Roe v. Wade and Black maternal mortality in the USA

The amazing Prof. Ndidiamaka Amutah-Onukagha, Professor of Black Maternal Health at Tufts University School of Medicine, joins Gavin and Jessamy to discuss the widening mortality and morbidity gap affecting Black mothers in the USA, the prospects for maternal safety following the overturning of Roe v. Wade, and how we can increase the diversity of NIH grant recipients.

Read our profile of Prof. Amutah-Onukagha here:
Ndidiamaka Amutah-Onukagha: advancing maternal health justice

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Jessamy: Hello and welcome to The Lancet Voice. I'm Jessamy Bagnall, and I'm here with my co host Gavin Cleaver. 

Gavin: Thanks, Jessamy. Today, we're very excited to be speaking with Professor Ndidi Amaka Amutha Anyukaga. Professor Amutha Anyukaga is the Julia A. Okoro Professor of Black Maternal Health at Tufts University School of Medicine.

She's the principal investigator of two multi year studies on maternal mortality and morbidity, which are funded by the NIH. Long time listeners will remember we talked with Dr. Rachel M. Bond about this topic a couple of years ago, but we particularly wanted to find out whether any progress has been made on outcomes, and very importantly, to ask what the prospects are for maternal outcomes following the overturning of Roe v.

Wade by the Supreme Court. So here's our interview, and please do feel free to contact us on podcasts at lancet. com with any thoughts. feedback or ideas for future topics.

And Didier, Marca, thanks so much for joining us here on The Lancet Voice. 

Ndidiamaka: Oh, thank you so much for having me. 

Gavin: No problem at all. It's a real pleasure. We're here to talk about black maternal mortality which is a real crisis in the U. S. Just to set the scene before we go on to talk about things like Roe v.

NIH as well. How big is this disparity in maternal outcomes between white and black mothers in the U. S.? 

Ndidiamaka: Yeah, thank you for this opportunity. The disparity is huge and it's increasing. The latest data that we have that was released in February of this year shows that the black white gap is actually widening.

Black women are three to four times more likely to die from pregnancy related complications than their white counterparts. The rates are actually getting worse. And the other thing that I want to notice is that We have the resources to combat this. It's not an it's not a problem of resource. It's a problem of racism.

And so when we see the rates are widening, we see that black women are 243 percent more likely to die from pregnancy related complications. We also know that 63 percent of all maternal deaths are actually preventable. And then if you stratify that by cause of death, 90 percent of maternal deaths due to hemorrhage are actually quite preventable.

And so it begs the question, if we know the data, we see the disparities are widening, we have the resources to combat it, what is the actual root of the problem? Now, some people say that Black women are more likely to have a lot of pre existing conditions that place them at further risk of dying and complications.

And some of those things are true. Black women are more likely to have gestational diabetes, hypertension. But that also begs the question, what is the underlying cause of a lot of these things, right? Underlying causes of gestational diabetes, underlying causes of hypertension, are around a social determinants of health, the physical and physiologic impact that racism places on black women's bodies causes increased levels of cortisol, increased rates of high blood pressure that cumulatively over time can have a really damaging impact.

So by the time that black women go to give birth, our reproductive health and our reproductive systems are actually 5 to 7 years older than our white counterparts. This is the work of Arlene Geronimous and the weathering hypothesis, which states that black women's bodies are more weathered entering into the pregnancy state.

And so you just have an accumulation of bad things happening. You have racism. at the core of it. You have this weathering that's happening physiologically. You have these underlying conditions that are impacted by the social determinants of health around hypertension and diabetes. And then you have just a healthcare system that's really broken and fractured and does not center or prioritize.

The needs of black and brown women either in pregnancy and postpartum and in labor and delivery. And so this accumulation is why we see the disparities widening and why we see black women being three to four times more likely to die from pregnancy related complications. 

Gavin: So I think you mentioned at the start of that, but is the issue actually getting worse over time in the U.

S.? 

Ndidiamaka: It's getting worse. The latest data that we have, we thought we would see a dip, but between COVID. So black women in the United States were already in a pandemic before COVID happened. COVID just exacerbated and just widened and highlighted the inequities around the workforce, around pay, around health care, around health.

And so, Black women were already in a pandemic of racism in this country. And then you couple that with COVID, and then we see that the rates of maternal mortality and severe maternal morbidity, which is what we call a near miss, is extremely high. And the rates are getting worse. And so, the latest data shows that this disparity is widening.

Black women is 55. per 100, 000 live births, black women dying. That is huge. That's huge. And so this three time fold, it just, it just begs the question, what else is going on? I actually was, the data just came out and we were all really excited to see it. Hopefully we would see a dip, but it's, it's higher for a number of reasons.

