What Black Mothers Experience and a Vision for Change | Francoise Knox Kazimierczuk

Note: The transcript has been lightly edited for clarity. Acronyms mentioned in this episode include: 

• ABCs: A public health shorthand for safe infant sleep practices: babies should sleep Alone, on their Back, in a Crib (or other safe sleep space) 
• CPS: Child Protective Services
• IMR (infant mortality rate): The number of infant deaths before a child’s first birthday, typically measured per 1,000 live births 
• MMR (maternal mortality rate): The number of deaths of women from pregnancy-related causes, typically measured per 100,000 live births 
• SNAP: The Supplemental Nutrition Assistance Program, which helps eligible households buy groceries
• WIC: The Special Supplemental Nutrition Program for Women, Infants, and Children, which provides nutrition assistance to pregnant and postpartum women, infants, and young children 

[00:00:00] Kristin Tully: Welcome to the Advancing Maternity Care podcast. I'm Kristin Tully, founder and chief scientist at Couplet Care. In this podcast, we invite maternal, infant, and family health thought leaders to share their perspectives and work. Connecting around research and lived experiences is key to implementing more meaningful support for families and those who care for them. Today, I'm excited to speak with Dr. Fran Knox Kazimierczuk, who is one of the Couplet Care clinical advisors. She is an associate professor at the University of Cincinnati in the Department of Rehabilitation, Exercise, and Nutrition Sciences. Her scholarship integrates public health and cultural issues focused around African American women's health, cardiometabolic syndrome, maternal health, breastfeeding, and obesity, all of which are mediated by racial and ethnic biases in the healthcare system. Fran, thank you for taking time to connect today. I look forward to hearing more about you and your work.

[00:01:13] Francoise Knox Kazimierczuk: Thank you. Thank you for having me. I really appreciate being here and being able to talk about this issue. It's something that is really near and dear to my heart. Obviously, being a Black woman, having four sisters, and then having just a multitude of cousins and friends and other family members who've experienced racial bias within the healthcare system, that's impacted them in negative ways.

[00:01:38] Francoise Knox Kazimierczuk: And so, just a little bit about myself. Um, I'm associate professor, as you already mentioned, at the University of Cincinnati. And I've been really doing Black women's health research for, I guess it's almost a couple decades now. Makes me feel old when, when I say it. I initially started off doing research looking at cardiometabolic syndrome and obesity, and then kind of shifted over into the world of maternal and infant health. And I really kind of shifted into that world related to breastfeeding and looking at breastfeeding as an upstream determinant for things such as obesity and hypertension and diabetes and some of these other chronic inflammatory diseases. And, I really kind of came into that particular space really looking at it from this life course health trajectory model or developmental of origins of health and disease and looking at, really just kind of epigenetic changes that can occur and how breastfeeding can modulate epigenetics, how breastfeeding can modulate inflammatory pathways as well, and just really the overarching benefits of having really early inputs for the baby.

[00:03:04] Francoise Knox Kazimierczuk: And so, I started off with looking at breastfeeding and those kind of early inputs and early first foods for baby to have this long-term impact related to chronic disease, but then started looking at, or I guess became more aware of, the disparities within maternal health and infant health, particularly the disparities related to maternal morbidity and disparities related to infant mortality and morbidity.

[00:03:33] Francoise Knox Kazimierczuk: And other people were doing this work, but it was something that was really kind of alarming to me, that there was such a chasm in terms of what the numbers look like for Black mothers versus other mothers. And I was like, really felt compelled and called to do something about it and really kind of look at it from a different standpoint and angle.

[00:03:58] Francoise Knox Kazimierczuk: I feel like with my background in nutrition and dietetics as well as in chemistry and then in exercise physiology, I felt like: Okay, I think I can come at this from a slightly different angle and a different, approach in terms of looking at, not only racism within the system and looking at social determinants of health, which end up impacting the life course of babies and moms, but also looking at it from the standpoint of the foods that we're eating and access to foods and access to early care and really thinking about, creating interventions and spaces to be able to have discussions about food access and have discussions about healthy choices early on, kind of looking at preconception, but then also looking at pregnancy.

