Jeanette Magnus

A Celebration of Life and Womanhood Innovations Case Commentary: The Birthing Project Although the United States has a technologically advanced health-care system, it ranks lower than many developed nations in life expectancy, infant mortality, and general health status. Studies have attributed this to the exacerbating effects of the social determinants of health, such as limited education, poverty, illiteracy, gender, and racial discrimination. Most of the burden of poverty and ill health falls on women, and maternal, infant, and child mortality increase as inequities rise within a given population. The health and well-being of women before, during, and after childbirth are pivotal factors in improving the economy and the future of any nation. The more compromised women are in a population, the worse the statistics on health indicators become and the longer lasting the effects are on future generations. With the Birthing Project, Kathryn Hall-Trujillo has cut to the core of the great disparity African American women experience in the United States. African American women are more likely to experience the death of a child and live a shorter life than white women. The 2006 infant mortality rate per 1,000 live births was 13.4 for African Americans, 2.4 times (or 240 percent higher than) the infant mortality rate for whites. African American women experience approximately 3,300 more infant deaths annually than should be expected in the United States.1 The Birthing Project brings an altered awareness to African American communities. Pregnancies and births are celebrated. Where pregnancy outcomes are regarded as the responsibility of the health-care system2 and are intricately linked to stress, racism,3 and lack of respect,4 a new framework is now emerging. Social support in the form of the SisterFriend network, which is centered on women giving of their time, experience, and care, is at the heart of the Birthing Project. A Dr. Jeanette Magnus is Chair of the Department of Community Health Sciences and the Director of Tulane Xavier National Center of Excellence in Women’s Health. Her work bridges clinical medicine, epidemiology, public health, and community research. She has more than 125 published works. © 2010 Jeanette Magnus innovations / summer 2010

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Jeanette Magnus SisterFriend facilitates the pregnant woman’s navigation of services related to prenatal care visits and discusses the expectant mother’s beliefs about and anticipation of childbirth and motherhood. This peer support network provides a security system for expecting mothers. Throughout history, women have shared all aspects of life related to womanhood, pregnancy, and childbirth. In our modern society, the simple truths of life have been transformed into science and taken away from women’s domain.5 Pregnancy and childbirth have been medicalized, and only “experts” know what, how, and when.6 The Birthing Project challenges this concept; through grassroots initiatives, communities of women rally around what they have in common and work together to establish a place where the old traditions can be awakened and celebrated. The Birthing Project offers African American women unique social support before, during, and after childbirth. Close to one hundred of these projects are located throughout the United States. A Birthing Project woman with a SisterFriend is more likely to attend prenatal care visits and give birth to a heavier baby. Researchers concur that social support and home visitation projects have demonstrated a reduction in unfavorable birth and infant outcomes.7 In a nonscientific way, based mainly on perception and instinct, Kathryn Hall-Trujillo created a program that meets each woman where she is, offering support and a place to be, share, and grow. The shocking television pictures from New Orleans witnessed just five years ago this August are still with us. Women desperate for baby food and water, the old and sick needing care and support—this was not the United States we were used to seeing broadcast. The weak infrastructure and inadequate emergency response surprised us all:8 So I’m here homeless. I’m trying to find my niche in life, and I guess the most stressful thing is for me to see this beautiful city abandoned by those who have the wherewithal to bring it back. —African American woman in New Orleans, 2006 9 The close-knit fabric of families, neighborhoods, and communities were gone,10 washed away by a manmade disaster:11 Family, our family, is all scattered. [It’s] not the same over the phone or with e-mail. We have to wait until we see each other. —African American woman in New Orleans, 2006 Volunteers overcame adversity to come to support us and helped us rebuild. The Birthing Project offered baby showers organized by women in communities around the United States, who helped New Orleans women celebrate life and a new beginning in the midst of rebuilding and renewing their communities. Slowly the community recovered enough so that New Orleans women could establish their own Birthing Project in June 2010. The New Orleans Birthing Project includes doula care in addition to the SisterFriend Program. A doula, a female who offers support throughout pregnancy, childbirth, and often the first year of an infant’s life, embodies the ancient tra70