One, because it actually is statistically higher, but two, because we're doing a better job. of recording and reporting maternal mortality cases that goes back to the maternal mortality review committees, right? These maternal mortality review committees are at the state level. They are tasked with reviewing every maternal death that happens in their jurisdiction.

We're doing a better job of funding these MMRCs, maternal mortality review committees. We're doing a better job of staffing them. And so the data is actually more accurate because we're starting to analyze it. So that's part of the uptick that we're seeing as well. 

Gavin: So, was the data quite patchy before?

Ndidiamaka: The data was just sitting there. A lot of states were not investing in their MMRCs for a number of reasons. One, because state budgets may not be able to support it. Two, because the resources and the staff are being pulled in different directions. Three, they may not have a statistician that can, that can analyze this data.

So, the data was Patchy and it was it wasn't being pushed out at the accuracy that researchers like myself needed. Right? CDC aggregates it and then they push it back out to the National Center for Health Statistics, which pushes it back out to the state level. The state knows, but the state is not releasing it in real time because they don't have the resources to accompany that.

Right? So if you say, Okay. We have this drastic uptick in maternal deaths. Then what's going to come with that? Is that more resources? Is that more doulas? Is that more midwives? Like what is the solution for pushing this out? So I think it was patchy for a number of reasons, but I am just really, really happy to see us finally starting to do a better job of collecting it, cleaning it, and putting it back out there for analytic and program planning purposes.

It does nobody any good for unfortunately a woman to die in pregnancy or postpartum and the data is sitting there not being analyzed and not being able to be repurposed so we can then try to avoid this again. 63 percent of maternal deaths are actually preventable, so the quicker we can analyze it, the quicker we can put the data back out quicker, we can allocate resources, training workforce.

Whatever it's going to take, the more likely we are to save a woman who could be, frankly, a near miss. A near miss is a woman that has experienced an almost deadly situation. Maybe it was a hemorrhage, maybe it was a rupture, maybe it was preeclampsia. These near misses are more likely to have complications in future pregnancies.

And so we're really on a clock here. We're really on a tight time frame to try to see the data, analyze it, push it back out in the hopes of catching future subsequent cases of severe maternal morbidity. 

Gavin: You're saying that the problem is getting worse, but I guess at least you kind of now know where you are.

Ndidiamaka: You now know where you are. And I've seen it anecdotally. I mean, I'm a black woman, so I hear the cases, I get the emails, people come to me, you know, on social media, people send me emails, people find me. So I am seeing the data anecdotally, but I was not seeing it aggregated and coalesced in a way that it needed to be to be able to get the resources liquidated at the federal and state level.

So it's really nice to be able to see this push. And it's frankly, because we're in a crisis. I mean, our house is really on fire around this issue. And It's not that we don't have the fire extinguisher is that we need to use the fire extinguisher, right? The fire extinguisher is how do we fix a fractured and broken and racist health care system?

And that system is operating from every level from the from the medical assistant to the nurse, the receptionist, to the OB, to the midwife. There is racism embedded without the system throughout the system that causes black and brown women to be actually. petrified to give birth. I get emails all the time.

Dr. Muta, I'm scared to get pregnant. I'm scared to give birth. It's a beautiful, joyous experience. I would love for everyone to, that chooses to become a parent, to want to go through that process and feel safe. And we're not seeing that. And so that's why we really have to start to think differently and more critically about how do we fix this problem.

Gavin: What difference does having such a fractured healthcare system make compared to say a more joined up system like we have here in the UK? 

Ndidiamaka: Well, the fractured healthcare system's left hand doesn't know what the right hand is doing. The left hand, like I was, I was talking to a young lady yesterday in the grocery store.

I could see she's very pregnant. I said, congratulations. You know, how many weeks are you? She said 33. I'm like, wow, you're almost there. I said, where are you delivering at? She mentioned the hospital. I said, where are you getting your care at now? Same hospital. She's getting her care completely different place.

They're not even in the same healthcare system. Now, I wasn't going to start having this whole conversation with her in an ice cream aisle, right? But the point I'm making is that her left hand, which is where she's been getting care up until 33 weeks, is not going to be able to transfer equitably, fully, comprehensively her medical records over to where she's going to deliver.

a potential problem. So I didn't want to scare her. I just said, listen, you might want to think about moving your, your care over to finding a new person at the place you're going to deliver. But that's just an example of the system here. We are in such a fracture system that you can be getting care in multiple places in different systems, and they're not talking to each other.

Even within the same hospital, the records may not even be transferring across the EMR. So that's a problem because you're not able to one get the fullest picture that you need to see. And frankly, everything here is about insurance. Everything in the United States is about insurance and reimbursement.

