Premature Birth

October 7, 2019

Paving the Path for my Granddaughter

by Ebony B. Carter, MD, MPH, assistant professor, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis

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“In the shadows of our finest medical facilities, where kings and shahs travel thousands of miles for the world’s best medical care, black babies continue to die.”

My mother opened nearly every speech with these words.  She was the Executive Director of the Ohio Commission on Minority Health and I have fond childhood memories of traveling the state with her as she gave voice to the voiceless.  I didn’t appreciate that my mom was providing my earliest lessons in advocacy and health disparities, or that I would grow up to be a high-risk obstetrician serving women in one of these fine medical facilities.

I care for women at Barnes-Jewish Hospital and many of my patients live in neighborhoods in North St. Louis City with infant mortality and preterm birth rates that rival the developing world.  I can personally vouch for the fact that we provide top-notch, evidence based care . . . and yet, just as my mother noted more than 30 years ago, “black babies continue to die.”

The number one reason a baby does not reach their first birthday is that he/she is born too soon.  A premature baby goes on to suffer from all of the consequences of having immature organ systems that do not function well; but, why are African American women more likely to have a preterm birth?  I don’t think there is a single answer; but, some of the patients I have cared for can help to provide insight.

“Heather” was nearly forty years old and despite wanting children, had never been able to conceive so she was pleasantly surprised to learn she was pregnant.  She’d been diagnosed with type 2 diabetes five years earlier and prescribed insulin but, despite working 60+ hours weekly as a nursing assistant, she lost her insurance and could no longer afford the medication.  She switched to a medication by mouth (metformin), which she could afford to take.

When I sent Heather’s prenatal labs, her diabetes was so poorly controlled that her baby’s risk of having a structural defect was more than 1 in 4.  My heart grieved for Heather and her baby because, despite doing everything in her power, she had an extremely high risk pregnancy—even worse, if she had had access to health insurance and preconception care, these risks were largely preventable.

“Heather” represents many of my patients.  I take care of her knowing that most of the time, while she has access to Medicaid during the pregnancy, I will get her medical problems under control. But, a few weeks after having the baby, she will lose that insurance and access to the tools that helped her to control the disease.  After delivery, small medical problems will grow into larger ones until she is able to access care again with her next pregnancy.  Then, the entire vicious cycle will repeat itself.  Access to insurance coverage is a significant burden born by many of my patients, but it does not stop there.

The people making medical decisions often do not reflect the people receiving care. I count myself blessed to work with loving, caring, amazing colleagues who provide care that is second to none.  However, all of us bring the sum total of our life experiences to our work and biases that we may not know exist.

As one of only two African American physicians on our team, I often cringe as I hear a nurse coaching an African American woman through labor with phrases like, “Come on GIRL, you can do it,” (I rarely hear white women referred to as “girl”) or physicians referring to older African American women by their first names, which is culturally a sign of disrespect.  These illustrations may seem insignificant, but the inability to connect culturally or understand the patients we treat has significant implications.  For example, patient “non-compliance” with medical care will sometimes lead the medical team to make the decision to deliver her earlier than would routinely be recommended.  I hate the term “non-compliance” because it has a negative connotation that blames the patient rather than the more nuanced explanation that she must work, or care for her children, or does not have the resources to come to physician’s and fetal testing appointments three times per week.  It is human nature to take shortcuts to quickly assess a situation and make a decision, but these short cuts are usually imbued with our own implicit biases and mean that African American women begin at a disadvantage.  Implicit biases are unlikely to favor us and are more likely to bring harm to us.

Six years ago, I was 35 weeks pregnant with my first daughter and working a 24 hour shift on the Barnes Jewish labor floor when my water broke.  As I called in my partner to relieve me, and prepared to transition from being the labor floor doctor to the laboring patient, I started sobbing uncontrollably.  In the grand scheme of all of the sick moms and babies I care for, my situation that day was mild in comparison, but I still knew that there were implications for being born too soon that could affect both my daughter’s health (respiratory distress) and my own health (increased risk for future cardiovascular disease).  I don’t know exactly why my baby was born 5 weeks early but, like many African American mothers, I suspect that high levels of stress contributed.

I am an African American woman.  Neither education, nor economic status, nor expertise in managing complicated pregnancies were enough to surpass the risks of being an African American woman in the United States for me and my baby.   I am outraged that my mother’s 30 year old words still ring true today and it should be a source of national shame.  My daughter is now a thriving kindergartener and I take great hope in knowing that I am part of the effort to assure that every woman has access to universal healthcare (because pregnancy is too late to intervene), we are calling out racism by name and addressing it, and acknowledging that racism comes with a stressful price that is being royally paid by black and brown bodies in our country.

I couldn’t protect my baby from coming too soon, but I stand in solidarity with the Institute for Public Health and we are Paving the Path to Reproductive Equity so that, if she so chooses, one day she will be a healthy mom who gives birth to a full term healthy baby.

Dr. Ebony Carter is a panelist at the Oct. 30th, 2019 Institute for Public Annual Conference: Healthy Moms and Babies: Paving the Path to Reproductive Equity

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