Improving Racial Equity in Birth Outcomes

A Community-Based, Culturally Centered Approach

Katy Kozhimannil

University of Minnesota School of Public Health

Rachel Hardeman

University of Minnesota School of Public Health

Rebecca Polston

Roots Community Birth Center

Acknowledgment: We gratefully acknowledge the input and writing

support from J’Mag Karbeah, MPH, Doctoral Student, University of

Minnesota School of Public Health.

Chapter Context

Our team’s goal is for African American mothers in Minneapolis and beyond to have access to care options that support a good birth. Our collective expertise includes the fields of health services research, sociology of health and illness, and critical race theory (Rachel Hardeman); midwifery, culturally centered healthcare, community advocacy (Rebecca Polston); and health policy, public policy, and statistics (Katy Kozhimannil). There are power and privilege dynamics among us and with the various audiences we wish to collaborate with and serve. To manage these challenges while conducting this research, we are committed to following principles that promote power sharing and trust building within our partnership and in interpreting findings and disseminating results among community, academic, and policy audiences. Our three-year, collaborative research project focuses on building the evidence base around one model of care—Roots Community Birth Center—and discerning generalizable concepts, knowledge, and wisdom that may inform broader efforts toward birth equity. In our work, we are documenting the content, experiences, and outcomes of pregnancy and childbirth care provided in the context of culturally centered care. This project first described the process of care at Roots, using interviews with staff and stakeholders as well as

focus group discussions with clients. We also conducted a web-based survey of all Roots clients during the postpartum period, in order to compare outcomes for Roots clients with outcomes for similar women with hospital-based care. The survey includes information on experiences of discrimination, communication, and early infant bonding in order to understand how care differs for Roots clients, compared with care that diverse patients typically receive in US hospitals. Finally it is an explicit goal of our work to communicate findings and implications broadly among those who can use this information to make personal and policy decisions to improve equity in birth outcomes.

Through this project, we have learned the potential impact of speaking truth to power and accomplishing change by targeting the clinical community through high-profile published commentaries, the payer community (through a blog series with the American Journal of Managed Care, and in Roots’ contract negotiations with health insurers), and the policy community (through engaging the media and legislation on maternal health and racism). A major lesson learned was the value of engaging on multiple fronts to achieve change. We believe that the legacy of our project is “centering at the margins” in our individual work, our collective work, and in the systems with which we engage. Centering at the margins requires re-anchoring a vision of change in the lived experiences of those who have been marginalized. It necessitates redefining “normal,” and it starts with ourselves and carries through all of our work.

Introduction

People of color, African Americans in particular, have systematically worse healthcare access and outcomes, in general, and around the time of childbirth (Bryant et al. 2010; Eichelberger et al. 2016; Hogan et al. 2012). Perceived discrimination and experiences of interpersonal racism, such as selective avoidance and microaggressions, contribute to the disproportionate barriers to high-quality, respectful, patient-centered care experienced by African Americans and other people of color (Eichelberger et al. 2016; Hardeman et al. 2018; Prather et al. 2016). Current disparities are rooted in a historical context. Centuries of policies—from slavery to segregation to unethical research practices—have resulted in African American women experiencing bias and discrimination through contact with the healthcare delivery system during pregnancy and childbirth (Bridges 2011; Oparah and Bonaparte 2015). Additionally, recent research suggests that structural racism—that is, the structures, policies, practices, and norms resulting in differential access to the goods, services, and opportunities of society by race—has an impact on birth outcomes. One recent study found that there is a joint effect of income inequality and structural racism on the risk of small-for-gestational-age birth (Wallace et al. 2015).

