This week Yarrow Global sat down (virtually) with Dr. Joia Crear-Perry to talk about the connection between maternal mortality, racism, and reproductive justice both in the US and globally.

Dr. Joia Crear-Perry is an OBGYN and the founder of the National Birth Equity Collaborative (NBEC), an organization that seeks to bridge the gaps between communities, hospitals, and governmental systems and focus on the social determinants of health driven by racism, classism and gender oppression. She has previously served as the Executive Director of the Birthing Project, Director of Women’s and Children’s Services at Jefferson Community Healthcare Center, and as the Director of Clinical Services for the City of New Orleans Health Department. She is a recipient of the Congressional Black Caucus Healthcare Hero’s award and the Maternal Health Task Force at Harvard University Global Visionary Award for Commitment to Advancing Women’s Health. She currently serves on the Steering Committee of the Black Mamas Matter Alliance and on the Board of Trustees for Community Catalyst, National Medical Association, and the New Orleans African American Museum. She is married to Dr. Andre Perry and has three children.

This interview has been edited for clarity.

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Yarrow Global: Would you mind telling me bit about yourself. What do you do and how did you get into the work that you’re doing right now?

Joia:  Sure. I practiced in New Orleans up until Hurricane Katrina and then became the director of maternal and child health for the city health department. I realized how much policy impacted not only my ability to provide health care services to my community, but also how much policy impacted the outcomes of the patients that I was caring for. Most people who attend medical school in the United States don’t have the opportunity to really see more broadly how policy impacts so much of our ability to provide care for our patients for them to be able to thrive. So I really started our organization (NBEC) with this understanding that both health and health care and health policy are really important. And that undoing the belief that Black people are broken in all of those areas was critical for us to end the inequities we see in health care.

YG: In 2016 you addressed the United Nations to urge for the creation of a human rights framework to improve maternal mortality. Why is human rights framework necessary?

J: Well to understand that I have to talk about reproductive justice, which feeds into that answer. Reproductive justice was founded by Black women 25 years ago after a United Nations Population Fund (UNFPA) meeting and was based this understanding that the United States was not built on a human rights framework. Both Black people, who were said to be two-thirds human and white women had to ask permission of their husbands in order to get birth control in the 1960s and they were never seen as fully capable to live and thrive on their own. And so policies were created with the understanding that we don’t have the capacity on our own to make decisions and choices and that we have to have policies made for us that are still harmful today. Back in 2015, when we first organized, we were invited to the Motherhouse, which is in Atlanta, where SisterSong is housed. The Center for Reproductive Rights brought in about 30 organizations from around the United States to talk about this report they had done around the statistic that Black women were three to four times more likely to die in childbirth in United States.

And so this movement was really coming together. And that was the birthing of the Black Mamas Matter Alliance movement. We knew that once the rest of the world started talking about the fact that Black women were dying and about three to four times the rate of their white counterparts, that they were going to start doing what they always do, which is blame and shame Black women. That they would say, of course, “they are so fat,” “they don’t listen” and so we really wanted to get ahead of that narrative.

YG: Right, and that kind of gets to another question I have. One of the articles you wrote is titled,“Race Isn’t a Risk Factor in Maternal Health. Racism Is.” But most medical professionals learn that race is a risk factor in birth complications and for maternal mortality.Can you elaborate on that?

J: Definitely. It’s such a critical point that goes on in history; the legacy of the belief that race is biological. I was taught in medical school in the United States in the late 1990s that there were three races: Mongoloid, Caucasoid and Negroid; that there were three types of skin. We’ve been teaching this for hundreds of years and we’ve spent billions of dollars trying to prove the biological basis of race. So we completed the Human Genome Project in 2003 and concluded and we know now for a fact now that there is no biological basis of race. In fact, I’m more likely to have genes more in common with you that I am with another Black person in the United States. With the gene mixing that happens, there are people who are white appearing who have African ancestry. And then there are people like me who are Black appearing: they have brown skin and kinky hair, but I also have Irish DNA.

The biological basis of race has been harmful for so many communities because of that premise – that belief that we as Black people were broken and so therefore we have higher rates of hypertension or higher rates of preterm birth or heart failure; that harmful belief that our kidneys are different or our lungs are different. All those things were written in textbooks. And over and over again, we keep proving that there were false narratives, that they were based on white supremacy and racist ideology.

But it’s still baked into our health care. And when you have the risk factor being the human being, being our Blackness, then you come up with all these strategies to try to fix us, right? So people say, “Well, if only you would just go to school, or if only you would just get a job or if only you would just show up to your appointments.” And so the truth is for Black American women, when we go to the doctor, when we are normal weight, when we get our prenatal care the first trimester and when we have good jobs and high education, the data shows we still have worse birth outcomes than white women in the United States who have done none of those things, who are obese, who don’t get prenatal care, who are not educated. It shows that the protectiveness of white supremacy is stronger than any kind of education. So what we have to undo is this devaluing of Black people. And that is what actually causes us to be harmed inside of health care and health care systems.

