Pregnant and unwed at 23, Noya Israel came face to face with a health care system that thought it knew her — and didn’t think much of her.
At her clinic, she felt judged for not being married, and dismissed because she was African-American. Her doctor, she said, would not look her in the eye and did a poor job answering her questions.
"I think I kind of fit a stereotype: young, unwed, black mom — ‘another one,’” she said, recalling her 2007 pregnancy. “The doctor didn't really take me seriously. He never really connected, or even tried to connect."
Today, that baby, Mordechai, is a tall young man. Israel is married to Mordechai’s father, Azariah, and the couple just welcomed their fourth child, a daughter named Kezia.
But while Israel is grateful for how things turned out, she hasn’t forgotten how she was treated.
In Minnesota and across the country, African-American women still face significantly worse birth outcomes than their white counterparts, in part because of how health systems treat them.
A growing body of research shows that stress, induced by racism, is linked to those health disparities and that women of color are more likely to be dismissed, ignored and discriminated against by health care professionals.
Some in Minnesota are trying to change that. A birth center in north Minneapolis whose clientele is roughly 50 percent African-American has created a new model of culturally centered care that shows signs of success in reducing stubborn health disparities for black mothers and their babies.
‘Has to be a better way’
Researchers use the term "weathering" to describe the overt and structural racism that wears down African-American women, creating chronic stress linked to poor health outcomes for pregnant moms and babies at birth.
Their babies are more likely to be born early or small for their gestational age compared to white babies. And while the overall infant mortality rate has declined, black infants are twice as likely as white infants to die before their first birthday.
According to the Centers for Disease Control and Prevention, black mothers are more likely to die due to complications in childbirth than white women — regardless of education or income.
At the hospital, they’re also more likely to be targets of demeaning behavior.
Aja and Solomon Parham said they felt racially profiled when they came to Regions Hospital in St. Paul three years ago, as Aja was ready to give birth.
The couple was prepared. They’d gone to birth classes and read about labor and delivery.
Aja also created a birth plan with details such as lower lighting during labor, wearing her own nightgown, no medication unless necessary and making sure Solomon was in the room if a cesarean section was needed.
On her due date, Aja arrived at a previously scheduled appointment with her provider only to learn that her water had broken. She was advised to head straight to Regions Hospital.
There, the Parhams said, they were treated disdainfully by staff who dismissed their requests and concerns. The Parhams felt racial stereotyping and discrimination were at work.
Aja and Solomon offered their written permission to Regions Hospital to discuss their case with MPR News. Regions declined, but in a statement said that its goal is to “provide the best care and experience for every patient, every time.”
Because her water had broken, Regions staff advised Aja she needed the drug Pitocin to induce labor to make sure the baby was born quickly; it’s a measure many hospitals employ to avoid a life-threatening infection.
Pitocin was something Aja had hoped to avoid. But Aja nevertheless handed the intake nurse her birth plan. Aja said the nurse’s response was, “Oh yeah, this isn't going to happen.”
The underlying tone, said Solomon, felt like, “Well, you're black. And black people don't have birthing plans. So, this isn't going to happen."
Aja says a series of mistakes and miscommunications made by her nurses administering her Pitocin meant she missed a critical window to deliver her baby vaginally, and led to a cesarean section — something Aja wanted least of all.
When doctors decided to put her under general anesthesia for the C-section, Aja said, she asked to see Solomon before going under so they could pray together. But she was told no.
Aja said she was in tears and terrified she wouldn’t wake up. Solomon argued his way into the room to see his son, Asa, born healthy.
But as Aja held Asa in the recovery room, upset and crying because nothing had gone the way she’d hoped, she endured another emotional assault, she said. A nurse appeared, saying Aja was more fortunate than another mother whose baby died right after Asa was born.
"And basically that I shouldn't feel the way I felt because I had a baby and she didn't,” Aja said. “In my head, I shouldn't be made to feel guilty because I had a traumatic experience as well. No, I did not lose my child, but I had a traumatic experience."
Aja and Solomon eventually complained to hospital administration about their experience, and Regions decided not to charge the couple anything for Asa’s birth. At Christmas, the Parhams said, Regions sent an additional letter of apology and $500 in gift cards.
Regions said in its statement that it works to make everyone “feel welcomed, valued and included … When that doesn’t happen, it’s important for us to understand where we fell short and work to make it better.”
Experts say the experiences of Parham and Israel are hardly unusual.
“African-Americans in general — but also African-American women in particular — report significant mistreatment within the health care system, and they attribute that mistreatment to racial discrimination,” said Amani Allen, a community health expert at the University of California, Berkeley.
Allen and other researchers are documenting such cases as they search for the cause of stark birth disparities among African-American women and their babies.
Noya Israel said the disrespectful treatment she felt at Mordechai’s birth didn’t surprise her. “I figured it was just natural, it was normal,” she said. “At that age, I didn't question my doctors."
Israel said that during the birth of her second son, Josiah, she felt pressured into getting an epidural — despite her desire for an unmedicated delivery — after the doctor said she was making too much noise during labor.
"After that experience,” she said, “I'm like, ‘There has to be a better way.’"