At the same time that African Americans have suffered health burdens resulting from racism, there is also a long history of resilience. For as long as African Americans have lived in the United States, there has been a practice of culturally centered pregnancy and childbirth care, whereby African American midwives (sometimes called “granny midwives”) cared for African American women outside of the medical care system. This separate care model developed out of both the strength of cultural practices and the necessity that arose from being excluded from traditional healthcare delivery systems. The medicalization of childbirth has affected African Americans and the general US population, moving 98 percent of births into hospitals; over 90 percent of births are now attended by physicians (Declercq 2015; MacDorman, Declercq, and Mathews 2013). While rates of midwife-attended births and out-of-hospital births are climbing again, the women that access these options tend to be white and upper-middle class (Declercq 2015; MacDorman et al. 2013). One of the reasons that the rise in midwifery access is concentrated among white women is a lack of racial and ethnic diversity among midwives and few out-of-hospital birth options for African American women

seeking a provider who shares their race or background (Bryant et al. 2010; Declercq 2015; Listening to Mothers III; MacDorman et al. 2013). Indeed, in their recent commentary in the Journal of Midwifery & Women’s Health, Jennifer Foster and Jodi Delibertis stated, “The demographic profile of certified nurse-midwives, certified midwives and certified professional midwives in the United States continues to be disproportionately White” (Foster and Delibertis 2016). The prevalence of whiteness among maternity care clinicians likely pervades not just the workforce but also the culture of clinics and hospitals, where the vast majority of pregnant women receive their care. One option for out-of-hospital birth is a freestanding birth center, which is a home-like facility existing within a healthcare system with a program of care designed in the wellness model of pregnancy and birth. Pregnancy and childbirth care provided to low-risk women in freestanding birth centers compares favorably with hospital-based care and comprises a promising strategy for improving value, but little has been documented about the potential role for out-of-hospital birth to improve cultural respect and reduce disparities in childbirth care (Alliman and Phillippi 2016). Specifically, for African Americans, who experience some of the worse outcomes and highest levels of racism, access to out-of-hospital (deinstitutionalized) care from a provider that shares their cultural background may hold promise for improving both the quality and outcomes of the childbirth experience. Our collective work investigates this potential.

In Minnesota a 2015 report from the Minnesota Department of Health revealed that African American and American Indian infants are twice as likely to die in the first year of life as white infants (Minnesota Department of Health 2015). As professionals and as mothers from these communities, we know these infants and their families, and we share a commitment to narrowing this racial gap. We are engaged in dismantling racism, a critical social determinant of health, influencing inequitable childbirth outcomes (Eichelberger et al. 2016; Hardeman, Medina, and Kozhimannil 2016).

This chapter outlines our vision for a collaborative research project, which is a vehicle for achieving our shared goal of greater equity in healthy childbirth outcomes. It describes successes and challenges we have experienced within our interdisciplinary, community-based research partnership. Together, combining community knowledge, culturally-grounded competencies, and rigorous research, we believe it is possible to address the complex structural dynamics that have produced long-standing racial disparities in maternal and infant health.

Our team and research project is funded through the Robert Wood Johnson Foundation’s Interdisciplinary Research Leaders (IRL) program. This three-year program funds three-person teams made up of one community partner and two academic partners, with a focus on conducting community-engaged research to advance the evidence base for creating a culture of health. The program provides funding for the research project and separate funding for a portion of time for each of us to devote to personal and professional development to improve our capacity for research leadership.

Overview of Goals

The long-term and overarching goal of this project is to produce knowledge that will help achieve racial equity in childbirth care and outcomes. In 2014 the Minnesota Department of Health (MDH) identified structural racism as a major cause of this inequity and numerous other inequities in Minnesota (MDH 2014). Broader awareness of the link between structural racism and health is growing, from the MDH report to the Black Lives Matter movement. The time to participate in the creation and dissemination of effective community-based knowledge to inform decision-makers who care as much as we do about the children from our communities of color having the same opportunity for a healthy start to life as white children is now. For policymakers and others who wish to act to improve equity, what is often lacking is a solid evidence base from which to build successful efforts to dismantle structural racism in childbirth care and beyond.

While our project team members come from different backgrounds and disciplines, our approach to disrupting the structural racism that shapes early childhood begins at the same place: pregnancy. Prenatal care is an important determinant of maternal-infant outcomes. For African American women, however, care in the medical context is insufficient to meet their needs. Prenatal care alone is woefully inadequate for addressing the role that structural and interpersonal racism may play in their day-to-day experiences and their encounters with the healthcare system (Eichelberger et al. 2016). African American women have greater barriers to access care and fewer choices for maternity care that meets their needs (Howell et al. 2018), compared with white women. Our work seeks to understand and articulate those needs, and to influence the policies and structures that shape access to care to ensure these needs are valued, honored, and met during pregnancy, childbirth, and beyond.

