Black women in Iowa are six times more likely to die during or shortly after childbirth than white women, and the reasons why are complicated. But this well-documented disparity also shows the role systemic racism plays in our entire health care system.
Selchia Cain has the kind of job where she sleeps with her phone ringer on loud.
"As a doula like you're anxious because worse doula’s nightmare is to miss a call. Client goes into labor, has baby, and you're conked out," she said.
Cain is a doula, someone who supports women during pregnancy, and she's one of just a handful of Black doulas in Iowa, working mostly Black clients doing things like making birth plans, helping with proper nutrition — and even asking important questions to doctors that her clients might not know to ask.
"Clients will talk to their doulas more than they talk to their doctors sometimes," Cain said, "and so we have this constant check in of what's going on.
In a society where Black women face substantially higher risks during pregnancy and childbirth, coupled with below average representation in the health care workforce, public health experts say Black doulas can be an incredibly important bridge.
"It's helping create additional providers within the workforce, who may look like clients, who may be able to relate to clients, who may be that extra voice to help advocate for clients when they are showing up in the health system as well," Nalo Johnson, the director for health promotion and chronic disease prevention at the state health department.
Johnson is part of the state’s maternal mortality review committee. A group of public health experts that tracks this issue.
She says Black maternal mortality is complex. Black women aren’t just dying during childbirth at higher rates. They also have lower rates of things like breastfeeding and prenatal care in the first trimester.
"So all of this is telling us that there's something around the ways in which Black women in Iowa are either being able to access health care or being informed about what kind of options are available to them," she said.
Yet, maternal mortality is far from the only health issue that highlights this deep racial divide.
Uchechi Mitchell, a Professor of Public Health at the University of Illinois - Chicago, said research has found conditions such as Alzheimer’s and dementia are also disproportionately higher in the Black population, and she said the reason can be tied back to race-related economic and social conditions that start way back in early childhood.
“It starts with the type of, for example, health care that you received from childhood on, your access to healthy nutritious food, your access to safe spaces, green spaces to exercise and where you live — and we already know, through redlining, that where you live is not random," Mitchell said.
She said in order to really address these disparities, there needs to be a shift in ideology. People need to admit the ultimate underlying issue is systemic racism.
“It starts with the shift that we're kind of seeing in terms of ideologies and beliefs, and people being less willing...to turn a blind eye to racism,” she said.
But another challenge is that rebuilding the Black community’s trust in the health care system will be hard.
Lynette Cooper, a professor of nursing at the University of Iowa, said many Black people have iatrophobia, which is literally, fear of the healer. Cooper means they’re afraid of health care workers.
"For Black people, it manifests often more so than — you know, it's not, 'I'm shaking in my boots afraid of you.' It's, 'I don't trust you. I don't trust that you have my well-being in mind,'" she said.
Historically, the system hasn’t had their well-being in mind. One well-known example brings us back to maternal mortality. J. Marion Sims, who is widely known as the father of modern gynecology, perfected procedures such as the cesarean section on Black slaves in the 1800s — without anesthesia.
Recent studies have indicated doctors are less likely to believe Black patients’ complaints of pain, underlining that the long-held misconception that people of color have higher tolerances for pain still persists.
Cedar Rapids native Markia Pryor said she encountered this stereotype when she had to fight for prescription pain medication three years ago after giving birth to her daughter, unlike her best friend, who gave birth around the same time - and is white.
"I think they were rotating like ibuprofen and Tylenol. I have the lowest pain tolerance ever," Pryor said.
Pryor said she encountered frustrations like this constantly during her pregnancy. She felt doctors and nurses questioned or ignored her symptoms and concerns constantly — unlike her white best friend — and failed to get test results to her in a timely manner.
Pryor said before she got pregnant at 23, she had limited contact with the health care system, other than for regular check-ups.
“I was just kind of naïve, I guess about the whole thing. Like, okay, 'it's gonna be so great. I'm having a baby and everybody cares,'" she said.
For her second pregnancy, a boy due in April, she’s working exclusively with a Black midwife and Black doula.
But she said her overall experience with the health care system has been so bad, it’s dissuaded her from having more children — or even going to the doctor at all.
"If I'm sick, like, I'm just gonna have to like lie in bed and cry about it. Because I don't want to have to go talk to anybody. I don't have to convince anyone that I'm dealing with I'm feeling or, you know, this hurts, and this is how much it hurts and what have you," she said.
Pryor said she feels exhausted by the system, and she isn't the only one.
"Medical racism is just so embedded into the fabric of our healthcare system, and that is really hard to untangle," said Olivia Samples, another Black doula in Des Moines, who is working with Pryor.
Samples said she was one of the first Black doulas in the state when she started taking clients three years ago. She said she was inspired to get training after reading a New York Times article on Black maternal mortality.
"It seemed wild to me that in 2017 people were still dying in childbirth, seems so archaic," she said.
Samples said she wants to address this systemic racism. She’s worked with the state health department and UnityPoint on some of these deeper issues.
But Samples ultimately sees a need for a whole system overhaul to really provide the care the Black community -- and others -- need.
"We can have so much more, like the resources exists. There's so much awareness about this issue. Like, what else do we need? Or what what kind of system can we dream up that will actually meet our needs?" she said.
But Samples said as a Black person, she still feels moments of powerlessness, where her voice is lost, but ultimately, she said that won’t stop her from continuing to fight and work with Black mothers.