Recreating pregnancy to improve birth outcomes for women of color in America by giving them the extended family and community support that only a “sisterfriend” can provide.
In America, the country with the highest infant mortality rate of the industrialized world, black babies are more than twice as likely as white babies to die before their first birthday. Kathryn Hall-Trujillo is changing that. Through the Birthing Project, she is building a social support system that will allow black women to support each other for healthier babies and healthier lives.
Kathryn is creating a new social support role for black women in America. She has recognized that the moment of pregnancy—a time when even women engaging in the riskiest behaviors may be open to change—is a prime opportunity to pair the most vulnerable young black women with a decision-making partner. To this end, the Birthing Project mobilizes African American women to assume this partnership role, taking responsibility for the future of an at-risk pregnant woman and her baby through, at minimum, the baby’s first birthday. Kathryn notes that there is a “magic” of sorts in this “SisterFriend” relationship, an emotional connection that opens women to change, which emerges when women come together to support each other. But the origins of this effect are no mystery. Kathryn has carefully engineered a series of activities and encounters designed to encourage empathy and openness between sisters.
Together, “SisterFriends” take on the health care monolith and the “little sisters” personal situations, doing whatever it takes—from drug rehab and regular doctor’s visits to planning and problem solving—to ensure a healthy baby and a mother prepared for stable motherhood. This partnership goes beyond the practical aspects of healthier newborns. The “big sister” role is designed to help a young, pregnant woman take action towards protecting her baby’s health and future. The process of birth then becomes a moment of hope and pride for women who have had much more experience with failure. As a result, Kathryn’s work gives children the chance to be born to, and to grow up with, mothers committed to their health and well-being. And it positions black women across the country to speak for their sisters—women with no voice in their own health care system.
Support and hope may be hard to measure, but Kathryn’s results are not: The Birthing Project works. Birthing Project babies tend to weigh an average of 7.5 pounds compared to a 6.5-pound average for African American babies. This key indicator traces to gestation periods of 40 weeks compared to the 38 week-term babies that African American women deliver on average. Evaluations also show that Birthing Project women attend 80 percent of their prenatal appointments after being matched with a SisterFriend and 70 percent of their postpartum appointments, as compared to about 35 percent and 40 percent in the target population.
The Federal Commission on Infant Health places America’s infant mortality rate 36th among the nations of the world, higher than any other western industrialized nation. Among black women, the situation is even worse. In every major U.S. city, black babies die before their first birthday more than twice as often as their white counterparts.
The roots of this problem are complex but the prenatal health care system plays a clear role. Available services are not ethnically or culturally appropriate, user friendly, or comprehensive enough to address the multiple challenges that contribute to poor birth outcomes. A woman may be chastised for a drug problem, rejected by a clinic after missing an appointment, or simply alienated by the communication barrier between herself and a white clinician. Since poor outcomes are often rooted in self-destructive behavior driven by feelings of unworthiness, these roadblocks may be enough to drive a woman out of the health care system altogether until the point of birth. Teen and single mothers are especially isolated and vulnerable to falling into this trap. Moreover, a woman who is pregnant, homeless, using drugs, or recently released from jail may receive services from several agencies, none of which communicates or assists her with the full scope of her needs: Housing, drug recovery support, prenatal care, and emotional support. No single entity has the authority or mechanisms to coordinate services across agency lines.
Government programs have sought to remedy this host of problems. Over the past twenty years, the health care system has increasingly been seen as the locus for both the medical and social components of prenatal care, yielding some respite for women. Yet often this has led to an over-medicalization of even the simplest support functions. Some government programs have attempted to better coordinate care—assigning either a social worker, nurse, or simply a trained case-manager to the role. But these women are often not from the same community as the expectant mother and often care for a case-load of thirty women at any time.
Of course, the poor birth outcomes are symptoms of a much broader set of problems. Perhaps more importantly, the health care policy has not, and perhaps can not, effectively fix the broken social structures of black, inner-city America which lie at the very root of these problems. The breakdown of families and traditional social structures means that women don’t receive the emotional or social support that is necessary for any successful pregnancy. Young mothers are isolated, lack confidence and the knowledge they need to receive good health care, advocate for themselves, or even feel at a fundamental level that they deserve to receive good care or have the power to be successful in pregnancy. And birth outcomes represent a particular moment in the lives of women and children in broken communities. Mothers and babies go on to lives together under the same physical, emotional, and social conditions in which babies are born.
Birthing Projects are groups of women who partner one-on-one with at-risk, pregnant SisterFriends to mentor them through the labyrinth of prenatal health care. But at their core, Birthing Projects are a structured venue for black women to support each other with an outpouring of empathy and support which members of broken, inner-city communities lack. Kathryn skillfully weaves together these two functions at all levels of her work.
A Birthing Project begins when a single group leader gathers nine other women into a “bunch” that will prepare each member to befriend an at-risk pregnant woman—a “little sister”—from her first trimester to her child’s first birthday. The SisterFriend’s role is that of tough friend, patient mentor, and unconditional partner in helping a little sister access all the services she needs for a successful birth including drug rehab, housing for a homeless woman, navigating the Medicare paperwork, and all similar needs. A SisterFriend also acts as an ambassador, bridging the language and cultural gaps between health care providers and little sisters to ensure quality care.
