After tennis legend Serena Williams almost died giving birth and pop megastar Beyoncé experienced life-threatening complications delivering her twins, their harrowing stories amplified growing concerns about maternal mortality rates among black mothers, as well as the striking racial inequities that afflict health care in the United States. 

According to the Centers for Disease Control and Prevention (CDC), African American and American Indian women have a three- to four-times’ higher risk of pregnancy-related death than white women. The CDC also found women of color are more likely to have adverse outcomes regardless of income, access to care, education, or health insurance status. 

Rachel Hardeman, ’07 M.P.H., ’14 Ph.D., a researcher and assistant professor in the University of Minnesota’s School of Public Health, believes racism is to blame. “Even when someone has access to care, if that care isn’t free of biases and if it isn’t equitable and doesn’t empower patients, then it’s not really high-quality care,” she says. 

Growing up African American in Minneapolis, Hardeman saw firsthand that opportunities to be healthy weren’t the same for everyone—including some of her own family members. “Minnesota is consistently ranked among the top five healthiest states in the nation. But it’s a little bit deceiving, because when you start to pull back the layers and look at things by race, we drop down to the bottom of the list because we have such severe racial inequities,” she says. 

And it’s not just moms who are affected. Minnesota’s black and American Indian babies are twice as likely as white babies to die in the first year of life.

Hardeman studies the role racism plays in these health inequities and educates clinicians about what that means for their patients. Racism, she explains, takes many forms, including implicit bias, or the automatic prejudices that clinicians (or any of us) bring to interactions with people who aren’t part of their group. Structural racism is built into policies on housing, education, mass incarceration, policing, and health care. 

“Our health care institutions are built with that history,” Hardeman says. “If we can’t understand and acknowledge that history, how do we expect to do anything different that’s going to save people’s lives?”

Hardeman’s interest in medicine and public health blossomed during the two years she spent after college at the Latin American School of Medicine in Havana, Cuba. There, she took part in what she considered to be a more responsive, humanistic model of health care that focused on preventive care and the doctor-patient bond. 

Curious as to whether something similar could be replicated stateside, she began her public health studies at the U of M, where she learned about infant and maternal mortality as useful markers of population health. But her interest in childbirth intensified after she had a baby of her own, a daughter who’s now 6. It was a good delivery, and her experience made her want to learn why. 

“I think birth is the perfect starting point for understanding how inequity can get under the skin,” she says. “It’s a transitional point in a mother’s life, but also it’s the start of life for an infant, and there are so many opportunities there to intervene to make that life better.” 

CULTURALLY CENTERED CARE

Hardeman has studied the benefits of doulas (birthing coaches) to women of color and the effects of racism on African American medical students, among other topics, but her newest research cuts to the heart of health equity and birth outcomes. She and School of Public Health associate professor Katy Kozhimannil are partnering with certified professional midwife Rebecca Polston, founder of Roots Community Birth Center in North Minneapolis, to explore the value of culturally centered maternal care—care that sees racial identity as a strength and not a detriment. 

“In very basic terms, it means respect and dignity and allowing folks to walk through the doors bringing their lived experience with them and letting that lead the process,” Hardeman says. For example, clients are encouraged to share cultural preferences or religious restrictions regarding diet. Staff then make recommendations that both honor those preferences and promote good nutrition.

The three women have been able to work together thanks to a grant from the Robert Wood Johnson Foundation’s Interdisciplinary Research Leaders (IRL) program, which enables researchers and community members to conduct academic research that’s designed to benefit the public. 

Hardeman’s work builds on that of the University of Michigan’s Arline Geronimus. In the 1990s, Geronimus developed her landmark “weathering” hypothesis. Weathering is the cumulative physiological impact of disadvantage and racism over a lifetime. She found that for black women, becoming pregnant and giving birth in their teenage years (far younger than what is generally considered optimal) led to better health for mothers and babies because they had suffered from fewer years of weathering. 

“A lot of the narratives we hear now are that black women come to pregnancy older, sicker, more obese, and things like that,” Hardeman says. “But instead of talking about weathering, we end up victim-blaming.” 

IMPRESSIVE OUTCOMES, HIGH SATISFACTION 

Located in the Webber-Camden neighborhood, Roots Community Birth Center is Minnesota’s first and only freestanding birth center owned and operated by an African American midwife (and one of only five in the nation). A former community organizer and documentary filmmaker, and a mom herself, Polston started Roots five years ago as a place for racially and economically diverse clients to receive quality care where they live. Of the 200 clients registered at the center in 2019, 65 percent are African American and 55 percent are on Medicaid.