‘Listen a little bit better’
Israel said she found a better way, one that a rising number of women are choosing, regardless of their race or ethnicity.
When it came time to deliver her third child — and again, most recently, with Kezia — Israel went to Roots Community Birth Center in Camden, a predominantly African-American neighborhood of north Minneapolis.
It's a free-standing birth center, which means it is unaffiliated with a hospital but nationally accredited. Most birth centers are staffed by licensed midwives, and moms who give birth there are low-risk.
At Roots, the goal is to ensure mothers have autonomy over their pregnancy and delivery. In part, that means prenatal and postnatal visits are longer in an effort to tailor care to the individual.
Deliveries in such birth centers have skyrocketed in Minnesota in recent years.
But Roots stands out from the rest because roughly half of the women it serves are black, and its model of care shows signs of shrinking some of the health disparities black women and their babies face during pregnancy and delivery.
When culture is at the center of care, it's a formula that works for anyone regardless of background, said Rebecca Polston, who runs Roots and is one of Minnesota's few African-American midwives.
Polston and her staff ask their clients a lot of questions and take a lot of time to listen. The answers not only help treat clients but sometimes reveal the depth of the struggles they face, which ultimately affect those births.
She recalled a mother who needed to exercise more during her pregnancy.
Talking with the mom-to-be, however, she realized it was not as simple as suggesting she take a stroll.
"Through talking, actually taking that time with that person, we're able to identify that they were afraid because they had lost a family member on the street outside of their home,” Polston said. “Her risk wasn't that she was black. Her risk was that she was experiencing violence. She was experiencing violence because of her blackness. Once you can name what you're experiencing, it disarms it. It disarms that beast within you and its impact on you."
After that, the mom exercised at Roots.
Polston keeps tabs on her clients long after they’ve given birth. Their children's names and birth dates are written on chalkboards around the center. The lobby is adorned with pictures of women of all ethnic backgrounds breastfeeding their babies, and the staff is equally diverse.
Clients say these details go a long way to putting them at ease.
"Someone who looks like you can relate more to you,” said Israel. “So, when you're saying, 'I'm in pain’ or ‘I have anxiety,' because they look like you, because they can relate to you, they listen a little bit better."
Polston says knowing a mother's culture and personal history is a path to reducing stress during pregnancy. She hopes the mothers she works with use aspects of their background to help manage their health long after their babies are born.
"You have your culture. You have your foods. You have your family. You have your lived experience. These are all tools and assets that you bring to your pregnancy,” she said. “Being deeper connected to your family, being deeper connected to your friends, that helps you combat the stress that society is putting on you."
Midwives tend to spend more time with their clients and work with their clients to come up with solutions, which doesn't always happen in the hospital setting, said Monica McLemore, a nurse and a professor at the University of California, San Francisco. She studies health disparities and how pregnant black women experience racism in hospital settings.
"There is less battling, fighting and trauma,” she said — and that's why midwifery might work better for women of color. “To allow someone to have a respite where they can birth with dignity … I think we would see improvement in pregnancy outcomes."
New University of Minnesota research bears that out. Women of color who gave birth at Roots reported greater satisfaction than women who delivered at hospitals.
"We've heard a lot of stories from women who perhaps were getting care someplace else and switched to Roots, or they had a previous pregnancy and birth at a hospital and then were looking for something different,” said public health professor Rachel Hardeman, who’s been studying Roots for three years.
“A lot of those stories are really heartbreaking stories around women who felt like they weren't heard, weren't respected,” she said.
Hardeman said it's too soon to tell if the Roots model of care will have long-lasting health effects for black mothers and their babies.
But the early numbers seem encouraging. In Roots’ first three years, preterm birth is less than 1 percent compared to 10 percent statewide. Breastfeeding rates are nearly 100 percent.
Very few women are transferred to a hospital for a cesarean section. And the Roots team has success using diet and exercise to help clients manage gestational diabetes, a condition that African-American women are at higher risk of developing in pregnancy and can lead to other life-threatening complications.
Those numbers caught the eye of insurers because they signal lower patient costs.
Roots has contracts with every commercial insurance plan in the state, as well as with all the Medicaid HMOs. About 60 percent of the center’s clients are on Medicaid.
Despite the success, Hardeman worries that the economics will make it tough to duplicate, and that reimbursement rates will be a massive challenge in replicating the Roots model elsewhere.
"The reimbursement rate is so low for Medicaid births at birth centers, there has to be a balance between employer-based insured families and Medicaid families,” she said. “And even then, it's precarious."
It also won’t be easy to build out culturally centered care in a standard medical setting, Polston said. For instance, appointments at conventional clinics are far too short. She said postnatal care is too sparse. And practitioners are unlikely to look like the patients.
"I think one of the biggest pieces is diversity in the workforce,” she said. “We need more midwives, physicians, nurses of color."
Researcher Monica McLemore agrees that more providers of color are needed. But she said practitioners and researchers should keep their focus on preventing traumatic pregnancies.
“How do we care for an entire pregnant person, and setting that family up for health and wellness across the life span?” she said. “That to me is a more important discussion than, ‘Can we have more normal birth weight babies?’ I think that's important, but I think there's a whole lot of things we’ve got to fix before we can get to that.”