If you don't have good insurance, particularly Massachusetts, we're very blessed because even our public insurance is excellent. But if you're not in a place like Massachusetts You're in some of these places that are deep south, you're in big trouble. You're in big trouble because everything is predicated on the type of insurance that you have and the type of insurance and reimbursement that your provider is going to get.

So for people that are already high risk, your, your insurance may not be reimbursing for this really, really specialized maternal fetal medicine care that you need. You may be limited with the number of prenatal visits you can get. You may be limited if you can see a nutritionist. All these other ancillary parts of your care over the course of the pregnancy.

really culminate in a healthier outcome. If you're able to see a nutritionist about healthy eating, if you're able to see a lactation specialist, if you're able to get a doula paid for by your insurance or reimbursed or subsidized, these things really make a difference in your care. That is the biggest part where our system is failing.

Not just black and brown women, but women. Overall, birthing people overall is this insurance piece. We have the majority of births in this country. Two thirds of the births in this country are to the Medicaid population. We got to figure that part out. This reimbursement really keeps people out of resources.

When I was pregnant nine months ago, I have a nine month postpartum. When I was pregnant. I had a lovely experience because I have great insurance. I went to see anybody I wanted to see as much as I wanted to see and they wanted to see me as much as possible because they're just going to keep billing and billing and billing and billing out the wazoo, right?

And so, and then even after the delivery. Uncomplicated delivery. I was out in two days. They still build an enormous amount of money. I'm like, what is this billing for? I didn't have an episiotomy. I didn't have a C section. It was largely unmedicated. I was out in 48 hours and it was still astronomically expensive.

What if I had had any one of a myriad of complications? Who can afford that? That is such, it's so scary. So for me, this, this country and the way that we are. Yeah. Itemize and, and quantify people's lives, frankly, around insurance is very, very problematic. 

Gavin: Yeah, it's an additional stressor, isn't it? I mean, from my time over in the U.

S., it was something I never really had to think about before. You know, I was constantly aware walking down the street in Texas that if I fell over and broke an arm, you know, like people sometimes do, that would be essentially, you know, a whole paycheck gone in the in the, in the excess paying for the insurance and the treatment in the hospital.

And, of course, everyone in the U. S. had, Everyone in the U. S. by this point has a horror story related to that sort of medical treatment, don't they? This is a really good chance, actually, for me to ask you how maternal mortality rates vary state by state and what some of the kind of interesting factors are there.

Ndidiamaka: Sure. So maternal mortality rates are really dependent on, I would say, a number of things. How well resourced the state is and what is the state's position on insurance. How does the state really prioritize doulas? What is the number of OBs in that state? Number of providers. Massachusetts has really great rates for a number of reasons.

One, our health care system is strong. Two, we have a lot of very high number of providers. Three, we have a lot of doulas. There are places we, I could see us doing better, like we could use some more certified professional midwives and we could use more midwives of color in general. But I think comparatively, we're doing pretty good.

When you look at states in the deep South, Maternal mortality rates are very high and those are related to access to care. A lot of States in the deep South are maternity care desert. You have to drive 45 minutes to an hour. I'm within, I would say 20 minutes, 40 minutes max of probably five world class.

hospitals. Like that's such a, that's such a luxury, right? I can choose to deliver at one of, and these are nationally rated hospitals that are within 30, 45 minutes. The United States is not set up like that across the country. So the issues that we're seeing with hospitals in the Deep South or maternal mortality in the Deep South and in other parts of the Midwest is resources and access.

If you have to drive 45 minutes to an appointment, how are you going to get there? I've done a lot of work also in my home state of New Jersey, which is currently ranked number 47. Horrible. And New Jersey actually is a pretty well resourced state. What we're seeing in New Jersey, though, are pockets of maternity care deserts, right?

So the hospital that I was born in, the hospital my siblings were born in, they don't have OB units anymore. You can't even give birth there anymore. Okay, so you have, and I was born in an urban city. I'm from Trenton, New Jersey. And it's the capital of the state. And frankly, there's no OB units within a 20 or 30 minute radius.

Now for people that have a car or can pay for an Uber, it's not as big of a deal, but look at the average per capita income in a resident of Triumph. Look at the percent of home ownership. These are the, these are what we use to look at. The financial stability of the community, percent of home ownership, the percent of the per capita income, the percent of people with a graduate degree, the percent of people that are married.

These are social and census level demographic data. If you look at that cumulatively, you're going to see that it's a really impoverished community. There's no place to give birth. I've talked to women, I've talked to friends of mine who have had to take an Uber, who've had to call an ambulance that they're then billed for when they're in labor.