Theoretical Model: Racism, Weathering, and Birth Equity

Long-standing and complex sociodemographic and historical factors perpetuate the challenges African American women and other women of color face in achieving positive birth outcomes (Giscombe and Lobel 2005; Hogan 2011). Approaches aimed at achieving birth equity require an understanding of the social determinants of health—conditions in which people learn, live, work, and play (Braveman, Egerter, and Williams 2011)—and a commitment to disrupting the pathways that allow these social determinants to predispose women to adverse birth outcomes.

The weathering framework, proposed by the social scientist Arline Geronimus (1992), provides a model that explains the biological pathway through which social determinants predispose women to adverse birth outcomes. This framework tells us that health inequities between races result from exposure to social, economic, and political marginalization experienced by African Americans (compared to white Americans). This marginalization—the exclusion from mainstream social, economic, and political systems—takes many forms, including the residential segregation of African Americans into poorer quality neighborhoods, with lower access to resources such as quality schools and employment. The physical and mental health toll of this marginalization accumulates with age (Geronimus 1992; Geronimus et al. 2006) and causes biological wear and tear that makes individuals more susceptible to adverse health outcomes. Most research, intervention, and policies to address inequity in birth outcomes have focused on health behaviors and access to healthcare. A growing body of research, however, supports the argument that these “proximate” risk factors do not adequately address the dynamic and complex nature of health inequity. An alternate hypothesis, such as Geronimus’s weathering framework, suggests that social context (social determinants) directly affects health. This claim is supported by a large body of literature that has documented the robust association between social determinants, such as neighborhood or socioeconomic status and health. Researchers have also documented the disparities between African Americans and whites in both the level and quality of many of these factors, including healthcare, education, income, occupation, housing, and neighborhood.

The weathering framework extends the concept of context further by asserting that health disparities can be specifically attributed to the social, economic, and political marginalization of African Americans. The extent of the health disparities reflects the level of marginalization experienced. A second component of the weathering framework suggests that the health effects of the contextual factors accumulate with age. In other words, health disparities are smaller at younger ages compared to older ages, reflecting the shorter cumulative exposure to these social determinants and continued exposure to various forms of marginalization.

The weathering hypothesis was empirically tested in 1996 using population- based data. Geronimus’s results show that the low and very low birth weight rates for singleton first births to African American women increase with age; however, that is not the case for white women. Notably, after controlling for numerous risk factors—such as inadequate prenatal care, smoking, diabetes, hypertension, and other high-risk factors—African American women in their mid-to late twenties (conventionally considered the ideal childbearing period), still showed greater odds of low birth weight and very low birth weight compared to black women in their late teens. In other words, the black women in this study seemed to be aging at a faster rate—or weathering—than their white counterparts, as reflected in birth outcomes (Geronimus 1996).

The causes of the accelerated aging or weathering are understood to be fundamental causes—as opposed to proximate risk factors—for health inequities. The data points to racism as a fundamental cause of health inequities seen in black-white infant birth weight. Racism—a fundamental cause of health inequity—operates to make the social determinants relevant and is a key component in weathering. Although many interventions have been developed aimed at eliminating racial inequities in infant outcomes, many focus exclusively on the proximate factors and neglect racism as a fundamental cause. Unfortunately until research and interventions explicitly focus on the fundamental cause of these risk factors (racism) and attempt to eliminate its influence, new risk factors will continue to emerge to reinforce and perpetuate health inequities.

Disrupting this pathway and intervening on the fundamental cause of health inequities is a challenge that requires multi-factorial and multi-sectoral approaches. Interventions aimed at addressing racism as the fundamental cause must focus both on the interpersonal relationships African American women have with their providers but also push for structural reform that centers the needs and experiences of all marginalized populations. One model that attempts to center both interpersonal and institutional reform is that of a culturally centered freestanding birth center. This model is one element that we can explore as part of the complex effort to disrupt the pathway between racism, social determinants of health, and birth outcomes.

