams who are in touch with the cultures of the families they work with and skilled at allowing families to feel fully heard and understood. In their work with healthcare professionals, collaborative members encourage greater investment in integrated healthcare teams, including at least one paraprofessional member, to enhance the health of mothers, neonates and children.

COVID-19 has not diminished ICHRP program performance. Attendance in online peer support groups and information sessions has continued to be high. The collaborative has also introduced several innovative program activities, such as drive-through pick-ups and door-todoor drop-offs of maternal necessities such as clothing, baby diapers and formula.

In-person screenings via Zoom or telephone have allowed the ICHRP teams to sometimes learn things about families and their basic needs that might not have been observed in typical maternal healthcare visits. These modifications during the pandemic have allowed the collaborative to continue its efforts to identify and respond to factors known to seriously impact a pregnant woman’s psychosocial health and to provide individualized care experiences that create seamless maternal experiences and healthy outcomes.

References: • Jamila Taylor, Cristina Novoa, Katie Hamm, and Shilpa Phadke, “Eliminating Racial Disparities in Maternal and Infant Mortality, Center for American Progress,” May 2, 2019, https://www. americanprogress.org/issues/women/ reports/2019/05/02/469186/eliminating-racial-disparities-maternal-infant-mortality/.

• Kathy, B. Kozhimannil, Ph.D., MPA, “Indigenous Maternal Health—A Crisis Demanding Attention,” University of Minnesota Rural Health Research Center, University of Minnesota School of Public Health, Minneapolis, Minnesota, May 18, 2020, https://jamanetwork.com/channels/health-forum/fullarticle/2766339.

• Jacklynn Blanchard, “Out of Sight, Out of Mind? What Is the True US Maternal Mortality Rate? No One Knows, Rockefeller Institute of Government,” August 2019, https://rockinst.org/wp-content/ uploads/2019/08/8-1-19-Maternity-Mortality-Brief.pdf.

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Improving Black Birth Outcomes

A Case for Holistic Maternal Care How Trill Moms is shifting the way society listens to and cares for Black mothers.

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rill Moms is an initiative dedicated to disrupting disparities that disproportionately impact Black mothers, improving the quality of life for all mothers, and providing social support for parents to raise well-rounded, conscious children. We host a podcast (Trill Moms Podcast), curate events, create products, and advocate for state and federal policies that impact Black moms.

As the creator of Trill Moms I created a framework called Holistic Maternal Care to describe the work we do and the fierce urgency to care for birthing parents, especially Black mothers in a way that acknowledges the historical exploitation of our bodies and how that manifests into the current inequities we face, especially in the medical field. Holistic Maternal Care is the social, emotional, cultural and political reckoning of reparative care that Black women have been denied since the inception of obstetrics and gynecology. All of the work we do inside of Trill Moms fits within the framework of Holistic Maternal Care, but our goal is to have hospitals, birthing centers, and medical practitioners partner with us to consider how they too can better support their patients, starting with Black women. A partnership with Trill Moms to implement Holistic Maternal Care provides the opportunity to: 1. Listen to Black women. At Trill Moms our first point of engagement is through a podcast. We needed a way to connect with mothers from

By Brittany L. Wright

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Spring 2021

the comfort of their own home and we recognized that so many mothers, especially Black women were feeling unheard, ignored, and as if their voice didn’t matter. We encourage practitioners and professionals who want to connect more authentically to get in the practice of listening to Black women and trusting them as the authors of their own experiences.

2. Acknowledge the historical trauma of birthing parents, and how the medical field’s current practices can sometimes be an extension of the exploitation or maltreatment that a patient, their community members, or their ancestors have experienced.

3. Integrate cultural rituals back into the prenatal, labor and delivery, and postpartum care. Trill Moms is rolling out a doula training program to support institutions invested in shifting their practices to join forces with community members and trained doulas to share our cultural

capital and introduce innovative solutions for navigating birthing during a pandemic.

4. Center Black mothers in media campaigns and organizational representation. It’s imperative that Black women see themselves and feel safe within their birthing institutions.

Digital media is the cornerstone of communication, especially during a pandemic. Whether it is a PSA, docuseries, or full branding campaign, it’s imperative that organizations reflect the communities they want to serve, and to acknowledge their worth.