This is how people die. This is how people slip through the cracks, right? One of my friends told me she had a placental abruption. That's a really dangerous complication of hemorrhage. She had to call the ambulance, wait for the ambulance, get there, and then she got a bill. And so, it's like Of course, we're going to see increased rates of maternal mortality because people have to make these really difficult either financial decisions or health equity related decisions about how do I even get to the care and frankly, if you're not able to access care, that's going to impact your prenatal care as well.

I was at the doctor. probably every once you get into the third trimester, you're supposed to go every week. I was there a lot and I didn't mind it. If my husband couldn't drive me or I didn't have the car, I take an uber or whatever the case is. That's 40 50 a day. Some people can't afford that. So transportation is a huge issue.

The number of providers per capita. I have my pick Of hundreds of bees at my disposal. This is, this area is actually oversaturated other parts of the country. You go to rural Kentucky, you go to West Virginia, you go to Indiana, you go to Ohio, you go to certain parts of Texas. There's not a number of providers.

There's not a saturation. You've got to wait. For more doctor appointments, which means a long wait time, which means potential complications are now sitting right and the E. R. S. Are backed up. It's just the system is buckling. The system is buckling and the people that don't have resources are the ones that are suffering the most.

And that is why you see maternal mortality rates differ by state. It's the level of investment and infrastructure and the workforce that's really going to make a difference in the state level outcomes. And I see it all the time. I see Yeah. maternity care deserts. I see people want to practice in places.

They're going to get paid more. There's they feel like there's more opportunities, which leaves certain parts of the country really, really untreated and really, really available for these disparities. Then you couple that with racism, right? You may couple that with English as a second language in certain parts of the country.

You're going to see these disparities continue to occur. 

Jessamy: Can I ask a quick follow up question on that? And I think you we sort of touched on it before. But when you say the system is buckling It sort of makes it sound like it's a new thing, but it's not a new thing. Right. It's something that we're, it's something that we are aware of and the, the fact that there's a, you know, no universal health coverage in the states and there hasn't been for the last however many, hundreds of years.

Right. It's sort of like a culmination, but, but do you feel that now, you know, there's a crescendo or is it the, is it that there's a, a deeper understanding and a movement towards actually taking action on this? 

Ndidiamaka: That's what it is. It's a deeper understanding and movement towards taking action. We've always known the disparities, but frankly, it has not gotten the type of exposure.

It has not gotten the type of national, international press. And there, there's not been a public shaming of the health care system. There's not been a public shaming of people die. Maternal mortality has But now we see cases, we see documentaries, we see podcasts, we see the White House has an Office of Maternal Health dedicated to this.

It's getting the national and international attention and pressure that needs to be placed on the system. It's always been there. But if it's one isolated case in Indiana, it's one case in Georgia, it's one case in New Jersey, nobody's going to do anything. But now when you see cases and it's gotten this ProPublica did an amazing write up called the Lost Mother Series that just knocked my socks off.

And it just was such a beautiful rendition of, it put faces to these maternal deaths. It put stories to the maternal death. I think that really was a turning point. Like I said, I see it, I have experienced it, I've lost friends of mine personally. This has not been anything new in my space, but I think as a country, we're now forced to reckon with how we really have failed women in this way.

Jessamy: Is there a situation in which the disparities and the very deep differences racially are overcome without a health care system is sort of free at the point of care? 

Ndidiamaka: Yes, there are things that can be done to mitigate. Overcome, I don't know, but mitigate, yes. Over, mitigate, for instance, doulas. Doulas are amazing.

I love doulas. I think everybody should have a doula. Doulas are a buffering. They're They're kind of like the glue or the oil, if you will, between a birthing person and a really racist healthcare system. Doulas are trained to support people. They are people that have had doulas, have better outcomes, lower rates of C section, more likely to initiate breastfeeding, less complications.

Doulas are an incredible Stop gap in the system. I would also say training a more diverse workforce. I am a medical school faculty. I represent less than 1 percent of medical school faculty that are black or brown. That is problematic. I have students that have never seen a black professor until they get to my class.

They're going to be OBGYNs. They're going to be clinicians. They're going to be dealing with a diverse patient population. I feel this moral imperative to weave anti racism into our curriculum. My colleagues and I, Dr. Schloff, Dr. Ona, we developed an anti racism curriculum because we're like, how are we going to send students into the workforce?

They've never been around diverse communities. That is a recipe for disaster. Because as soon as you see a patient that either has an accent, you don't recognize the name, you can't connect with them on things that you feel like you can connect with that's comfortable for you. Your biases are going to pop up, so you're not even listening to the patient what they're saying.