The Research Project

Our three-year, collaborative research project focuses on building the evidence base around one model of care—Roots Community Birth Center—and discerning generalizable concepts, knowledge, and wisdom that may inform broader efforts toward birth equity. Research in fields outside of maternity care has identified access to culturally focused care as a predictor of improved health outcomes. In our work, we are documenting the content, experiences, and outcomes of pregnancy and childbirth care provided in the context of culturally centered care. The goal of this chapter is to describe our process, including successes and challenges, in undertaking a collective, community-based research project.

This project describes the process of care at Roots Community Birth Center, using interviews with staff and stakeholders as well as focus group discussions with clients. Through analyzing data collected during interviews and focus groups, we are documenting the processes and practices for providing culturally centered care, including the distillation of key concepts and mechanisms of service delivery so that they may be more broadly replicable.

We are also conducting a web-based survey of all Roots clients during the postpartum period, in order to compare outcomes for Roots clients with outcomes for similar women with hospital-based care. The survey and comparison includes experiences of discrimination, communication, and early infant bonding in order to understand how care differs for Roots clients, compared with the care that diverse patients typically receive in US hospitals.

Finally, it is an explicit goal of our work to communicate findings and implications broadly among those who can use this information to make personal and policy decisions to improve equity in birth outcomes. Specifically, we aim to disseminate findings to community, academic, and policy audiences, which includes pregnant residents of north Minneapolis and surrounding neighborhoods, clinicians caring for diverse pregnant patients, researchers studying birth equity, employers making decisions regarding health insurance benefits, health plan administrators making financing and coverage decisions, state and federal Medicaid program administrators, and state and federal legislators. Communicating our findings to ensure change is an essential component of our work.

Our Research Site

Roots Community Birth Center opened in 2015 in north Minneapolis, the neighborhood with the highest infant mortality rate in Minnesota. Founded by Rebecca Polston, Roots is Minnesota’s first and only African American–owned and operated birth center. In establishing Roots, Polston believed she could create change in her community by creating relationships, offering employment, and training more midwives and doulas of color. This for-profit birth center is an intentional effort to bring equity and not charity to the population it serves. The plan to develop and launch Roots was financially supported through a partnership between four community organizations: WomenVenture, Neighborhood Development Center, Northside Economic Opportunity Network, and the Minnesota Black Chamber of Commerce. With this funding, Polston established her business and hired six staff members from within the north Minneapolis community. Roots seeks to improve maternal and infant outcomes in the African American community by addressing the root—structural racism—and its corollary impact: chronic physical, psychological, and environmental stress (Geronimus et al. 2010). To do so, Roots provides culturally centered, relationship-based care to meet its clients’ clinical, emotional, psychosocial, and relational needs. The hypothesized means through which the care at Roots would disrupt the manifold, pernicious consequences of racism is by centering the birthing person and harnessing the strength of their culture through the process of pregnancy and childbirth. The three of us share a commitment to the vision on which Roots was founded and have committed to a research project to document and understand its actualization, challenges, and potential. Systematically disrupting the pathways between racism and poor birth outcomes will take more than one birth center can offer, but we hope to uncover knowledge from Roots’ model and approach in this research project, and to offer community wisdom into the academic and policy context of evidence for change.

Our Team

As a team, the three of us have a diverse set of talents and perspectives to support this work. Each member brings an essential skill set and perspective to achieve the goals of our proposed research project. Rachel Hardeman and Katy Kozhimannil have collaborated for seven years on both academic and community-based research projects. Our partnership was seeded four years ago when Rebecca Polston provided initial input and feedback from a cultural perspective on Kozhimannil and Hardeman’s community-based doula project (Hardeman and Kozhimannil 2016; Kozhimannil et al. 2016). Over the three years, Hardeman and Polston have both been part of the establishment of the Minnesota Birth Workers of Color organization. What brought us together is a shared commitment to understanding ways to achieve equity in birth outcomes through an innovative community-based approach.

