When Marna Armstead was only a few weeks along in her first pregnancy, she noticed spotty bleeding and visited her longtime doctor for a consultation. Though the pregnancy was unplanned, she told her doctor she would keep the baby.
“It was a cold and insensitive appointment,” Armstead said. She recalls the obstetrician used the word “pregnancy,” not “baby,” to describe the child she was carrying, and suggested that Armstead might be better off not going through with it.
That was nearly 22 years ago. While Armstead says some things have changed for Black mothers like herself, much has stayed the same.
San Francisco lost 10 mothers during childbirth in between 2007 and 2016, according to the San Francisco Health Improvement Partnership, a group of service providers and community-based organizations that fights for health equity. Five of those women were Black.
Their babies are also more likely to die. From 2012 to 2016, 5.6 per 1,000 Black infants died within 12 months of birth as compared to 1.7 per 1,000 white infants, SFHIP data shows. Both of these figures fall below statewide and national averages.
“My basic premise is that your health shouldn’t depend on the color of your skin or the neighborhood that you live in,” said Malia Cohen, former District 10 supervisor. “The harsh reality, even in this great, wealthy city, is that it does.”
These stubborn disparities haven’t changed much over time. How The City plans to tackle them, has.
Zea Malawa, a San Francisco-based pediatrician, says that while these inequities have existed for decades, most interventions have been clinical — a new medication or a prenatal care program, for example — as opposed to addressing the root cause of these outcomes.
“If we want to close the disparity we need to get honest about what is driving the disparity — that is stress, in particular racialized stress,” said Malawa, who runs Expecting Justice, a Department of Health program that seeks to close maternal health disparities. “We have to be willing to take active steps to dismantle all that.”
Doulas are one place to start. They provide mothers with information and support throughout pregnancy and childbirth as well as advocate for mothers’ needs to practitioners.
Such a person would have been a huge help to Armstead. The stresses of her life — finding a new doctor, dealing with an unraveling romantic relationship and thinking about life as a single mom — caught up with her, and she was diagnosed with gestational diabetes, high blood sugar during pregnancy, and preclampsia, a condition caused by high blood pressure. Her daughter then ended up in the newborn intensive care unit.
Armstead recalls voraciously reading pregnancy books to educate herself about the conditions.
“I had lots of support from my family, but I still felt really alone,” she says. “What if I had a doula, someone who would have been able to talk to me and help me understand what was happening?”
Black mothers today are still more likely to suffer from pregnancy complications such as these, according to the city health department’s 2019 Community Health Needs Assessment. They’re more prone to food insecurity, temporary homelessness and unemployment, all of which can contribute to stress-induced health outcomes.
“There’s actually a lot of research that shows how stress gets under the skin and changes your biology and affects your health,” said Anu Manchikanti Gómez, the director of the Sexual Health and Reproductive Equity Program at UC Berkeley. “Medical interventions have not made a big difference in some of these health disparities, so we know that the causes of these inequalities are really deep.”
Doulas help teach a mother about pregnancy lifestyle changes and prepare them for possible complications. They can attend medical appointments, liase between the doctor and patient and help educate mothers on care options. According to a study in the Journal of Perinatal Education, doula-assisted mothers were four times less likely to have a low birth weight baby, two times less likely to have a birth complication and significantly more likely to breastfeed their child.
San Francisco has directed city funding toward programs that try to make the services of a doula — which often come with a hefty price tag — more accessible to the women who need them most. These programs also focus on providing culturally competent care to patients.
“Having racial concordance in your provider can often be protective,” Malawa said. “Having somebody who sees your full humanity is really important for developing trust and rapport with any provider.”
Armstead, who herself trained to become a doula, now serves as executive director of SisterWeb, a nonprofit that gives Spanish-speaking, Black and Pacific Islander women a stipend as they train to become doulas. Cohen, then on the Board of Supervisors, helped to launch a partnership between SisterWeb and local hospitals that allows practitioners to pair doulas from the network with mothers from the same communities.
Expecting Justice runs a training program of its own. It will graduate a class of 25 new Black and Pacific Islander doulas in the coming weeks with the hope of creating a second cohort later this year. The four-month course is free to attendees thanks to a combination of public and private funding.
The City is also experimenting with a universal basic income program for Black and Pacific Islander women.
Participants, about 150 of whom just received their first checks in July, will receive $1,000 each month during their pregnancy and six months after giving birth with no conditions on how the money is spent.
The Abundant Birth Project is intended to give mothers facing financial insecurity some peace of mind, and reduce the rate of pre-term births, the leading cause of death for Black infants in San Francisco, and other chronic conditions that are directly tied to stress.
Manchikanti Gómez, who will lead efforts to analyze the outcome of the program, says survey participants will be asked about anxiety levels, levels of joy and financial security, among other indicators, to see if payments help mothers underlying stress levels.
“We are really trying to something different,” she said of the pilot.
Finally, there’s the question of basic public awareness.
San Francisco banded together with four other Bay Area counties in July to launch #DeliverBirthJustice, a campaign designed to bring attention to these disparities and galvanize public support for change. But many feel a true reckoning around maternal health requires a more robust transformation of The City’s systems.
Events of the past 18 months have sparked a more honest conversation around race and inequality, but Malawa says true change will require recognition that all our futures are tied together.
“What does it cost to have Black people so unprotected, in the birthing space or from COVID?,” she said. “We need to move into a space and have recognition that, in fact, we all share the same air, literally, and if somebody isn’t breathing right we will all be impacted.”