YG: It’s like when you go to the American Diabetes Associations website and basically every race and ethnicity is considered a risk factor for pre-diabetes except “white”.

J. Right, it’s like public health doesn’t know how to stop. Like we’ve used it as an excuse for so long not to act, the belief that people are just biologically broken. You see that in Europe right now with Black and Immigrant communities.  I’ve seen articles about those communities having higher maternal mortality rates and worse health outcomes and then they are being blamed, “there must be something about their ethnicity.” We will make it about anything except for undoing this belief in a hierarchy of human value.

It plays out in our policies and our culture and that is harmful for groups of people. We can’t move forward in health and health care without acknowledging that some of our basic scientific premises were off.

YG: Can you explain a little bit more about what reproductive justice is and how that differs from the general framework of reproductive rights?

J: Yeah, for sure. So as an OBGYN I provide reproductive health care services. So that’s the transactional nature of pap smears, hysterectomies, delivering babies.

Reproductive rights are the laws under which I can do those things. And they’re also the laws in the United States that dictate if you can have access to contraception or if you can teach sex education in your schools. So all the policies either at the local, state, school district, or federal level that dictate what can happen with our reproductive and bodily autonomy. And they range based upon the politics of the individual communities. So those laws really can change based upon who’s in charge and what their worldview is.

So the rights are created and the laws are created by individuals that are then used differently across different groups of people

So reproductive justice really says we believe that in addition to having access to this transactional nature of being able to get access to health care, and also this need for having laws, that the only way to get there really is if you have a reproductive justice framework, which is a movement you have to organize. You have to have a purpose higher than transactional health – it comes from a human rights framework, that we all have the ability to live to our full potential.

And so the first tenant is that you have personal bodily autonomy. So if there is a law that says that you can tie tubes or give long term contraception to people in jail, but you don’t do it anywhere else, then that is an affront, that is reproductive rights issue that you have to organize around reproductive justice to change it.

For example in the European context: I was in Amsterdam last year and they have had access to fertility treatments as a reproductive right for public benefit. But as the government changed, became more conservative, the net benefit was seen as something to treat illness. The new government came in and said, so if you are in a same sex marriage or if you are single, you no longer qualify for this reproductive right.

So then they need reproductive justice. They need organizing to really push back and say: “I have the right to have children,” – this second tenet of reproductive justice. So with this right, we have to organize in the government and with our partners in the community to ensure our rights, the ultimate right of being able to have children. No matter if I’m married or not, or no matter if I’m in a same sex relationship or not, it is not a medical illness or a health care illness issue. It’s a justice issue.

And then also to say, “I don’t want to have children.” So if I want access to birth control, if I work in an organization that does abortions or if I want my child to have access to contraception or school, then I have to organize and fight for that.

And then the last tenet has been important, especially for marginalized communities in places like Europe and in Black and Brown communities in the United States, which is the ability to raise our children in safe and sustainable communities. When you disinvest in our communities, when we don’t have money, when we segregate our schools, when the country devalues our homes and doesn’t invest in our infrastructure then our children cannot be raised in safe, sustainable communities.

I worry that in the international community because we rely so heavily on rights and don’t think about justice that we’re losing the point. We’re missing out on the idea that everybody’s rights are not equally met and people can have laws but it doesn’t mean they have justice. I mean, slavery was legal.

The ultimate goal is making sure that we’re all looking towards justice because there will always be people who are fighting to harm others and to justice is much higher than any individual law or policy.

YG: You’ve spoken a lot as well about this idea of holistic care. What does this holistic care framework look like and why is that important, especially for both for maternal health, but maybe even especially important for communities that have also been historically oppressed and disadvantaged?

J: So the field of obstetrics, at least in the US context, was created in response to the decimation of granny midwifery. We had a robust midwifery infrastructure that was led by Black women in the United States. We birthed Black and white folks here for generations. And as we began medicalizing birth and saying that it’s an illness, and that we want to improve our outcomes, we started blaming and shaming those midwives, and calling them dirty and uneducated. And so we decimated our midwifery workforce. Now we have a very limited and small midwifery workforce in United States, which has its roots in a…Blackness.

Instead we then created a workforce of white men who created obstetrics, including J Marion Sims, the father of gynecology who traveled around the United States with three Black women who were enslaved : Lucy, Betsey and Anarcha. And he performed surgeries on them without anesthesia to create some speculum that we all use now as gynecologist. And he said that they didn’t feel the pain. Black people did not feel pain. And so this beginning of hypermedicalization by white men and the patriarchy, taking away midwifery, blaming midwives and making birth an obligatory procedure at the hospital, putting women to sleep, putting forceps on and telling women they don’t really need to feel all this pain.