[00:04:55] Kristin Tully: That's so exciting. And can you share more about, you mentioned interventions and spaces. Tell us more about what that means with you.

[00:05:05] Francoise Knox Kazimierczuk: So, one of the things that I've been working on, I guess it's now been a few years now, been working on an intervention called Healthy Eating and Active Living for Pregnancy, and the crux of it is really about trying to bring pregnant women together, primarily in their first and second trimesters, to be able to learn a little bit more about healthy eating, learn more about what's termed as “food literacy” and really specifically looking at critical food literacy.

[00:05:40] Francoise Knox Kazimierczuk: So, just basics of cooking skills, knife skills, basics of how do you store food after it's been prepared and food safety. And then also basics around shopping and trying to set budgets within your household to be able to afford healthier food options and then be able to prepare those different healthier food options when you maybe are time-constrained.

[00:06:08] Francoise Knox Kazimierczuk: But we also know that moms are stressed and we know that in particular, Black mothers have an extra burden navigating racism and navigating policies and structures that have bias inherently embedded into it. And so there's a weathering effect that occurs for Black women. And so, really thinking about, like, how do we also not only provide education, but also trying to make a space where women feel like they can come and just be and relax and feel like they're supported and have a community there with them.

[00:06:46] Francoise Knox Kazimierczuk: And so not only are we having this intervention, but we're also trying to let moms just come and show up there in that space. So, like, if they wanna come an hour early, couple hours early, stay a little bit later to kind of sit, have some tea, eat something, and just be able to talk to the other women that are there. We've been really trying to, like, create community there as well, and also trying to address some other needs for them. And so we have a community closet that I have tons of donated items, anything from cribs and clothing to baby bottles to breast pumps to whatever I end up with. People just give me stuff, 'cause they're like, "Oh, you do stuff with moms and babies. Well, I just had a baby." Or like, maybe it was a couple years ago, and they're like, "I have all this stuff." And so I just inherit a lot of stuff. So I literally have, oh my gosh, a giant room with multiple shelves in it with tons of baby stuff. And so, being a resource for moms in that way as well to be able to get things that maybe they need and don't have there as well. And so that's kind of the space that we're trying to create in addition to doing the intervention.

[00:08:14] Kristin Tully: So that's the first time I heard “food literacy”. That's so important and so also directly related to human milk storage, 'cause when you were talking about how to store other foods, then my mind went there and I was reflecting back and actually thinking about how confusing that was for me.

[00:08:31] Francoise Knox Kazimierczuk: Yeah. Yeah. And I will say, I kinda think about some of these other pieces with this that we're doing. I kind of forgot to mention - we're also giving mothers produce as well. And so, like we... It's not enough to provide the education and the information, and then to also connect them to resources in the community.

[00:08:53] Francoise Knox Kazimierczuk: So like if they're not signed up for WIC, trying to make sure that they get signed up for WIC, trying to help them with getting signed up for SNAP. And there's just a lot of confusion going on now with a lot of the Medicaid cuts that are going on because if you have your Medicaid cut, that's often linked to your SNAP and your WIC benefits, and so you may or may not be eligible for your WIC or SNAP if you're actually receiving those particular things because it's means tested against your Medicaid.

[00:09:23] Francoise Knox Kazimierczuk: And so that's, I mean, I'm pretty sure that's gonna be a big problem. That was already kind of a problem when some cuts happened previously, and so we were able to kind of fill the gap for some of those women because we were giving them biweekly groceries with the program 'cause we did some focus groups and basically heard from women like, "Okay, this is great. I'm getting this information. However, if I go home and I don't have any of these items, so I don't have any, any produce at home, or if I don't have the whole grains that you're talking about at home, how can I do these particular things?" and so that's something that we're really hoping to be able to continue, but it takes grant funding and other resources to be able to do that.

[00:10:10] Kristin Tully: It's so inspiring to hear about this intentionality around time and so I think moving forward from counseling which is important, you know, knowledge, and then extending it to make that more possible and consistent.

[00:10:30] Francoise Knox Kazimierczuk: Yep.

[00:10:31] Kristin Tully: That's amazing. And is that what you'll be presenting on at the Academy of Breastfeeding Medicine? Or tell me more about that upcoming conference.