5. Build systems of support for birthing parents beyond the 6-week postpartum check-up. The CDC reports that 33% of maternal deaths happen within the first year that a woman gives birth. For every one woman that dies, 20-30 more are severely injured. If systems of support were built to check in on new parents to ensure that their bodies are properly healing from childbirth and related complications, the rates of maternal mortality and morbidity could shift drastically.

6. Advocate for public policies that work to disrupt disparities. Community advocates often do this work for free. Partnering with them and paying them would be a great way to support the community and build trust.

One of the bills Trill Moms supports and has advocated on behalf of is the

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Care framework and how you and/or your organization can support the work of Trill Moms visit TrillMoms.com.

Dignity in Pregnancy and Childbirth Act. This bill was introduced by MN Representative Ruth Richardson; it supports ongoing and mandatory implicit bias training and increased research on Black maternal mortality and morbidity. What I love about this bill is that it includes a mandate for further reporting on Black maternal morbidity, recognizing that there are so many women, like me, that are severely injured after giving birth. It’s not enough to focus on the deaths associated with birth, the near deaths and injuries are equally problematic and disproportionately impact Black and Indigenous women.

When I was pregnant, I spent the final weeks of my pregnancy searching on Google for which hospitals and birth practitioners were the least likely to let my baby and me die, but there’s no magic algorithm to filter out bias, negligence or malpractice. As a first-time mom I was well aware of the rates of Black infant and maternal mortality in the United States and was terrified that my child and I wouldn’t survive childbirth if I didn’t find the “right” facility to support us. At the time I was living in a state with no community to help inform my decision, no social support to help my husband and me adjust to our new life, and I couldn’t find a single MetroDoctors

medical institution in my area that was willing to acknowledge the crisis of Black infant and maternal mortality on their website. I didn’t see myself in the institutions I researched. I longed for culturally responsive and holistic care, I wanted an affirmation that I was more than a number and that my Black life mattered, but I never found that.

I faced my biggest fear and gave birth to my daughter, and neither one of us died, but my quality of life has drastically changed since childbirth. My six-week postpartum checkup affirmed the intrapartum fever that crossed my placenta during childbirth and diastasis recti, but nothing more, yet I returned to that medical institution 55 times that year with a variety of complications that I’m still dealing with to this very day.

This is why I created Trill Moms, and Holistic Maternal Care. A safe and positive pregnancy, birth and postpartum experience is a basic human right. When we fail to acknowledge the biases embedded in the systems so many of us are dependent on, when we fail to hear Black women when they describe their pain, and when we fail to support new parents beyond the 6-week checkup we miss an opportunity to provide birthing parents with the support they truly need. To learn more about the Holistic Maternal

The Journal of the Twin Cities Medical Society

Brittany L. Wright is a Digital Storyteller, Social Impact Strategist, Maternal Health Advocate, and Creative who fiercely advocates for equity and Black liberation. She’s a published writer, freelance journalist, and podcast host who focuses on the nuances of the Black life and motherhood. In the fall of 2019 underneath the umbrella of Gray Matter, Miss Brit released Trill Moms, an initiative focusing on Black Maternal Health, womanhood, and conscious parenting. The Trill Moms Podcast is available on all podcast streaming platforms and at TrillMoms.com. Brittany is a Josie R. Johnson Leadership Fellow, and the host of the Black Life Amplified Town Hall Series focused on COVID 19 and health and wellness within the Black Community.

grow Help grow peace by contributing to the future of the Philando Castile Community Peace Garden, a space for reflection, education, and unity for generations to come.

DONATE AT philandocastile-peacegarden.org

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Environmental Health— Another Reason Why Transit is Important

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ur primary care Internal Medicine clinic is on Chicago Avenue in Minneapolis, just 10 blocks from where George Floyd died. Like in many neighborhoods of color, poor public transportation infrastructure is a serious issue in the area. To get to our clinic, many patients take the Number 5 bus, a busy line and very slow.

Patients arriving late often caused us to fall behind schedule, so we instituted a policy: more than 15 minutes late and you have to reschedule. We allow some leeway for snow days, patients with limited English proficiency, etc. And yet, patients regularly arrived late because their bus was late or they missed a transfer.