You're not even giving them the time of day. You're not sitting down. You're not making eye contact. You're not taking good records because you have already checked out. That's how racism bubbles up. That's where implicit bias can be really, really dangerous in the delivery of care. So I think some of the things we can do to kind of mitigate is you know, obviously the training of a more diverse workforce, utilizing doulas, having more nurse with wives of colors.

Things like my mother lab, the research lab, where you're training scholars, students, professionals to go into the workforce with this arm and this charge around how do we eliminate these disparities. Those are some of the things we can do to mitigate it, but the system as a whole is quite broken. 

Jessamy: Yeah, and we should clarify as well and say that we see the same disparities in other healthcare systems that do have universal, you know, we see it in the UK, good evidence from Australia and New Zealand.

I mean, it's a global phenomenon, really. 

Ndidiamaka: You know, it, it just begs the question is, is how do we really address the impact of racism? Cause that's the, that's the common thread in all these systems. That's a common thread. And until we can call out and hold people accountable for their racism and their biases, we're, we're not even scratching the surface.

These implicit bias trainings, and I think they're great, but that's not going to get to the root of it. People really need to sit in their privilege. People need to sit in their racism. People need to sit in their judgment, and that's the beginning of it. Until you can really own your role, white privilege, white fragility.

the history of colonization, the history of oppression. If we're not having those types of conversations, we're not, we're just dancing around each other. And in the meantime, people are still going to be dying. 

Jessamy: Totally agree. And we see time and time again, that physicians rarely think of themselves as racist, even though they have those very deep, you know, we, you know, we all do, even though we all have these implicit biases in place.

Ndidiamaka: That's right. That's right. We have a lot of work to do. 

Gavin: I wanted to ask actually about the after effects of the recent decision to strike down Roe v. Wade. I'm interested to hear if you think that that would disproportionately affect black mothers, because, you know, we've talked about these disparities already.

And it was interesting as well, when we talked about something like COVID, how it tends to exacerbate these inequalities rather than affect everyone equally. So how do you think, how do you think Roe v. Wade might affect these inequalities? 

Ndidiamaka: Roe v. Wade is a disaster. Roe v. Wade being overturned is a disaster.

Roe v. Wade being overturned is a disaster. I don't know how many times I can say this. I, I, I get chills every time I speak about it because women are going to die. People are going to die unnecessarily. It is so scary. It is such a failure that that was a really hard day that day the day the decision came out.

I remember exactly where I was when I got the email. I felt physically ill. I felt nauseous because my first thought was People are going to die. We're already seeing an uptick. We're already seeing cases of maternal mortality, cases of severe maternal morbidity being unaddressed. That has direct implications to access to care.

Black and brown women who are already on the center, excuse me, already on the margins of the healthcare system and not being centered are going to have to travel further. To get the care that they need. They're going to have to travel longer distances. They're going to have to stay in a hotel. Like, the logistics of it.

Financially and social support. Who's going to watch the other kids? How are they going to take off of work? How are they going to afford to travel to another state? Who's, like, the logistics of accessing care. For groups that are already disproportionately impacted are going to be exacerbated. That is going to cause people to either try to self medicate and do things by themselves, which is complicated and scary, or people are going to have to carry to term children that they are not ready for, want, or are prepared to take care of.

That's also going to be a burden, and it's just, it stresses an already fragile relationship with the health care system in the space of abortion care. But I mean, luckily in states like Massachusetts, we still have access to a lot of resources. A lot of states have maintained it, but, and then we see victories like what happened last week in Kansas.

That was a huge victory. I thought that was a really, really good accomplishment that the state is standing up. We also have a lot of these trigger laws. right? A lot of these states are just out of control. That is going to completely, completely, disproportionately burden black and brown women. They're going to have to travel further.

They're going to have to carry longer, complicated pregnancies, complicated deliveries, more likely to have, to be in situations where they're not going to get the care they need or in a timely manner. And this is already, we're already seeing lower rates of prenatal care. We're already seeing lower rates of access to care, which is just going to be further complicated by this overturning.

So there's nothing good. that is coming out of this overturn of the Roe v Wade being overturned. And frankly, once we start to really figure out how to quantify and aggregate the data, it's, it's going to be a very, very, very desperate situation. 

Gavin: Right. Because we've already talked about, you know, such an unfriendly fractured healthcare system in the U S but now it feels like.

That was already a problem, but rather than address any of that, actually what's happened is they've just added lawyers, legality, and kind of levels of culpability into the equation as well. As you've talked about, you know, time is often of the essence in these situations. But now doctors are having to make kind of ethical legal judgments on the, on the go as well.