We meet in person on a monthly basis, either on campus or at Roots, and more frequently as needed. In order to balance the many competing demands on our time, but also to maintain the strength of our partnership and personal relationships, we prioritize regular, respectful, timely communication with one another via phone, text, and email, in addition to in-person meetings. Each of us takes leadership on distinct aspects of the partnership, and we return regularly to our focus and shared commitment. Later we describe both successes and challenges within our partnership, but our orienting mechanism has been shared vision, mutual respect, and specialization. That is, we continually affirm—individually and collectively—our dedication to realizing equity in childbirth, and we recognize the different strengths that each brings to the partnership.

Early Outputs, Dissemination, and Outcomes

Our overall goals are ambitious and may take longer to achieve than the three-year time frame of our current collaboration, yet we celebrate each new piece of knowledge and each product as a step along the path toward loosening the powerful grip of racism on birth outcomes. The goal of our research-dissemination plan is to raise awareness among key stakeholders about initial findings and how they may help guide the actions of policymakers to improve equity in childbirth care and outcomes in Minnesota and across the United States. As we conduct the research itself, we are focused on building strong networks for dissemination by communicating about the racial equity issues that drove us to conduct this research and relying on the expertise that each of us brings to the collaboration. We do this through our work with the media, policymakers, health plan administrators, academics, and community roles.

To date, we have created products in three major categories: community- oriented, policy-oriented, and academically oriented. Our community-oriented products and dissemination have focused on media outreach and contributing to media stories, locally and nationally, which draw attention to racial disparities in maternal and infant health, illuminate the lived experiences of people of color, and present positive alternatives and solutions to entrenched disparities. The policy-oriented awareness work we have initiated focuses on the establishment of a blog series on the website of the American Journal of Managed Care, a top journal in the field of health insurance and managed care (a key audience for shifting childbirth payment policies). A blog may seem an unlikely platform for policy dissemination, but health insurance plans—including private and Medicaid–managed care organizations—are key players in maternity care payment policy. This blog series has reached our key audience for three main reasons: (1) it distills complex concepts underlying and motivating our research into accessible language and a context that is relevant for health plans, (2) it is freely publicly available and is not behind a paywall (as many academic publications are), and (3) it builds on the credibility and reach of the American Journal of Managed Care.

Academic publications include a case study describing the model of care provided at Roots as well as qualitative and quantitative analyses of themes that arose from survey data, focus groups, and interviews with Roots clients, staff, and stakeholders. Preliminary themes describe care that is respectful and culturally centered, and acknowledges and embraces the knowledge and lived experience of each client while also naming and actively fighting against the structural barriers within their lives by providing them with a safe space and the necessary resources. These themes show the importance of culturally concordant care, but, more broadly, the data indicates that nonconcordant providers can provide culturally centered care when they acknowledge racism as cause of inequity and understand that reducing these inequities requires a commitment to racial justice—a commitment that often means creating space and opportunities for a more diverse maternal care workforce.

Successes

It is impossible to find words to state the depth and urgency of the personal devotion that each of us has to birth equity, and never before have we had an opportunity to work collaboratively to make a change. Our successes thus far are built on our shared commitment to this vision, and our personal commitments to one another and the people and families in our communities whose lives have been unmistakably altered by experiences of structural and interpersonal racism during pregnancy and birth. Interestingly, our successes in this project have not taken the typical form expected of and anticipated from large, national grants. Rather than having a long list of academic manuscripts, our successes have taken the form of visibility and dialogue in the media, giving voice to women’s stories, engagement in policy discussions, mentorship, and personal growth.

To that end, as we collaborate on our research project, we look ahead to the transformation toward greater access to culturally centered care as we: (1) uncover the tenets of this care concept, (2) work to support maternity care payment reform that rewards quality over quantity, and (3) support the recruitment and retention of a diverse maternity care workforce. Additionally, we continue to draw attention to the foundational need to address structural racism as an underlying cause of birth inequities.

