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The Impacts of SDOH on Maternal Health: Q&A with Jennifer McLean, Certified Doula, Birth Equity Advocate

The United States has a lackluster record regarding the health of new mothers. Data released by The Commonwealth Fund revealed that the US has the worst maternal death rate of any high-income nation in the world. It gets worse––Black women face almost three times the risk of their white peers. 

This crisis is a symptom of a larger problem within our healthcare system: women of reproductive age, especially black women, are the hardest hit by the impacts of the social determinants of health. Women are at a higher risk of poverty and domestic violence and are more likely to have issues paying their medical bills, and have higher rates of chronic illness.

We sat down with Activate Care Community Engagement Manager Jennifer McLean, MPH, CD(DONA), to discuss the issues facing women before, during, and after childbirth and what needs to change to better support women to deal with SDOH impacts and achieve health equity on their journey to motherhood. 

Q: How can we earn and maintain the trust of women when it comes to their health?

A: We have to start by recognizing that a huge change needs to happen. Education for medical professionals is full of problematic teaching, affecting how they care for people. For example, in my doula training, our instructor showed us her nursing book from just a few years ago. The text claimed that Black people experience less pain. While the author printed a correction and released a statement admitting that the information is not factual and should not have been included, changing textbooks that taught a falsehood for decades is not enough. Even as new generations enter the medical field, they are being instructed by older doctors, and dangerous biases and untruths are still being passed down. We have to unlearn what has been taught for hundreds of years, particularly surrounding women and women of color. The way we teach has to change.

In addition to changing how we teach, we must treat people like individuals. Doctors sometimes get in a pattern––they see similar issues all the time, so they rush through appointments and jump to conclusions based on their previous experience. But for that one patient, it is new, it may be scary, and it is important. We need clinicians willing to be patient, sit with patients and let them ask all of the questions they have without making light of their concerns. Listen to them. Walk through what they are going through and why you think a certain diagnosis is right. 

Q: What do we need to do to help women feel safe?

A: Women know what is safe for them. The best way to create a safe environment is to ask what each individual woman needs. When we talk about maternal health and reproductive health, it is deeply personal. Ask questions like, “What do you need?” “What is safe for you?” Showing genuine care goes a long way toward building that trust. Women are doers and aren’t necessarily used to asking for what they need without prompting. It may add minutes to the appointment, but who cares? We need to make sure people feel safe and comfortable and get what they need. 

When working with families, I ask, “What do you need to feel safe?” And then––just as important––I listen to their answer. When talking about birth, the safest place to give birth is where the patient feels safe. There is no single right choice. What makes the mother feel most comfortable, and what do they need?  

Q: How do you talk to women about creating safe spaces for themselves?

A: Most of the time when I’m working with a client, they are pregnant. Concern for their safety starts with the care they are getting from their provider. I tell all of my clients that they are the customer regardless of what kind of insurance they have if they are paying out of pocket or on Medicaid. They have the right to voice concerns, ask questions, and tell their providers what they need. 

I also talk to the families of my clients and get them involved in that conversation. I’ll hear what the pregnant person needs and what their options are, then invite the family to hear those needs. It’s so important for families to be on board, so they know what is most important to the soon-to-be-mother. That way, when it is time to give birth if the mother can’t talk through contractions or because of some other circumstance, their families know what they need. Getting families on board is an important part of creating that safe space. 

My clients and I go through a lot of different things together about how people around them can help them. I give them tips for communicating with their partner and family to make sure they’re getting what they need. I direct them to community resources that fit their circumstances. I am also always available. A lot of times, people will come to me before they go to anyone else when issues arise. Sometimes all they need is a listening ear. 

Q: What are some best practices/lessons you’ve learned when building a community around a woman?

A: We have to be authentic. When I go in and work with people, it’s important for me to begin with, “I’m not an expert on you, so I’m not going to tell you what to do.” Just saying that lets them know we’re a team. I will be my authentic self; I won’t pretend I know everything. 

We all have to go in with listening ears and humble hearts. This is the best way to build communities, and it needs to happen more often. 

Q: How does developing relationships with women around their reproductive health benefit them in other areas of their lives?

A: Family planning impacts many other aspects of a woman’s life. For one, it affects mental health, which creates a domino effect on the quality of life and how they operate every day. A lot of what I do is to ensure they’re in a good place with their mental health. That way, they can continue to work, complete an education, apply for assistance where needed, and take care of their physical health––so many different things. 