[00:10:41] Francoise Knox Kazimierczuk: Actually, I will not be presenting on that at the Academy of Breastfeeding Medicine. I'm actually presenting on some safe sleep data that we have. We did some focus groups. Well, I did the training for some peer or community researchers to be able to do focus groups for Queens Village here in Cincinnati. And I have to say Cincinnati 'cause sometimes I'll wear a Queens Village shirt out, and someone will ask me, "Oh, like New York?" I'm like, "Nope, not New York. Um, Queens Village from Cradle Cincinnati." And they're like, "Okay, never heard of it." And I get to have a nice conversation with them about the work that's being done here in Cincinnati.

[00:11:28] Francoise Knox Kazimierczuk: And so I trained, I wanna say six or maybe eight community researchers, and they conducted a number of focus groups, and so we're basically talking about what came out of that focus group. I think safe sleep is something that is frequently talked about a lot, particularly when it comes to infant mortality and there is a lot of tension with the Black community and with providers around safe sleep. And so often when these questions come up or when data's collected, often it's not really accurate data 'cause people are like, "I'm not telling them what I'm doing at home with my child because, like, they might call CPS on me. And then now I'm going through a whole process of dealing with social services in and out of my house because they feel like I am not able to keep my child safe." And so that's a big concern, because we really need to get accurate data to really be able to provide, appropriate education and also appropriate assistance and interventions to be able to address safe sleep.

[00:12:46] Francoise Knox Kazimierczuk: And so, the focus group, and I don't wanna give all the information away about what I'll be presenting on, but in short, one of the key things that came out of the focus group, I feel like it directly relates to Couplet Care and the Bassinet because a lot of the women talked about breastfeeding. They wanted to breastfeed because they had kept getting information about breastfeeding and it being the best thing for their baby. And so they're like, "I'm trying to breastfeed. However, if I'm trying to breastfeed, then it's really difficult to get up and down out of bed." You know, even if there's a bassinet or there's one of, particularly in the hospital, there's like the plastic bassinets that they roll in, and, you've seen them with the kind of high lip on them, you're trying to reach over to get your baby out of the bed.

[00:13:42] Francoise Knox Kazimierczuk: And they're like, "Even that is challenging to be able to do." And then sometimes they roll them where they're not even really right next to the bed, and so you're like, "Okay, so now I have to get up out of bed to go and get my baby to be able to come back and breastfeed." And so what ends up happening is women will decide after being really tired, you know, like, “I can't do both. I can't breastfeed and then also have baby in the bassinet next to me or in a bassinet on the other side of the room. I have to put baby in bed with me to be able to do the thing that I also know is gonna be best and healthy for them." And so I think, you know, where there's that tension there that I'm seeing, more with women wanting to actually try to initiate breastfeeding and wanting to try to be successful at it, but then not having the necessary supports to really do so.

[00:14:42] Francoise Knox Kazimierczuk: It's really interesting, even a lot of the women who talked about having a spouse or a partner at home, they're like, "I'm still doing this on my own, even with a spouse and partner there." They're like, "The best I might be able to get is them going and getting the baby and then bringing the baby to me, but I'm still the one having to do this at, the end of the day. And, by the time I'm done, they're maybe asleep, and then now I'm having to get up and take baby back." And often baby doesn't end up going back, you know?

[00:15:13] Francoise Knox Kazimierczuk: And those are the women who have not had a cesarean section, which is a whole 'nother issue, that like trying to lift a baby up and over to you to put them down to be able to actually breastfeed is really challenging and painful, quite frankly.

[00:15:32] Francoise Knox Kazimierczuk: And so there's a lot more work that needs to be done to provide better supports. And so I'm grateful that you have the bassinet that's making its way around to different hospitals. I would love if you created a home bassinet as well, so that way it'd be easy once moms get home to be able to say, "Oh, I'm just gonna slide this out of the way and just slide baby over, and here we go."

[00:15:59] Kristin Tully: Yeah, that's the tension, it's... Is your perspective that that stems from this mismatch of support, where we have these expectations and instruction to do certain things, and then we don't have the informational support, the emotional support, the logistical support, and the physical structure…

[00:16:28] Francoise Knox Kazimierczuk: Yeah.