Visibility and Dialogue in the Media

The core work of this project is not just the process of collecting and analyzing data but in communicating findings and implications broadly among those who can use it to make personal and policy decisions to improve equity in birth outcomes. One of the most meaningful successes of our collective work has been the opportunity to engage with media—locally, statewide, and nationally—to share our vision and to connect our goals with the lived experiences of women and families of color. For example, in the summer of 2017 the Minnesota Spokesman-Recorder did an in-depth, two-part story about Roots Community Birth Center, the need for more midwives of color, the goals of our research, and the urgent challenge of racial disparities in birth care and outcomes in north Minneapolis. The Minnesota Spokesman-Recorder, established in 1934, is the oldest African American–owned newspaper in the state of Minnesota and one of the longest-standing, family-owned newspapers in the United States. As such, having our work highlighted by this publication was deeply meaningful to engaging directly in the community where we hope to have the greatest impact.

At the national level, Hardeman and Kozhimannil have had the opportunity to contribute to the background and to share our own research to shape media coverage of the racial equity aspects of the maternal mortality crisis. Speaking directly with reporters and providing them with detailed information has an impact on how women’s stories are told and woven together. It is deeply important to us that, given the pervasiveness of racism, the tender and vulnerable stories of maternal and infant loss in the African American community are not tokenized or stylized, but that they reflect the richness of the lived experiences and honor the tragedies that people have endured.

Additionally, our team has worked with a photojournalist to share the story of Roots. In April 2018 Black Maternal Health Week was a national effort to draw attention to the disproportionate vulnerability that African American women, infants, and families experience around the time of pregnancy and childbirth. Through our work with the media, we were able to help amplify attention to these issues on social media and also to shape the stories being told by sharing our data and connecting journalists with women who have stories to share. For example, both Kozhimannil and Hardeman spoke with Nina Martin, a journalist at ProPublica, who won a Peabody Award for her co-leadership of a project on maternal mortality called “Lost Mothers.” In our conversations with Martin, we were able to emphasize the links between structural racism and maternal mortality and encourage her to address these directly. Indeed, she did exactly this in a December 2017 article titled, “Nothing Protects Black Women from Dying in Pregnancy and Childbirth,” highlighting the story of Shalon Irving, who died early in 2017, shortly after giving birth to her daughter, Soleil. Since Martin and her colleagues published this piece, both Hardeman and Kozhimannil continue to be in touch with her and with other journalists who are interested in highlighting stories of inequity in birth.

Giving Voice to Women’s Stories

Our initial data collection and findings from focus group discussions and interviews have created an archive of important and impactful narratives of the lived experiences of African American women—and their families—who are participating in culturally centered care during pregnancy and birth. When describing her birth experience, one participant remarked:

I felt like it was too much because I didn’t know what pushing felt

like. Rebecca said, “Take your time, I’m not rushing you… Ok,

you’re pushing!” After that, [my baby’s] head came out and it was

the strongest contraction I ever had in my life. I looked at Rebecca

and she said, “Now catch her.” I said, “I’m not catching her, I can’t

do this.” It’s what I said… you know, send me to the hospital… just

send me to the hospital. And she just looked at me so calmly, like

just caring. Like a mother, a natural feeling. And she just said, “Just

push. Like you have to yell.” I yelled and the baby came out on the

second push. I’m proud of having the baby, honestly.

This quote was one of many that highlight the immense support women note having at Roots as well as the control they feel during their laboring process. We see a paradigm shift in this participant’s ability to see her child’s birth as something she accomplished rather than a task accomplished by her provider. These are the narratives that have the power to shift the culture of health when effectively communicated to a range of stakeholders—from policymakers to clinicians to healthcare delivery systems administrators to employers to health plans. Our work with the media is one way in which we have had success, but the research itself— from interviews to surveys to focus group discussions—is elevating stories of extraordinary empowerment. Bearing witness to and recording these transcendent moments of physical and emotional transformation is a deep honor. So often the media portrayals of African American childbirth show the tragic side of how racism affects care and outcomes. In this project we hear, again and again, positive stories of African American childbirth, and we are aggregating and analyzing women’s stories to understand the common threads of their experiences of culturally centered care.