Ndidiamaka: On the go as well. I've heard cases of women that are literally sitting Bleeding or literally seating trying to access care while the doctors are on the phone with the lawyers trying to figure out if they can even provide the care we don't have that time. We don't have that time. People's lives are at stake.

And this is such a ridiculous insulting just dismissal of reproductive rights. I never thought in my lifetime. Or in my kids lifetime that I would see this. It's like I'm watching a bad movie. I can't believe it. I just cannot believe this tremendous failure of our country for the reproductive rights of women.

This is, this is the worst thing that could have happened. And frankly, I don't think anybody was really prepared for it because we just thought that, like, that is untouchable. Like, okay, we know this country's a little all over the place, but that is never going to be touched. But then you see that completely eroded.

So that begs the question, what is safe? What is, what is You know, what can we really lean on? There's nothing we can really lean on with certainty that's going to protect the health of women, of birthing people. If this really core piece of legislation can be overturned, then what is safe? Nothing. 

Gavin: And of course, all the, you know, the recently nominated Supreme Court justices all said it was settled law as they, as they came through the nomination process.

So yes, and we've already seen, haven't we, states starting to talk about things like contraception laws, you know, marriage equality, all that kind of thing. Yeah. 

Ndidiamaka: Yeah. It just opens the door for so many other issues. 

Gavin: I'm interested to ask you, what role clinicians play in these outcomes? And we've talked a little bit about kind of legality and doctors being on the phone to lawyers.

But with the overturning of Roe v. Wade, do you think it kind of Signals of direction that might make this difficult for clinicians. 

Ndidiamaka: Clinicians are going to shy away from it. You cannot tell me that students who are in medical school right now are not changing their course. I would. I would think twice about going into obstetrics and gynecology if I felt like I was going to have to be making these decisions all the time, right?

This has absolutely changed and will continue to change. people's careers, people's lives. We're going to see less people of color going into obstetrics. We're already seeing lower numbers. This is going to be absolutely life changing for people's academic and clinical careers. And frankly, people that are in obstetrics are going to get out of obstetrics and go to gynecology because it's one of those things where it's Get out of gynecology and go to obstetrics because people don't want to deal with this.

People don't want to deal with this. It's very stressful. It's very difficult to have to make these decisions that are against the core of what most reasonable people would do. And so clinicians are caught right in the crosshairs of this really ugly legal battle. And frankly. It's at a detriment to the patients.

It's also a detriment to the clinicians, but it's really, really a huge detriment to the patients because you're going to see less and less providers who are going to be even wanting to stay in this field. That's what's going to happen if this thing is not addressed. You're going to look back and you're going to see a precipitous drop in 2022 and thereafter around people who are going to the field of gynecology because this is not, it's not, it's a huge deterrent.

People are not going to want to deal with this. They don't want that blood on their hands, literally. And figuratively, people are not going to want that blood on their hands. 

Jessamy: And I guess the important thing to say about all of, all of these sort of things are that, you know, the legal determinants of health are enormous, the impact that they have.

It's obvious for Roe v. Wade, but some of the other things that people are concerned about that might now start being up for grabs, those things also have an enormous impact on the health at a population level. Which, you know, is impossible to quantify while it's happening, but very clear in hindsight.

And it's hard, I think, to get that narrative across a lot because people view these things as isolated and separate, and they're not. And it's, I think it's, you know, talking to non medics or people who are not in the healthcare field, it's very difficult to see how interrelated these things are. You know, how interrelated they are and how just completely illiterate it is to pursue a direction which will negatively impact the whole population.

Ndidiamaka: It's maddening. It's maddening. That is the narrative that we as a field need to be telling now. Like, we need to be weaving it together so people can see the full comprehensive story. Where people are falling. short, frankly, we as a field and also people that are trying to dismantle this is around the emotional piece.

They're playing to people's moral values. You know, that's, that's it. And you're stuck at that layer and people just are zombie like in their response. But if you look at the system cumulatively, you look at how this is going to impact everyone. You can tell a stronger, more cohesive story. That's what we, as a field of public health and medicine, need to be telling.

Because when you look at it isolated, it plays on the heartstrings, people, pro life, pro choice, wherever people sit, and that's stuck at that layer. They're not able to step back and look at the cumulative impact this is going to have. 

Gavin: Yes, it's We tried to do that, didn't we, Jesmyn, when we wrote the editorial, is tell this kind of this story of public health and how these kind of political decisions taken in the abstract have a very real, on the ground, day to day effect on what happens to people.

Perhaps we can finish up, Ndidia Makar, by talking about your NIH research on black maternal mortality. We, we profiled you in the Lancet last year, I think just as the research grant was starting. How, how is it progressing and what are you looking forward to over the next few years? 