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A Celebration of Life and Womanhood dition of women supporting each other during these critical phases of life. Doula support is offered to women who want more than a SisterFriend, because Doula has more knowledge about prenatal care, childbirth, and the postnatal period than SisterFriends, but not as medical experts, just as female supporters. A doula’s role is to support the mother and the father and reduce their stress related to the pregnancy and birthing experience. Recent studies have demonstrated a reduction in cesarean delivery and a reduced need for an epidural when a doula is present during labor.12 In other Western countries, doulas are frequently offered through hospital delivery units,13 as the research clearly has demonstrated that their services lead to improved birth outcomes. The doulas and the SisterFriends also support and encourage women to breastfeed their infants. Although considerable progress has been made through the promotion of breastfeeding in the United States, gains have not been equal across racial or socioeconomic groups. The goals of Healthy People 2010 are that 75 percent of women initiate breastfeeding in the early postpartum stage, 50 percent continue for six months, and 25 percent continue for one year. A child born in Louisiana is 8.36 times less likely to be breastfed than if it were born in Oregon. No other state compares to Louisiana when it comes to failure to breastfeed; even after adjusting for all relevant social, demographic, and behavioral factors, a Louisiana infant is still one-fifth as likely to be breastfed.14 In Louisiana, we have the third highest infant mortality rate in the United States. Breastfeeding can substantially decrease infant mortality and morbidity. It has been estimated that 911 deaths could be avoided and $13 billion could be saved on medical care and treatment in the United States if 90 percent of infants were exclusively breastfed in the first six months of life.15 For infants, not being breastfed is associated with an increased incidence of infectious morbidity, as well as elevated risks of childhood obesity, type 1 and type 2 diabetes, leukemia, and sudden infant death (SIDS). Breastfeeding for six months reduces the risk of SIDS by approximately 50 percent and is regarded as an important SIDS risk-reduction message.16 Being African American is associated with less breastfeeding, even after controlling for education, age, socioeconomic status, etc. In Louisiana only 32.4 percent of African American first-time mothers reported ever breastfeeding their infants;17 the number that breastfeed their children for six months is less than 5 percent. Social norms have a strong impact on issues related to breastfeeding. Focus groups with different generations of African American women have disclosed that young African American women are unlikely to reevaluate their beliefs about breastfeeding without support from the community, and without convincing evidence and encouragement from their elder female relatives, to whom they turn for advice about mothering:18 My grandmother did not breastfeed my mother so when I had mine, my mom was like, if you do not want to do it, then do not do it. —African American woman in New Orleans, 2006 innovations / summer 2010

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Jeanette Magnus The understanding that breastfeeding is a skill that has to be learned and does not just come naturally is lost when generations lack role models and new mothers never have seen an infant being breastfed: I think I was the second one in my family to breastfeed out of my entire family, but there is nobody else. It was only me and my aunt on my mom’s side. —African American woman in New Orleans, 2006 With a focus on breastfeeding, the Birthing Project creates a bridge across the generation divide and challenges the current social norms related to infant feeding practices in the African American community, both in New Orleans and across the United States. A significant future impact should not be underestimated. The intuitive Birthing Project initiated by Kathryn Hall-Trujillo has great merit. Pregnant women need to experience community acknowledgment and celebration. Each SisterFriend is doing this on behalf of each of us, as they are making sure that the next generation is brought to life and well cared for. A now wellknown African saying is, “It takes a village to raise a child,” and it also takes a community to nurture pregnancy, labor, and childrearing, including in the United States. We need to change the way we think about pregnancy, childbirth, and infant feeding. One can but wonder if some of the disparities we see in the United States could be mitigated if more communities, as well as the medical community, adopted the concepts of the Birthing Project. It’s about what you think, first of all, what you think, that’s the way you gonna act. First of all we have to change the way we think, I know it’s hard to do that y’all. I know it is. But that’s what keep me [going] sometime because if I keep on focusing on where I’m hurting, of course, and if I keep on saying how I’m hurting, you know of course I’m going to be hurting. But we have to change the way we think first. And when you change the way you think, then we’ll change the way we act, and then we change the way we feel. —African American woman in New Orleans, 2006 1. G. R. Alexander, M. S. Wingate, D. Bader, and M. D. Kogan, “The Increasing Racial Disparity in Infant Mortality Rates: Composition and Contributors to Recent U.S. Trends,” Am J Obst Gynecol 2008; 198:e1-9. Epub 2007 Sep 17. 2. G. P. Quinn, E. M. August, D. Austin et al., “High Risk Community—Men’s Perception of Black Infant Mortality: A Qualitative Inquiry,” Am J Mens Health 2009; 3:224-37; T. D. Baffour and J. M. Chonody, “African-American Women’s Conceptualization of Health Disparities: A CommunityBased Participatory Research Approach,” Am J Community Psychol 2009:44:374-81. 3. G. L. Barnes, “Perspectives of African-American Women on Infant Mortality,” Soc Work Health Care 2008:47:293-305; A. Nuru-Jete. T. P. Dominguez, W. P. Hammond et al., “‘It’s the Skin You’re in’”: African-American Women Talk about Their Experience of Racism. An Exploratory Study to Develop Measures of Racism for Birth Outcomes Studies,” Matern Child Health J 2009;13:29-39. 4. J. J. Coleman, “Culture Care Meanings of African American Parents Related to Infant Mortality and Health Care,” J Cult Divers 2009;16:109-19.