Engagement in Policy Discussions

Once we are able to uncover these positive stories, it is essential to translate these not only to the general public and to the community where we work but also to policymakers and others with the power to make decisions that shape the opportunities that women have for a safe, healthy childbirth. Our partnership and project is creating a pathway for those in positions of privilege and power to learn from those with wisdom and knowledge that is critical to the success and efficacy of public policies, especially payment policies, aimed to set children and families on the right track from the moment of birth, and over the life course. For example, as mentioned earlier, to inform health plans and managed-care organizations about aspects of maternity care reimbursement that could contribute to greater equity, we established a blog series on the American Journal of Managed Care’s website. We have had extensive traffic to these posts, especially “How Health Plans Can Support Moms” and “As We Mourn Infant Death, Let’s Take Care of Moms,” along with “Our Maternity Care System Is Broken: Here’s How We Can Fix It.” Polston recently successfully used the blog posts to support her discussions regarding reimbursement with a local health plan. Additionally, both Hardeman and Kozhimannil have provided input to federal legislators on proposed policies that relate to maternal mortality, and Kozhimannil provided testimony on a bill in the Minnesota legislature that would designate funding within the state’s broader equity initiatives to focus on racial disparities in prenatal care. In December 2018 the Preventing Maternal Deaths Act, a federal bill designed to support a maternal mortality review infrastructure in every state, was signed into law. Importantly this legislation encourages representation of communities most affected by maternal mortality, including black women.

Mentorship

In addition to successes in outward impacts, we have reflected on feelings of success that relate to interpersonal relationships as well as building the future workforce in our fields. Mentorship has a critical role in the way that our research team operates and is successful. Relying loosely on a cascade framework in which knowledge and experience flow from the most senior to the most junior, our team is composed not just of the two researchers and community partner—we also include a high school student, a midwifery student, and a doctoral student. All three student partners are involved in every aspect of the project and have taken the lead on coding a majority of the qualitative data.

Through our project, our high school student has developed leadership skills that have translated into discussing issues of race and gender among her classmates and school leadership. She has presented her work on this project at her school’s science fair and as a culminating experience for her advanced science research course. She has grown as a leader and has strengthened her ability to critically analyze issues; also, her work has been instrumental in our project. She began her freshman year at Yale University in the fall of 2018. She begins her undergraduate career having been trained in quantitative and qualitative methodology but, most importantly, is intimately familiar with the ability of community- led, woman-led, and people-of-color-led organizations to uplift and eliminate inequities within their own communities.

Our midwifery student recently graduated, becoming one of only seven midwives of color in Minnesota. She recently joined the academic faculty at the University of Minnesota, where she practices midwifery and conducts research related to reproductive health outcomes. She was recruited for the position in part due to her role as a researcher on our project.

Our doctoral student has taken the lead on conducting and leading focus groups and writing manuscripts. As a scholar of color in the field of health services research, we are intentionally preparing her for a successful career in academia. Additionally, her experience working alongside a community partner has given her the research experience that is not only professionally desirable but will allow her to advocate for similar projects in her training and career.

Personal Growth

We are grateful for the tremendous personal growth that has accompanied our work on this project and on these issues. This work has not been easy (more on that shortly), but facing these challenges individually and as a team has influenced each of us.

We gratefully recognize the position of privilege and power we hold as recipients of a major national grant, and by virtue of our positions as professionals. This recognition is a gift, as it allows us to harness our own agency in the face of the impacts of persistent racism in our communities and in our own lives. The close proximity to those who have experienced maternal or infant mortality and those who are struggling to care for themselves and their families during pregnancy and childbirth have clarified for us the value of the credentials we have earned, elevating the urgency of our work to address racial disparities in childbirth.

This research collaboration and partnership have added credibility to our voices that we can use in new and unique ways to influence knowledge (especially Hardeman), policy (especially Kozhimannil), and clinical practice (especially Polston). Additionally, through a success that we have achieved, finding a way to specialize as teammates and to work with others who respectfully challenge us, we have each developed some humility about the limits of our knowledge and understanding. Finally, we are grateful for the camaraderie we have built in facing the depth of challenge presented by antiracism work, including mutual respect for the need for self-care.