A woman having control over her reproductive health is vital. It can change the entire trajectory of her life.

Additionally, as a doula, I have a long list of resources in my area. People come to me with things that are not pregnancy related. I have had clients come to me with SDOH needs, like food insecurity, family planning questions, and financial issues. I help point them in the right direction. Sometimes all it takes is having someone in your corner.

Q: If women have questions/concerns about their reproductive health and don’t want to turn to their physician(s), where should they seek support?

A: There are so many community-based programs there to help people. The organization I am part of, Alliance for Black Doulas for Black Mammas, provides services at no cost for people who qualify. It’s all about finding people you trust, then asking questions to find the right connection and get the help you need. Asking questions will open all kinds of doors; you will eventually get where you need to go.

Even asking a friend about their experiences can steer you towards the right people who are trained to help in your unique circumstance. 

Q: How do you work with women to proactively plan for the postpartum period?

A: I have a workbook for my clients that is always evolving and changing. We go through every section together, starting with the question, “Who are your support people?” Together, we write their information down so it is front and center and the mother knows who she can rely on. This may be a spouse, partner, mom, sister, friend, neighbor, or someone else who will be there to support that individual after the baby is born. 

Next, we talk about boundaries and advocating for themselves. For example, if someone comes over to see the baby, write down some chores or tasks they can help with, like loading the dishwasher, washing bottles, or folding laundry. No one needs to sit for two hours staring at the baby. If they are there to support you, they can provide that support in a concrete way.

It’s also important to plan ahead. Who pays the bills when the baby comes? Who will do certain tasks to keep the household running in the postpartum period? If you want to breastfeed, what does that look like for you? What lactation consultant can you call? What are your most important resources? If we map it all out, it is less overwhelming. 

We also talk about relationships. What will your relationship with your partner be after giving birth? What makes you happy? What do you need to keep your relationship going? What does your partner need? Who can you call when the time comes to leave the baby with someone? What things can you do at home together to feel supported and loved by one another? When a baby arrives, it is chaos. If you don’t talk about your relationship beforehand, it can feel very strained. I love to have partners in on this conversation where possible. 

Most people spend all their time planning for the baby while neglecting to think ahead about their and their partner’s needs after the baby arrives.

Q: You’ve said that being listened to and heard is one of women’s biggest concerns. What are their other biggest fears about the postpartum period? 

A: Postpartum depression is probably the number one fear women have, especially if they have seen people close to them go through it. It feels scary, and it is not something that is predictable. It looks different for everyone. 

Another big worry I hear a lot is that they won’t be able to breastfeed. That is a goal many women have, and if they don’t have the right support, it’s hard for them. I try to show them what the reality is. They may want to breastfeed, but if they have to return to work in 6 weeks, does it make sense? How will they maintain a schedule with their baby? Do they have space to pump and store milk? We have to talk about the real fear behind not being able to breastfeed, which is to give their baby the best they can. That looks different for everyone, and that is ok. 

Q: How do you encourage women to speak up and advocate for themselves in the workplace? 

A: Set up a meeting with someone in power that you feel comfortable with. If that is your manager, great, but if not, that is what the HR Department is for. Talk through any concerns you have, including maternity leave, pumping when you return to work, what you will do if childcare falls through, and any other accommodations you think you might need. 

Sometimes it is hard to speak up in our society, especially for women. We may feel like we can’t express what we need and advocate for that. Girls are not always taught to advocate for themselves, so learning to do that when you’re an adult is difficult. It can help to find a mentor in the workplace who has gone through the process before. Women can ask each other questions or maybe even go to meetings together simply to provide support. 

Q: How can women take what they learn during the maternity and postpartum periods and apply those lessons to their ongoing care?

A: I think, in general, as women, sometimes we settle or don’t ask for and get what we need. That’s something I work to teach, and hopefully, it stays with them. Even if the conversation is hard, not speaking up only impacts you in a negative way. It is about finding your voice but also figuring out what you need and how to ask for it. I want to see my clients be more assertive in all aspects of their lives. When it comes to work, it may start with advocating, “I need a private space to pump, a place to store my milk. What can I do to make sure I have what I need?” Later down the road, that same attitude can be applied to conversations about pay, scheduling, and benefits. In relationships, I am leading women to talk openly with their partners to make sure they are both giving and receiving love in the way they need it. 

The hope is that this helps them maintain healthy long-term relationships and friendships. I feel like women are natural givers. If we’re giving, somebody should pour into us, too.