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Interview with Dr. Ndidiamaka Amutah-Onukagha: racism and Black maternal health in the U.S.

By Sophia

The thing about maternal deaths in the U.S. is that they are preventable. We know what medications are needed; we know how to give transfusions when haemorrhaging. People are getting stuck in the margins due to delays in treatment, delays in access to care, and delays in escalation when there are complications. Those delays are due to racism.”

Dr Ndidiamaka Amutah-Onukagha

In this interview with Dr Ndidiamaka Amutah-Onukagha, Assistant Dean for Diversity and Inclusion and the Julia A. Okoro Professor of Black Maternal Health and Associate Professor at Tufts University, we explore Black maternal health in the United States. Specifically, the political causes associated with inequitable differences in health outcomes experienced by Black women, and their historical roots in slavery and colonialism.

Sophia: Dr. Amutah-Onukagha, it is a pleasure to speak to you today for Race & Health Quarterly. Please could you tell us about your current role and research at Tufts University School of Medicine and how you got there?

Dr Amutah-Onukagha: Thank you for this opportunity to be included in the newsletter, I’m very excited to be speaking with you today. I’ve been at Tufts for about 6 years. I started in 2017 as an Associate Professor with a focus on maternal health. My official title is Julia A. Okoro Professor of Black Maternal Health, which is an endowed professorship named after my grandmother who was a traditional midwife and birth attendant back at home in Nigeria. The work I do in the birth equity space is because of all her amazing birth work with women from Nigeria and from the Igbo tribe.

I’m also the Founder and Director of the Center for Black Maternal Health and Reproductive Justice. We are about a year and a half old. The centre has six departments which focus on community engagement, policy, the MOTHER Lab (which is my student research group), education and training, epidemiology, and grants. It is a national centre, focused on Black maternal health and issues of reproductive justice. It’s really about the process of centring the Black birthing process and making sure that we are raising awareness and driving resources towards this inequity – or really, this crisis - around Black maternal health. Black birthing people are at such a tremendous disadvantage in the birthing space because of the impact of racism, so the Center, which is academically based but community focused, is really trying to rally people to hold healthcare systems and structures accountable.

Sophia: The maternal mortality rate in the U.S. is the highest among high-income countries and is four times greater among Black women than their White counterparts. Why do you think that is?

Dr Amutah-Onukagha: As of 2021, the maternal mortality rate of Black women was 69.9 deaths per 100,000 live births. The year before it was 59.3 per 100,000. This translates to about a 40% increase within a year. It’s really quite problematic.

The high rate has to do with a number of things. The first is the impact of racism on healthcare. Even thinking back to the history of obstetrics, the field was founded by racist providers who didn’t centre and prioritise Black bodies. Dr. J. Marion Sims, up until recently, was seen as the ‘father of modern gynaecology’. People were so impressed with his surgical techniques and devices, but many may not know that these techniques and devices were perfected on the bodies of Black enslaved women. He had a makeshift hospital in his backyard in Alabama in the late 1840s, and held women there against their will, without their consent, without anaesthesia, and performed surgical procedures to try and perfect his craft. This is how we know how to do basic gynaecological and surgical techniques like how to repair a fistula or what to use a speculum for. There were up to twelve Black enslaved women, but we only know the names of a few – Betsey, Lucy and Anarcha. These women are really at the forefront of the field, and we call them the ‘mothers of gynaecology’ because they sacrificed their bodies. So you have this historical context which does not appropriately honour, prioritise, or respect the Black body, and then fast forward to the training of clinicians who receive little-to-no training on racism in medical school. Put these clinicians in spaces of healthcare delivery where they are treating patients from diverse or minoritized backgrounds, and there is a real problem with implicit bias, racism, and structural racism. The clinicians are supposed to do no harm, but we see in many places that implicit bias, or explicit racism as I tend to call it, takes its toll.

You couple that with Black women’s risk of chronic health conditions including the impact of stress. We know that allostatic load is higher in Black women. And because Black women’s bodies are physiologically aged and weathered due to racism, the cumulative impact of chronic stress increases a Black women’s biological age up to 10 years older than that of their White counterparts. That 10-year difference significantly impacts the risk of maternal death, which goes up significantly with age.