Challenges

Our different perspectives are our strength, but they also present challenges. We have trained in different fields. We bring different personal and professional experiences and expectations and—importantly—we face different constraints and incentives in our professional environments. In our collaborative work, we have faced challenges in setting expectations, time management, meeting externally imposed criteria for success, and financial sustainability.

Setting Expectations and Time Management

We come to this project with different backgrounds and different exposure to the professions of academia and small business ownership and to the fields of research and midwifery. Coming together from a university and community perspective was—and continues to be—a challenge for us. Both setting and articulating expectations required more time and attention than we anticipated, and each of us had unarticulated assumptions that needed to be challenged.

The challenge of setting expectations and the time required for relationship- building, trust, and deliberative discussion, which are required for collaborative decision-making and co-ownership of the work, was exacerbated for us by the many competing priorities that we each have in our personal and professional lives. For example, the pace and requirements of research differ immensely from the pace and tenor of midwifery work, which—by its very nature—is unpredictable and high intensity. Balancing our individual workloads in a way that supports our collective work has been a challenge.

Meeting Externally Imposed Criteria for Success

Additionally, each of us—in our professional roles—has externally imposed criteria for success, and these criteria differ among us. Specifically, Polston is the owner of a for-profit business and, as a businesswoman, needs to attend to the needs of her clients, staff, and operations. Also, Hardeman is a tenure-track faculty member whose progress toward tenure is annually assessed—her contract renewal is dependent on how tenured faculty assess and vote on the value of her work over the prior year. Kozhimannil is a tenured faculty member but also remains in a soft-money academic environment, where the imperative to generate salary support through grant funding and to publish prolifically in peer-reviewed journals remains paramount. The transformative work that this project requires is frequently not directly contributing to many of the expectations we need to meet in order to advance or sustain our professional work.

This has manifested in dropping planned products, either because they do not meet the immediate needs of our community or because they do not meet the expectations required for professional advancement on the tenure track or the business needs of a birth center. Our ability to manage these challenges has depended on the strength of our personal relationships and honest discussions with one another—including a willingness to be vulnerable to share and to listen.

Financial Sustainability of the Birth Center Model of Care

With a commitment to providing relationship-based, culturally centered care, open to all potential clients, Roots has faced serious financial challenges to support its model of care. This is directly relevant to one shared goal of our work: ensuring financial sustainability for a model of care that honors culture and overcomes racial disparities.

For example, clinic-based maternity care is reimbursed as a single payment for all prenatal and postpartum visits. Extra time spent is not reimbursed, but extra procedures, tests, and laboratory results are. In the Roots model, it is not uncommon to provide thirteen to fifteen prenatal visits, each lasting thirty to ninety minutes. Visits go beyond the usual tests and include time-intensive services, such as nutritional counseling, care coordination, and family support. In the current maternity care financing model, the Roots model is not well supported, adding strain on staff and resources, which limits Rebecca’s time for research collaboration, and calls into question the premise of whether the level of transformation we envision is possible. We are working to change policies, but change is not coming fast enough for Roots.

Principles for Building on Success to Meet the Challenges We Face

In our collaborative work, we aim to manage our challenges by abiding by the following guidelines in maintaining trust and partnership among members of our team: (1) starting conversations about our partnership early, (2) clearly identifying priorities of each partner, (3) clearly identifying the goals of the project, (4) openly discussing prior experiences—positive or negative—with collaborative and research partnerships, and (5) assuming good intentions and making good on our commitments.

Further, there are power and privilege dynamics among us and with the various audiences we wish to reach with our work. To manage the challenges that relate to power and privilege in the conduct of this research, we are committed to the following principles to promote power sharing within our partnership, and as we interpret findings and disseminate results among community, academic, and policy audiences: (1) reflect on and acknowledge socially defined power differentials, (2) strive to lessen impact of privilege by creating an equitable partnership, (3) acknowledge and value the expertise and skills of all partners, (4) emphasize needs identified by community, and (5) spend time on relationships with each other and with the target audiences of our work.

However, there is little we can do on a daily basis to transform the enormous obstacles on our progress that are created by historical and contemporary manifestations of structural racism in policies and institutions, including the places where we work and live. Yet we continue to strive toward greater equity, and we believe it is a goal worth fighting for.

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