I remember one patient in particular, who burst into tears at the front desk and was ushered into an exam room and given a box of tissues. She was a woman about age 35 with a grade-school-age daughter and had recently left an abusive partner.

She described her schedule: get her daughter off to school, take the bus to work and back, take another bus to pick up her daughter from the after-school Minneapolis Kids program, take buses to get groceries and see the doctor. So when our office said we couldn’t see her because she was late, she lost it. My patient was doing all that she could, but our underfunded transportation system kept her perpetually struggling to meet her family’s needs.

What to do about these glaring systemic differences? Let’s focus on actions proven to work, like investing in bus rapid transit (BRT).

A large and careful study ranked factors that predicted whether children growing up in poverty would escape poverty as adults (http://bit.lyNYTransit). Number one on the list was decreasing the time parents spend commuting to work. Less time on the bus means more time for nurturing,

helping with homework, and better access to jobs and critical services like health care.

Local elected officials are united in asking for BRT lines serving low income neighborhoods as it is fast and relatively inexpensive. Unlike light rail (LRT), which works best in a few very heavily travelled corridors, BRT lines can crisscross neighborhoods and lead to many destinations.

Like LRT, fares are paid before the bus arrives, stops are spaced out, traffic lights can stay green for a bus, and boarding is fast. Two metro BRT lines are open and functioning well. More are planned; one would run by our clinic.

George Floyd’s death has made us aware of the social injustice that accompanies this area’s prosperity. A better transit system is one change that’s affordable, can be put in place right now, and would have a real impact on the lives of patients.

Richard Adair, MD was an internist at Abbott Northwestern Hospital for many years and ran an outpatient clinic for primarily people of color. This experience led him to become an advocate for better and more accessible transportation systems within Minneapolis. This article is about his experience.

CAREER OPPORTUNITIES

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Be a part of a collaborative work environment in a primary care group of family physicians, internists, pediatricians, general surgeons and OB/GYNs. • 4-day work week with 32 contact hours achieving excellent work/life balance • Excellent compensation with a 2-year partnership track to earn in the top 10% in the state • Outstanding benefits including 100% paid family health insurance and dental insurance, 401K and profit sharing • We have 4 sites in the southwest metro: Chaska, Waconia, Norwood, and Watertown

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CONTACT: administration@lakeviewclinic.com PHONE: 952-442-4461 ext. 7215 WEB: www.lakeviewclinic.com

By Richard Adair, MD

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Spring 2021

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Community Conversations— Beginning by Listening

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ngaging our members in supporting community-driven initiatives that are led by those who are most impacted by injustices is at the heart of TCMS’s mission. The events of the past year have underscored that urgent work is needed to address systemic racism and the harm it inflicts on our community. As we each consider how we can play a role in dismantling the racist systems that are harming the health of Minnesota’s Black, Indigenous and people of color (BIPOC), it is critical that we begin by listening.

In that spirit, TCMS launched a new series of conversations with BIPOC leaders who are working on the front lines of addressing racial injustices in the Twin Cities. We hope these conversations will inspire our membership to think more deeply about these issues and find ways to deepen their work to address systemic racism and advance health equity. metrodoctors.com/communityconversations.

We are also thrilled by the opportunity to spotlight several current and past TCMS Dr. Pete Dehnel medical student Public Health Advocacy Fellows as conversation hosts.

Voting Rights and Engagement with the ACLU of Minnesota Policies that disenfranchise BIPOC have been embedded in our nation’s voting system since its founding and have a real impact on voter engagement in Minnesota’s BIPOC communities today. In our first community conversation medical students Mina Krenz and Jenna Robinson sat down with Ismael Dore, an Organizer with the ACLU of Minnesota, to talk about his work to advance racial equity by engaging BIPOC Minnesotans in voting. While it can be tempting to disengage from this work during non-election years, effective, equitable voter engagement requires ongoing work.