The thing about maternal deaths in the U.S. is that they are preventable. We know what medications are needed; we know how to give transfusions when haemorrhaging. People are getting stuck in the margins due to delays in treatment, delays in access to care, and delays in escalation when there are complications. Those delays are due to racism. The likelihood of getting distress escalated and needs met is much lower in Black and Brown birthing people compared to White birthing people. That is the insidious nature of racism and how it is so embedded in the healthcare system. This is why racism is so problematic in the U.S.– it’s not a structure, a person, or a series of bad actors – it’s the system, the policies, the way things have always been, which is a problem.

Sophia: High maternal mortality reflects broader societal injustice and inequalities. Do you believe that populism and politics have exacerbated the Black maternal mortality crisis in the U.S.?

Dr Amutah-Onukagha: I think the current space of politics and populism is interesting because the broader societal injustice that we saw exacerbated by Covid is absolutely at play here. Luckily, we have an administration now that prioritises Black maternal health. Vice President Kamala Harris is a huge champion. We had the first White House Day of Black Maternal Health. We had the Momnibus Bill pass through Congress, and now Momnibus 2.0 is progressing. So the current political climate is much more amendable to addressing the maternal health crisis. And frankly, because the data is so bad, we are seeing a greater response from people who may not have come to the table before. NGOs, government agencies and foundations are being much more intentional about addressing Black maternal health. One thing I will say is that there isn’t enough money or resources for someone to buffer themselves from the impact of racism. The way racism shows up so fully in clinical spaces is so pervasive and while the political climate makes it a bit easier to hold systems accountable, we still have a long way to go.

Sophia: How is the U.S. health system responding to the Black maternal mortality epidemic?

Dr Amutah-Onukagha: A number of things are being done. We have research centres, such as my own, for Black maternal health. In Massachusetts, the MOTHER lab is training a group of students from a range of disciplines, including medicine, nursing, public health and social work, in a reproductive justice framework. We aim to diversify the public health and clinical workforce so that when people come from minoritized, Black and Brown communities, they are adept at handling, managing, and supporting their healthcare needs. We also have political will around getting doulas reimbursed for up to twelve months post-partum, which is a major legislative issue that is gaining traction in Massachusetts, but also other states. The Momnibus Bill which, if passed in Massachusetts and at federal level, will support Black and Brown people and liquidate additional resources.

I’m very excited about the awareness and saturation that this topic is getting and feel hopeful about all these entities coming together, whether it’s policy, research, funding, or community. I feel like we haven’t had so many eyes on this topic as we have now. However, we don’t have the luxury of taking our eyes off the ball because we are still seeing so much preventable death. But I feel really optimistic and excited that we are turning a corner. It’s such a topic now that hospitals face scrutiny if they don’t address it.

Sophia: What can our readers, academics, clinicians, and policymakers, do to support maternal health justice, particularly for Black and Brown women?

Dr Amutah-Onukagha: I think platforms like this, where we amplify the issue to people who might not be aware of it, are important. There’s a real privilege in being able to tap in and out of the topic area. I feel confident as long as we continue to saturate the landscape and make sure that we are abreast with what is happening in the research space and continue to hold healthcare systems accountable. I think exploring what’s happening with nurses at bedsides, and clinicians in the delivery room, are real opportunities for change.

When we see racism in a healthcare setting, we must show up and call it out. We should also advocate for Black and Brown communities, more diverse workforces, resources for centres like mine so that they can be funded to do the research that they do and show up in a way that honours and centres the Black and Brown birthing experience. The birthing experience should be about joy. People should not be scared to be pregnant or have kids. I get so many messages saying, “Dr Amutah, I’m so scared to get pregnant, I don’t want to die”. We, as a system, have accountability and an obligation to support Black and Brown birthing people so that they can have joyful, rich, beautiful experiences as they enter motherhood. We can create new systems and new ways of being that incorporate people’s experiences and their lives. If we can shift the healthcare system and how Black and Brown women are seen, treated, what assumptions are made about them, listen to them more and train clinicians on how to treat people from diverse backgrounds, then we can chip away at the racism that we’re seeing.

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