We haven’t gotten rid of that patriarchal idea that “you need me to do this for you, your body can’t do this by itself.” Meanwhile, for generations, thousands of years, women have been having babies without the assistance of any special surgery and of any special doctor in a white coat.  We would argue that this medicalization has created the harms and that that is the reason that we have these high rates of poor outcomes, especially here in the United States, where we have C-section rates above almost 30 percent.

The idea that birth is a surgical event that has to be an ICU environment and really not allowing people’s bodies to do what they naturally do, not having midwives and the support to have birth as a communal event is a result of us not valuing women in the first place and especially Black women.

YG: What would true holistic care look like for childbirth?

J: We’ve created a system where everybody starts at the highest level of care. When I say highest level, I mean with the most intrusive level of care, you know, so in a hospital. But when we ask birthing people what they want, they want less intervention. They want more time with their with a midwife or doula, more birth centers, more home births, more tying birth into a larger network of institutions that are there and available if you need higher levels of care.

Right now what we do is shame people if they want to go to a birth center or if they want a home birth and we marginalize them and we’ve never included it, at least in the US, it in our structures around providing care. We want people to come downtown to a big fancy medical center to receive care, and that is not holistic.

YG: What are the kinds of concrete policies and actions and things that people can do to center Black birthing woman and their experiences in the US and elsewhere and start to transform our concept of birth and move towards holistic care?

J: Well, the first is we have to decolonize how we talk about birth, right? So retraining and rethinking and retooling our entire system to not see birth and pregnancy is an illness, but instead as a natural part of life. So for Black birthing people that means affirming that they are not inherently broken.

I think people want there to be a magic wand. But until we can agree as a country and a world that there is no such thing as a hierarchy of human value based upon skin color, based upon gender, based upon class, then there’s no magical policy that will fix the ways that we treat people based on how we value them.

So it’s really important for us to have a global conversation that we need each other. We’re all equal. And also how do we support people that we have harmed and disregarded and said were expendable in the past?

We have had laws in the past as Black people. We had a civil rights movement where we, by law, de-segregated hospitals and de-segregated schools. But today, both hospitals and schools are more segregated than they were before we passed those laws. And the reason is because still people still think Black people are broken. So they don’t move their children into those places. Hospital providers will not see Black patients. And so that fundamental need is there to really reevaluate our values as a community and as a world community is really important.

But then in addition to that, really rethinking how we fund care. We have not agreed in this nation that health is a right.  We have millions of people that don’t even have access to health insurance. We really need to reevaluate tying insurance to jobs. All of those things are harmful to marginalized communities because we’re more likely to have higher job turnover. We’re more likely to have jobs that don’t provide health insurance. And so, once again, creating health inequities through policy, through a policy choice that says you can only receive valuable health insurance through your employer. It’s very perfunctory.

Then lastly, policies where we really hold accountable providers who have implicit bias or who are treating patients poorly based upon their race. We also have to create policies that say if you are unwilling and if you continue to treat people properly based upon their race or class or gender, you cannot continue to work in this field.

YG: I’m wondering if that kind of global experience with COVID-19 can also be used to raise awareness and action on preventing maternal mortality, in part because so many of the same risk factors of maternal mortality apply to COVID-19, such as poverty and preexisting conditions and, you know, “race.”

J: Yes, and this is our hope. I think the more we can make this a global conversation, the more we can talk about global Blackness, the more we can talk about the fact that it’s racism and not race that creates health inequalities, that when you are devalued fundamentally by the government, by the beliefs inside of the culture, you’re going to kind of see worse outcomes.

And so this hopefully is an opportunity for us to see with the pandemic, that the virus itself is just a vector. And it pays attention to and it takes advantage of our biases. It moves into spaces and harms the people who we’ve forgotten we’ve left behind – the elderly, people who are workers who are still having to work even though we’re supposed to be at home. Those are the people who we ignore; the people we’ve walked by as a society that the virus is attacking. And those are the same people we also ignore that are at high risk for maternal mortality. And if we’re going to improve as a world, we’re going to have to agree that those people are not expendable, that those deaths are not acceptable, and that we can do better. That we should do better because we we value all people.

YG: Final question. Can you expand on the connection between maternal mortality, racism, and reproductive justice, especially in light of the current protests in the States?

J: We are hoping to explain in this movement right now that the link between how black birthing people have been treated in the United States, how doctors have disregarded their pain and their complaints, that that same through-line exists when it comes to police violence and mass incarceration and that that is also what has happened with COVID. The devaluation of people is what causes all those things. It’s important not to see those as separate. It’s all at the core.

We’re not going to have small policies here or work around the edges there. It’s fundamental shift of our understanding that we need, that all of us are equal and we all need each other.

You can read more of Dr. Crear-Perry’s writings here