Ismael Dore

Mina Krenz, MS2

Jenna Robinson, MS2

Community Safety Beyond Policing with MPD150 While George Floyd’s murder once again brought systemic racism and violence to the forefront, these issues are not new. Policing, as it is, is not providing public safety to all our neighbors and in many cases, is actively doing harm to BIPOC people. In this community conversation, Medical student Aaron Rosenblum connected with Minneapolis-based artist and organizer, Ricardo

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Spring 2021

Levins Morales, to discuss the work of MPD150 and how they are working to open our collective imagination to co-create creative solutions to keep all members of our community safe.

Ricardo Levins Morales

Aaron Rosenblum, MS3

Homelessness and Creating Safe Housing with Street Voices of Change Safe and affordable housing is foundational to health, safety, employment, and overall well-being, but the systems that we have created keep many people in a cycle of homelessness. In this conversation, medical student Jillian Millares connected with Street Voices of Change member, Sherry Shannon, to discuss barriers to affordable housing, what safe housing looks like, and how the medical community can support creative solutions to address homelessness.

Jillian Millares, MS3

Sherry Shannon

Food Access with Appetite for Change Everyone deserves the right to eat and feed their families fresh, living food that makes them feel good, yet access to nourishing food is often limited for BIPOC Minnesotans. Appetite for Change has been living out their mission to use food as a tool to build health, wealth and social change in North Minneapolis since 2012. In this conversation, medical student Prasanna Vankina connected with Appetite for Change co-founder, Princess Haley, to discuss their efforts to increase food access and food knowledge in North Minneapolis, and how the medical community can be a part of the local food movement.

TCMS will continue to release additional community conversations throughout 2021. We hope that you will join in deeply listening to local BIPOC leaders and sharing your thoughts how the medical community can more actively engage in the anti-racism work that is needed to truly achieve health equity.

Prasanna Vankina, MS1

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The Journal of the Twin Cities Medical Society

In Memoriam–

January 2020 – February 2021 Remembering Our Colleagues

Mark Banks, MD

March 17, 2020

Henry (Hal) Meeker, MD

February 26, 2020

Berton Barrington, MD

January 7, 2020

Eric A. Melum, MD

November 4, 2020

Richard D. Benjamin, MD

January 6, 2021

Sheldon Mendel, MD

April 30, 2020

Robert B. Benjamin MD

April 15, 2020

William Peters Miller, MD

William J. Boardman, MD

April 16, 2020

Robert Molenaar, MD

May 19, 2020

October 5, 2020

Roy Daumann, MD

July 21, 2020

Bjorn Monson, MD

July 25, 2020

Keith Dawson, MD

May 5, 2020

Timothy Nealy, MD

March 26, 2020

Francis Denis, MD

April 24, 2020

Richard Olson, MD

January 19, 2020

January 1, 2020

Robert Powers, MD

April 26, 2020

May 2, 2020

James Presthus, MD

July 31, 2020

Robert Rocknem, MD

May 31, 2020

Edward Donatelle, MD Steven Erickson, MD Alexandra Hult Filipovich, MD Robert Foley, MD

May 18, 2020 October 27, 2020

Ernest Ruiz, MD

November 5, 2020

Richard Foreman, MD

April 11, 2020

Gary E. Schnitker, MD

June 9, 2020

Richard Gebhart, MD

May 15, 2020

Albert Schroeder, MD

August 25, 2020

Kenneth Hodges, MD

November 2, 2020

David Spencer, MD

May 29, 2020

April 8, 2020

Jens Strand, MD

June 15, 2020

Ellen R. Stubbs, MD

June 28, 2020

James Householder, MD Robert B. Howe, MD Robert Jensen, MD

November 14, 2020

Richard E. Student, MD

August 22, 2020

May 26, 2020

George Tagatz, MD

January 16, 2021

Robert Junnila, MD

August 12, 2020

Richard Taylor, MD

January 23, 2021

James Kramer, MD

March 31, 2020

Jack Wallinga, MD

May 10, 2020

Joseph Wethington, MD

April 20, 2020

Robert Johnson, MD

Kevin M. Lawler, MD Harold Londer, MD Mark Mahowald, MD

MetroDoctors

May 4, 2020

November 11, 2020 July 29, 2020

Terrell Yeager, MD

February 20, 2020

March 18, 2020

The Journal of the Twin Cities Medical Society

Spring 2021

29

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