[00:16:29] Kristin Tully: …to enable it? And then we sometimes blame the people, right?

[00:16:36] Francoise Knox Kazimierczuk: And that's the tension.

[00:16:37] Kristin Tully: Yeah.

[00:16:38] Francoise Knox Kazimierczuk: Yeah. So that is definitely where the tension arises from, where, it's like, "Here's what you need to do. We want you to, you know, put baby in the crib. You know, put baby alone there on their back. We're gonna teach you the ABCs." And then it's like, "You should go out and be able to do it perfectly, and then we're not gonna have any, um, infant deaths, and we're gonna be able to keep our numbers low."

[00:17:06] Francoise Knox Kazimierczuk: And it doesn't, it doesn't really... It doesn't work that way, quite frankly. So it's like all the women, they knew the ABCs forward and backwards. They could talk about what they were told by their physicians, and they all were very candid and said, "Hey, like when, when we get home, that's a whole 'nother story.” Maybe going home and not having appropriate supports at home, like the appropriate physical supports or emotional supports or going home and maybe you're alone. You're the only person in the house, and you have two other kids, and now you're trying to juggle being a mom to two other kids along with a newborn.

[00:17:46] Francoise Knox Kazimierczuk: Or, you know, you have the issue, particularly with not wanting to say, "Here's what's happening in the house," because there's a real kind of institutional and, this personally mediated bias that's there for Black women and their children. And, it seems that if you are Black and parenting, you're much more likely to have family services called on you for things and you're more likely to have your child taken outside of your home.

[00:18:30] Francoise Knox Kazimierczuk: And so there's... That's also where the tension arises as well. So this tension of, “Okay, if I'm honest, something bad might happen.” There's also the tension, as you kind of pointed out, with this mismatch of what are the services, what are the supports that are needed. It's not just providing education or a campaign.

[00:18:54] Francoise Knox Kazimierczuk: And I think the campaign was successful. The campaign, everyone knows ABCs, you know? So it did what it was supposed to do, where people understand it and know it. But actually being able to live that out in the context of, people's real lived circumstances is something entirely else.

[00:19:13] Kristin Tully: And Fran, when you sort of step back and think, you know, if we had a appropriately structured system for maternity care or maybe broader…what are your thoughts,  how would we know that? What would that look like to you? What do you hope for?

[00:19:33] Francoise Knox Kazimierczuk: Yeah, I think what I would hope for would be, that there would be policies, institutions and structures in place that afforded equitable and sustainable economics for families. So that way if you had a child and you wanted to stay home to be able to caregive to that child, then you can do that particular thing.

[00:19:56] Francoise Knox Kazimierczuk: Also kinda thinking about that in terms of, long-term, like 12 weeks - that's not nearly enough to be able to really support a child and support the mother to be able to care for herself and care for the baby. And so, like, really structuring it where it's a year-long. Paternity leave as well. Like, making sure that there's adequate leave also, so that way there's additional supports there in the house.

[00:20:26] Francoise Knox Kazimierczuk: And so, like, I feel like we have really structured society in a way where it's really, anti-family, anti-woman, anti-child, and we are really focused in on, this extraction of, of resources and labor from the family unit. And so that means that we don't have a year of maternity. We don't have six months of paternity. Like, some places don't really even allow for paternity for a father to be able to be at home and have the support systems there. Also I think about other things, in some of the other countries that I visit and work with.

[00:21:10] Francoise Knox Kazimierczuk: Whenever I go to Germany, I'm always really impressed with, how they do pregnancy care, how they do midwifery care and support. Every woman has a midwife. Every woman has the option of being able to birth at home or do a birth center, or they might choose to do a hospital. There are very few babies that are delivered by OBGYNs in Germany. It's actually enshrined into their law that it's the midwife that provides care and does delivery. And I was just like, "Oh," I'm like, "Okay." I'm like, "That's interesting." It's only in those really rare cases where it's really high risk and there's gonna be potentially a need for cesarean that the baby is delivered in the hospital, and there are very few cesareans in Germany.