Ndidiamaka: Oh, this is great.

Thank you. So being funded by NIH is such an honor, such a high in my career. There are such a small percentage of principal investigators of color that are women that are under 40. I, I, it's, I feel like a unicorn. I am a little bit of a unicorn in that space. And I remember when I got the grant, one of my mentors called me, she said, welcome to the unicorn club.

And I didn't understand at the time, but this has absolutely changed my career. My academic trajectory will be forever changed by getting this funding. So we are going into year three of five. It's an R01 grant funded by NIMHD, National Institute of Minority Health and Health Disparities, which is one of the institutes of NIH.

And we're focused on three. general areas. One looking at secondary data. Massachusetts has a database called the Pell pregnancy, early life and longitudinal database that looks at a lot of pregnancy related indicators. We're pulling out the data on the women that are most risk, highest risk for severe maternal ability.

What is their case? What is their narrative? What's their profile? How do we intervene? What is what are they impacted by? Is it cardiomyopathy? Is it hemorrhage? Right? What's the case? And how do we intervene pre pregnancy? And in pregnancy intervals. The second thing we're looking at is the role of maternal safety bundles.

The Alliance for Innovation and Maternity Care has put out a set of interventions that have implemented with fidelity across hospital sites will save lives, will reduce complications. We're looking at maternal hemorrhage, maternal hypertension and the racial disparities of what we're calling the equity bundle.

If you implement these set of protocols across our study sites, which is a number of hospitals here in Massachusetts. What are you going to see? Who is implementing it? What is the buying that needs to happen from leadership? Is it the nurse? Is it a resident? Is it the attending? How do we really get the hospital to buy into these set of protocols that we know are going to really impact the quality of care that all women receive, but frankly be more beneficial to women of color?

We who we already talked about are more disproportionately impacted by it. Thanks. disparities. And then the third is looking at the role of doulas, right? I've talked a lot about doulas. I think those are amazing. They're trained support people that have a really positive impact on the birthing and postpartum experience for women.

How does it look when a woman has a doula? Does she have better outcomes than women that don't have doulas? What type of doulas are necessary? Is that a hospital based? It was a community based dealer. We're in the process of birthing and postpartum are doulas most critical. And that's what we're asking.

We're drilling down with surveys. We're drilling down with postpartum interviews with birthing people who are between seven and 16 weeks postpartum, and we're, we're starting to tell this really, really rich story around severe maternal morbidity, around outcomes, around opportunities. I'm just so excited to have an incredible team that I'm working with, which includes an implementation science, Dr.

Alicia Larson, a biostatistician, Dr. Howard Cabral, my co P. I. s, Dr. Jean DeClercq, who's also a global scholar. area of maternal health. Dr. Fifi Job, who's from the State Department of Public Health. Dr. Audra Meadows is an OBGYN. Christina Gable, who's a doula. Our amazing project manager, Judith. This, this is the dream.

That's the dream team. And so I'm the face as the lead PI, but I have to mention them because we all sit and grapple with this. We all sit and put our heads together. We're all here to save lives. We're all here to really wrestle with this. The other things that I'm excited about over the next few years are my Center for Black Maternal Health and Reproductive Justice.

To be able to launch a national center in the middle of a maternal health crisis, one, is not a small feat. And two, I'm building the plane as I'm flying it, there's, there's very few blueprints for this. I think this is the largest in the country. I have six units in the center. I have a unit on policy, a unit on community engagement, a unit on mother lab, which is my research lab training the next generation of scholars, a unit on data, right?

How do we quantify, analyze, and put out data that people can then look at to address this? A unit on education and training. How do we train doulas? to go into high risk births. How do we train clinicians to be actively anti racist? How do we train midwives, right? Training the health care workforce. So I'm very proud.

It's a tall order to leave this national center, but I'm excited about that. And we have all of our unit heads in space in place. We're finalizing our physical location. We're gonna do a groundbreaking. I have all my students like it's coming together in a way that is going to be a legacy that is hopefully here for generations to come.

This Center for Black Maternal Health that is community facing, policy facing, data driven, training. I don't think there's anything out there that exists like that in, in the United States. So I'm excited about that. I'm also really excited about being able to do the work from a place of privilege in that I'm in the academy.

I have electricity reaches, but also a place of lived experience. I'm a black woman. I'm newly postpartum myself. And so A lot of people cannot sit at that intersection so clearly, right, because I can't turn it off. And when I walk down the street or I'm in the grocery store or I'm getting care at a provider myself, I'm really clearly aware and reminded of my blackness in this space.