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A Celebration of Life and Womanhood 5. D. C. Parr, “‘We Want a Birth Experience, Not a Medical Experience’: Exploring Canadian Women’s Use of Midwifery,” Health Care Women Int 2008;29:784-806. 6. M. J. Harrison, K. E. Kushner, K. Benzies et al., “Women’s Satisfaction with Their Involvement in Health Care Decisions during a High-Risk Pregnancy,” Birth 2003;30:109-115. 7. A. Dunlop, C. Dubin, R. D. Raynor et al., “Interpregnacy Primary Care and Social Support for African-American Women at Risk for Recurrent Very-Low-Birthweight Delivery: A Pilot Evaluation,” Matern Child Health J 2008;12:461-8; E. Lee, S. D. Mitchell-Herzfeld, and A. A. Lowenfels, “Reducing Low Birth Weight through Home Visitation: A Randomized Controlled Trial,” Am J Prev Med 2009; 36:154-60. 8. A. Ndep Ola, M. Tarver, G. Rome, and J. H. Magnus, “Assessing New Orleans Women’s Physical and Psychosocial Response to the Devastation Caused by Hurricane Katrina: A Qualitative Case Study.” 9. A series of focus groups and key informant interviews with African American women related to stress, social support, infant feeding, childrearing, and woman’s health were undertaken in 20052007 in New Orleans. Selected quotes are presented in this document to reflect the community voices on the issues addressed. 10. A. Ola, J. H. Magnus, T. Hong, and C. Johnson, “Perceived Stress and Coping Self-Efficacy of a Sample New Orleans Evacuees Residing in Shelters and Transitional Housing Three, Six and Nine Months after Hurricane Katrina: A Case Study.” 11. C. E. Colten, An Unnatural Metropolis: Wresting New Orleans from Nature. Baton Rouge, LA: State University, 2004. 12. S. K. McGrath and J. H. Kennell, “A Randomized Controlled Trial of Continuous Labor Support for Middle-Class Couples: Effect on Cesarean Delivery Rates,” Birth 2008; 35:92-7. 13. I. Lundgren, “Swedish Women’s Experience of Doula Support during Childbirth,” Midwifery 2010;26:173-80. 14. M. D. Kogan, G. K. Singh, D. L. Dee, C. Belanoff, and L. M. Grummer-Straw, “Multivariate Analysis of State Variation in Breastfeeding Rates in the United States,” AJPH 2008; 98:18721880. 15. M. Bartick and A. Reinhold, “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis,” Pediatrics, 125:e1048-56. 16. M. M. Vennemann, T. Bajanowski, B. Brinkmann et al., “Does Breastfeeding Reduce the Risk of Sudden Infant Death Syndrome?” Pediatrics 2009; 123; e406-10. 17. A. C. Chin, L. M. Meyer, and J. H. Magnus, “Race, Education and Breastfeeding in Louisiana, 2000-2004,” J Hum Lact. 2008;24:175-85. 18. M. Tarver, D. Broussard, and J. H. Magnus, “New Orleans, Why Aren’t You Breastfeeding? Understanding the Barriers to Breastfeeding in the African American Community,” APHA 2005.

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