As a postdoctoral fellow at UCSF’s California Preterm Birth Initiative, it was important for me to work in community spaces to understand where people were at: Did they understand the racial disparities and how to best protect themselves? The Black maternal and infant health crisis is one of the longest-standing disparities in the United States. There are so many conversations about it, but often not involving the people actually affected by it.
I’m from California, born and raised, and spent half of my life in Southern California and half in Northern California. I didn’t really know a lot about the Central Valley and its uniqueness. So for me, it was a good time to engage in that space. At the same time, Fresno had just been accepted into the Best Babies Zone (BBZ) program and was getting ready to launch that effort. The BBZ initiative is a place-based program that works at a neighborhood level to address the social determinants of health affecting birth outcomes.
As far as the medical systems go, a person would probably have very similar experiences in the Central Valley as you would anywhere else in California. The interesting part is the area’s mix of risk factors, all of which can contribute to adverse birth outcomes. When we’re thinking about social and structural determinants, it is unique in the sense that it does have this rural element and there are a lot of issues related to environmental injustice and exposure to toxins throughout the life course. In Fresno, there are also land use debates going on — again these sorts of things happen in Northern and Southern California as well. It’s unique that there is also everything that is going on in more urban areas, such as disparities in socioeconomic status and racism and all that, but then there is this added layer of the environment. Studies have shown that prenatal exposure to air pollutants are associated with adverse birth outcomes, including the baby being born with low birth weight, preterm, small size for gestational age, stillborn, as well as other congenital anomalies.
The biggest environmental injustice issue for years and years was the Darling Rendering Plant in Fresno. It was a meat rendering plant and was essentially polluting the air. Just recently, stakeholders and community members were able to get the plant shut down. There are a lot of these situations in Fresno. You’ll see land use decisions that don’t include the community and aren’t reflective of how the community would prefer to use their spaces, in terms of greenery and access to parks. That is a constant political determinant. Civic engagement is important so that residents in Fresno are aware of how they can be a part of the decision-making process. It is really, important.
Getting the Darling plant shut down was a major win. But it’s an ongoing battle because when it comes to power and politics, these oppressive structures are going to reiterate and show up in a different way. It’s one win for the war, but it is still an ongoing effort that they have to engage.
There needs to be a paradigm shift, but really you’re talking about addressing a root of an inequitable system: structural racism, occasional racism, and making sure that people are being held accountable for the care they provide. Making sure that these health systems are being properly monitored with the right kind of metrics that are really speaking to the root of the injustice.
Because of racism, we’re seeing inequitable outcomes, experiences, and care for communities of color — Black communities especially. Until we all agree that that is the case and until we are all on the same path to addressing that root cause, I don’t think we will see sustainable change.
I want people in Fresno to know that this isn’t an individual-level issue. Infant mortality and preterm birth are very much related to the environments and the health systems Black people are exposed to. Both are built on the back of structural racism, and so the fight is going to be not only ongoing but something that could take generations to address.
I think there is an opportunity to recognize the resources that already are available. For communities to thrive, we have to put people in a position where they can address those root causes and inequities. Give people more power to decide how they want to raise their children and grow up and live and work and play. The more that we can reorient ourselves, the more we can reframe the issue to be less about a deficit and more about bringing positive resources to the forefront — doula access, socioeconomic opportunities, and more.
There’s a ton of programming, specifically for Black families in Fresno communities. Investing in those programs is so important. We need to turn on a dime and get with it because the Black maternal and infant health crisis needs to be addressed from all sides. The Black Wellness and Prosperity Center is definitely a program that comes to mind. Black Infant Health as well. First 5 Fresno County is invested in the well-being of children ages zero to five. West Fresno Family Resource Center is another one. All are doing their best to develop solutions rooted in the community, what their vision and desires are in terms of what life should look like in West
The relationships I’ve made in Fresno are definitely long-lasting, and so I see myself as a resource: As somebody who has a wealth of expertise that could be a value for moving the vision and wisdom of the community from an idea into a sustainable practice.
Researchers and public health practitioners are always coming up with interventions and solutions. A lot of times these interventions never make it, they don’t become a common and widespread practice. Even if they have been tested and validated in a small population, they are never scaled or something happens during implementation that ends the program (e.g., running of out budget, difficulty staffing). So we never really see the change, even though we have all these tested solutions that are supposed to be effective. It’s really, really important to think about why these interventions are not taking root in places that we expect them to.
Most of the time, they don’t take root these ideas are not born of the community itself. The issue then is that there is a mismatch between theory and the realities, so if you can get community at the table to begin with, you can set an intervention up in a way that better addresses the lived experience of the people you are trying to help — and these solutions will be more sustainable.
Glow! was developed in response to the African American infant mortality report, which was conducted in 2015 by a whole bunch of stakeholders. Some of the recommendations were related to directly addressing this issue of higher rates of preterm birth in African American communities in Fresno. In one of those recommendations was to develop a group prenatal care program, because there was a need for new models of care that were improving the quality of care that individuals were receiving as well as addressing things like social isolation in pregnancy and making sure that people had their needs met during prenatal care.
Glow! was definitely developed in partnership with the community from the get-go, and so the EMBRACE study is really the next iteration of that work. Based on the success of the Glow! feasibility study, we were funded by the Patient-Centered Outcomes Research Institute (PCORI) to conduct EMBRACE, a comparative effectiveness study of two prenatal care programs to help women with low income get support and services to help ensure a healthy pregnancy and baby, Glow! and the Comprehensive Perinatal Service Program, which provides assessments and education to women who are receiving prenatal care in the usual one-on-one format.
EMBRACE asks the question, “Does it work in the real world?”. For this study, we’re trying to compare the impact of group prenatal care against individual care, specifically looking at outcomes by race and ethnicity. My role in EMBRACRE is to evaluate from a big-picture point of view. So, yes, we’re going to determine whether or not this works and whether or not it is impactful for improving birth outcomes in Fresno among Medicare-eligible people — as well as asking how did it work. And if it didn’t work, then why didn’t it work? Those are the questions that drive my work, and is what academics call implementation science.
In addition, through EMBRACE, I will be answering questions about sustainability and equity through these research projects. For instance, if we’re only seeing that certain types of providers are able and then willing to offer group prenatal care, then that’s a big problem for this type of program in terms of equity. In the real world, ideally, you would want everybody to be able to offer it so that everybody potentially have the ability to access the program.
Having worked in the community, you always hear that part of the narrative when community member realizes that they weren’t the only one. I would change that. I would find a way to make it so that more people knew that this wasn’t something that they had to go through alone, that this horrible experience is something that is occurring throughout their community, and that there are resources for Black families to help them. That moment of isolation and helplessness feels so avoidable. That’s why I think Voices for Birth Justice is so valuable — because the more that we get this message out there, the more we can help people. Because when you experience these types of situations, such as a preterm birth, it is important to know that (A) it was not your fault and (B) you are not the only one. That is really powerful because we can build a cascade and coalition that realizes that this is happening to certain people and together they can question the systems, their environments, and galvanize their energy to make a real difference.