[00:22:06] Francoise Knox Kazimierczuk: Like, they have, really extensive midwifery care, and it's wraparound services that you get with your midwifery care where they're doing home visits throughout your pregnancy. They're doing home visits during that postpartum period and doing checks. And in a lot of cases, they are doing checks even a year out after the birth, making sure that things are good, providing education to the mom related to breastfeeding, related to changing over to solid foods, just kind of general checkup care and different things that you might have questions about or if you're doing this right.

[00:22:46] Francoise Knox Kazimierczuk: Did I treat this diaper rash appropriately? 'cause I think we've kind of shifted away from these communal spaces of being able to share knowledge where maybe it was, grandmother and aunts around you being able to help and support. And so, if we don't have that anymore, something else needs to kinda step in and shift and fill that space.

[00:23:07] Francoise Knox Kazimierczuk: And so I think about, wraparound maternity care, but I also think about doula support and care, and also community health workers support and care. And so we need to really create a much more robust system for, all three of those professional pathways. And then we also need to pay them appropriately because, you know, you're also kinda looking at positions that are lower-paid as well, where these individuals are struggling to try to take care of their families.

[00:23:37] Francoise Knox Kazimierczuk: And so it's really hard to ask them to then come in and care for somebody else's family if their families aren't being cared for. And so to me, when I start thinking about what a system would look like, I think there are models for it, you know, that are already out there. There are models in Scandinavia, there's models in Germany that work well.

[00:23:58] Francoise Knox Kazimierczuk: I know that you were in England for a time period, and they have a model where they're also using some midwifery care as well. And so I think that we can learn from some of these different models that are out there to be able to create a institution that really supports moms and families.

[00:24:20] Francoise Knox Kazimierczuk: But then we also have to think about policy because we really have kind of fragmented policies related to midwifery care as well as doula supports in the US. And so, how do we have one kind of... I don't know if it should be a national policy, where we're kind of able to have supports and legalization for midwifery, like kind of a blanket thing, or if it should be state by state. That's beyond me. I think we need to have more conversations and more discussions about that and really kinda dig into the data from these different countries that have these different models. And I will say, like, if you look at the infant and maternal mortality rates in these different countries, they are much, much lower than where we are at.

[00:25:10] Francoise Knox Kazimierczuk: I think that, one of the other pieces to this is, addressing the biases and racism that's also there and inherent within our system and structures. And so we have like a long way to, to go to be able to really kind of fix some of those different issues, and some of those issues relate to redlining, which impacts housing and which impacts food access and disinvestment in neighborhoods and disinvestment in educational systems. And that in turn has impacts on health and community cohesion and ability to get jobs which will end up impacting preconception health and pregnancy health.

[00:25:53] Francoise Knox Kazimierczuk: And, and so it's really like, it's kind of a domino effect or, you know, like cyclical dominoes that are set up in like a spiral where like things just kind of start kind of touching one another, then kind of spiraling down. And so, it feels like it can be kind of hopeless and hard to get out of.

[00:26:13] Francoise Knox Kazimierczuk: I think I'm kind of working my way around to an answer to your question. I'm just kind of taking the long way, I guess. And so I think some of this is allowing Black women to figure out some of these things for ourselves. And what that means is: at times being an ally, and at times really advocating, at times stepping out of the way, at times, supporting monetarily to be able to help create the structures. Particularly if, the larger system is unwilling to, is incapable of creating some of these different structures because of the really entrenched narratives and models of racism that are there. Then it's like, okay, then we can create over here to care for and try to improve these, really terrible numbers for the IMR and the MMR, and also the numbers which kind of improved a little bit for breastfeeding in terms of initiation, but still are not good for, duration or exclusivity. Trying to, say, "Okay, we're gonna do this parallel path and, you know, create our own over here with support."

[00:27:29] Francoise Knox Kazimierczuk: And then hopefully, at some point, the system will be ready for us to shift over and be like, "Here's what we've created. Here's what's working. How do we build this into the larger system?" You know? So, those are my thoughts.

[00:27:47] Kristin Tully: Those are extremely powerful. Thank you. It is really a lot to hope for and work towards and support as you outlined. Thank you so much.

[00:27:57] Francoise Knox Kazimierczuk: You're welcome. You're welcome.