Although midwifery care is associated with better outcomes compared with physician-led care (in part because most midwives, including those at Roots, only serve women with low-risk pregnancies), Roots has seen striking results, including:

• a 4 percent C-section rate, compared with 31.9 percent nationally

• a breastfeeding rate of 99 percent at one year, compared with 35.9 percent nationally

• a 97 percent success rate for vaginal births after cesareans, compared with 60 to 80 percent nationally

• a 0 percent preterm birth rate for U.S.-born African American mothers, compared with 14 percent nationally, and

• high satisfaction with the birth experience.

Set on a quiet residential street, Roots is serene and welcoming. The cozy waiting room has thoughtful touches like low-hanging coat hooks for siblings, a lending library, and help-yourself tea fixings. A small chalkboard lists the names and birth weights of this year’s babies. Downstairs, prenatal rooms are fitted with comfortable couches, soft lighting, pillows and blankets, and exam tables without stirrups. Upstairs, the two birth suites, one of which has a large birth tub (65 percent of deliveries are water births), hold several people and function like small apartments, with a fully stocked kitchen, living room, and dining space. The yoga studio is out back.

Other services include hour-long prenatal visits, volunteer doulas, postpartum home visits, mental health care, one-on-one lactation consultations, and even chiropractic care. 

In interviews conducted for Hardeman’s study, Roots clients talked about feeling judged in hospital or clinic settings. Several mentioned being drug tested without their knowledge. That’s why Roots strives to help clients feel seen and heard. For example, they’re always asked for their consent before being touched or examined, whether it’s their first visit or their 15th.

“Clinical settings serve to distance clients from their health care experience by saying, yeah, you’re in a different place; this isn’t what you’re used to,” Polston says. “We really pride ourselves on making clients feel comfortable.”

“AMAZING” BIRTH

Helen Pang, ’15 B.S.B, had strong opinions about her maternity care when she arrived at Roots. She and her partner, J.J., had just moved back to Minneapolis to be near family for the birth of their first child. After seeing obstetricians in Denver and Minneapolis, she was eager to work with a midwife. Pang, 26, a certified natural food chef and manager of a local gym, wanted a natural birth and a practice that would respect her wishes. 

“As a woman of color, there are a lot of issues with not receiving proper care or our wishes being ignored by providers. It was important to me to be in a facility where I knew that they respected me,” she says. She was especially impressed with the way the midwives practiced informed consent. “They were always like, is it OK if I touch your belly? With an ob-gyn, it’s like they think they have the right to touch your belly.” 

Pang gave birth to her son, Jaleel, at Roots, after 10 hours of labor and 45 minutes of active pushing—a water birth she describes as “amazing.” With her in the room were J.J., her mother, her best friend, and her doula, making up what Roots calls her “circle of support.” Roots encourages moms to choose their own circles of support early in the pregnancy. 

Says Pang, “Basically, all of the preferences I wanted were checked off. I didn’t have any interventions. My entire labor was here, and I felt like I was at home.”

Since Jaleel’s birth, Pang has returned to Roots for postpartum visits, a moms group, and well-baby checks. She says she’ll miss having a reason to come in. “I joked yesterday, ‘Hey, this is Jaleel. He’s 48 weeks.’”

REPLICATING ROOTS

Hardeman says the support from the Robert Wood Johnson Foundation is sure to open doors to future funding, but, more importantly, the leadership training component of its IRL program has allowed her to move into policy work. Hardeman has spoken on racial disparities in maternal deaths at the National Institutes of Health and at a Congressional briefing. She and Polston recently appeared on a Congressional Black Caucus panel with congresswomen Ilhan Omar and Ayanna Pressley.

In studying and documenting best practices for culturally centered care at Roots, Hardeman and her team hope to provide a blueprint for other African American midwives who want to open their own birth centers. Polston is working on a business-development toolkit that will offer advice on navigating insurance billing standards, licensing and zoning laws, and financing. 

Their efforts aren’t limited to birth centers. Hardeman hopes to spread the model of culturally centered care to clinics and medical practices as well. “I think about taking what we’ve learned here and talking to ob-gyns and maternal-fetal medicine docs,” she says. “This isn’t about birth centers being better than other settings or other ways of birthing. This is about how we can provide better care for people who are not getting the highest quality of care right now.”

Laura Silver is a Minneapolis writer and editor.