That makes me a better researcher. That makes me a better academic. That makes me a better person because I constantly am seeing the gaps and the opportunities in our healthcare system to improve the health for other black and brown birthing people. So those are the things that I'm excited about. You know, some days, some days are really long and then some days are amazing like this where you get to really put your work out in a global platform.

for people to understand, see the passion and commit to doing better. We as a global society need to do better for all birthing people, not just lifting black and brown, but all birthing people. When you lift black and brown women, you lift everybody. That's the secret people don't want to talk about. It's not, I'm not just pulling out black and brown women because we're amazing.

Although we are, you lifting everybody at the same time, and you're creating a system that is more equitable, more just. And frankly, safer for everyone. And those are some of the things that I'm looking forward to. We're planning our next conference, which will be April 7, 2023, which is focused on the role of black midwives, talking about the historical implications of black midwives and how the field of midwifery went from being very black and having frankly, better outcomes to very white.

And credentialed and we lost a whole generation, a whole group of people who were doing amazing home birth. We're getting back to our roots now. This is how we're trying to save lives because we see the health care system is broken. We see the hospital system is broken. So we're going back to home birth.

We're going back to the roots, which is frankly looking at the role of Midwest. So that's the conference. It's April 7, 2023. We have an incredible lineup of people. Hopefully everything will be done with my space. I can actually host the conference in my physical space. So it's just, it's a, it's a tremendous time.

It's it's an enormous time that I'm also excited about my two amazing children. I have a three year old. I have a nine month old They're just innocent beautiful boys living in the world, right? They don't know that mommy's carrying this huge load and I'm excited about watching them grow I have a lot to be excited about over the next couple years as my life and my career continue to climb It's just tremendous honors a tremendous window into what's to come 

Jessamy: That's so exciting.

Thank you so much for giving us such a wonderful summary. A quick question off the cuff, just on a follow up. Sure. You said you're a bit of a unicorn in getting NIH funding and being a kind of principal leader and obviously the role of funders in breaking the, the sort of racist helper care system that we have and the research that direction, it plays an enormous role.

So what are some of the things that you think need to happen from a funder's point of view to make you not a unicorn? 

Ndidiamaka: Oh, this is a great question. Thank you for asking it. The way we give out funding is absolutely ridiculous. So, for instance, and it's an old boys club. It's an old white boys club. The first time I ever got invited to sit on a study section, I felt like I'd arrived, right?

They bring you to D. C. It's very formal. They bring you to D. C. They put you in a hotel. You have to review all your grants. I walk into the meeting. I'm like, yeah, I finally made it into the club. I'm here. I walk into the meeting. It's 99 percent old white people. These are who are making the funding decisions around health disparities and health equity.

So I was already a little bit unnerved. Right. And I'm looking, I see one other black woman who looks just as shell shocked as I am. I'm like, okay, I'm here. I got this. The way that we reviewed the grants is insane. It's insane. You're just slicing and dicing. You're not even giving them a chance to be reviewed.

People coming with their biases, right? It's just, it's such a horrible, stressful process. I don't know how anybody actually gets funded. When we got funded, I couldn't believe it because I, I've been in a room. I, you have to go through this needle to get on the other side. And then you still have to go into a private.

NIH level review. So you're making it through your committee level and you go into this private room and then you get funded. Who's going to make it through that? It's insane. We have to rethink the way that we give out funding. That's only for foundation. That's NIH foundations. They're sitting on millions and billions of dollars.

They have these arbitrary requests for proposals. You have to be invited. Like, it's a really closed door society, you have to cultivate relationships, you may or may not be funded. Like, in the meantime, while we're not giving out all this funding, we're not moving the needle forward. So the way that foundations and the federal government are giving out money has to be completely different.

just dismantled and redone. I mean, we're really missing opportunity here, patting ourselves on the back and sitting around drinking coffee in these two day meetings. That money needs to go on the street now. 

Jessamy: Thank you for that very succinct answer. You're welcome. And thank you for talking to us. It's been an absolute pleasure.

Ndidiamaka: Oh, this is such a pleasure. I could do this all day. I loved it. Thank you so much. 

Gavin: Oh, no, it's really great to have you on and what a great chat. I really, I really enjoyed it. That's

it for this episode of The Lancet Voice. If you want to carry on the conversation, you can find Jessamy and I on Twitter, on our handles at Gavin Cleaver and at Jessamy Bagunal. You can subscribe to the Lancet Voice if you're not already, wherever you usually get your podcasts. And if you're a specialist in a particular field, why not check out our In Conversation With series of podcasts, tied to each of the Lancet specialty journals, where we look in depth at one new article per month.

Thanks so much for listening, and we'll see you again next time.