To make this relationship work, Kathryn has created a training and technical assistance program that prepares women to become an emotional and practical support for her little sister. Kathryn has carefully designed a series of activities that facilitate openness and empathy in a community where toughness is often valued above all else. Before anything else, women together build a “quilt” of experiences and expectations, partnering in a series of activities to discuss the experiences and expectations that drew them to the program, and their general hopes and fears. These initial training sessions allow the group leader to get to know her sisters better and give members a sense of ownership over the continued learning and training program that they will build for themselves over the next eighteen-months. Each bi-monthly meeting held over the next two months has a ritualized opening and closing check-in which gives women the space to discuss any serious issues in their lives and pressing situations they are facing with their little sisters. This not only builds a support system for these women and makes them emotionally available for their little sisters, but it also allows them to model the behaviors and activities which they will then carry out with their little sisters as well.
On the practical level, women are oriented to the Health and Human Services (HHS) community to better understand the available resources for their little sisters. As a part of this technical assistance, the Birthing Project connects local Birthing Projects to government and citizen organizations that can be powerful allies in the quest for a better birth. SisterFriend groups might tap the March of Dimes capacity for training on the nutritional needs of pregnant women. At the services level, they learn how to navigate the range of public health care provider organizations and are assured that someone at these institutions will be available for problems faced along the way. The Birthing Project USA also opens doors at the political level to build support for the group’s community efforts.
The training program helps big sisters identify the types of barriers that little sisters face and the appropriate solution in each scenario. In some cases, the problem is programmatic and requires some extra effort or creative thinking—for example, a clinic that is only open during work hours or requests multiple forms of identification. In others, the barriers are systemic and more coordinated action is needed. It is here that that the Birthing Project goes beyond positioning individuals as one-on-one translators for their little sisters. Big sister groups, in their continued meetings, exchange notes on their experiences and identify common impediments to successful pregnancies. In the process, a group of voiceless women—the little sisters—come to be represented by a group of volunteers who understands their issues well enough to speak on their behalf. In one example, SisterFriends discovered that the nutrition program for pregnant women had a multi-month waiting period, rendering it essentially useless. Further investigation showed that a bureaucratic failing had left the state with fewer open spots in the program than intended; the sisters pressured the state Board of Supervisors to claim all of the designated spots, and ultimately made a significant impact in the availability of nutrition programs for pregnant women in California.
Kathryn has developed a structure for local Birthing Projects that ensures that the movement’s growth will not be hampered by a need for resources and will retain the community roots that make it effective. After initial training from Birthing Project USA, Birthing Project SisterFriends take responsibility for recruiting professionals to train them. Birthing Projects are responsible for raising their own funds and receive a template outlining partner organizations (e.g. the March of Dimes or Healthy Start), foundations, and other fundraising options that are appropriate for particular needs. Early on, Kathryn encourages groups to attach themselves to another entity or to exist as a loose coalition of women rather than incorporating formally as a 501(c)(3). She also helps groups keep fundraising to a minimum as they start, suggesting ways to cover baby showers, for example, with little money. As commitment grows and strong leadership emerges, groups may form their own nonprofit entities or begin more serious fundraising efforts.
Birthing Project USA has two tracks for expanding the number of local projects. Kathryn recruits women who contact her with an interest in starting projects in their communities and she targets recruitment in cities that have high infant mortality rates and extreme circumstances, such as post Katrina New Orleans and Memphis. In other cases, Kathryn is continuing the time tested approach that spawned the first 82 replications of her work by leveraging the celebrity status that her success has brought her in the black community to reach women across the country. Targeted appearances on media geared toward the black community will accompany a campaign to be launched and funded by a popular hair care product line for African American women.
Regardless of how an individual Birthing Project starts, there are critical elements that stay the same. A group begins when a single woman finds nine friends to join her and signs the standard Birthing Project agreement which outlines her responsibilities and those of the Birthing Project USA. Training begins when a member of the Birthing Project USA’s training team—someone who has run a successful group herself—spends several days with the group leader or with several group leaders, transmitting the basic values and training components of the Birthing Project. This may take place at the group’s location, or in Sacramento, where Kathryn’s own Birthing Project has become a demonstration and training site. Group leaders learn the rituals of the Birthing Project meetings, the quilting exercise that begins the training, and the tricks behind making successful SisterFriend matches. Other elements of the groups are flexible. Some are attached to a particular institution—a church, clinic, or community center—while others are based in a neighborhood or social group.
The Birthing Project USA is also developing a strong data collection and evaluation component. Unlike many fields, maternal and child health statistics can be gathered relatively painlessly and there are no long periods of waiting for outcomes. Moreover, on the national level and even locally, the public health system is statistics-based. Strong evaluations carried out by independent research institutes have been instrumental in the program’s success, and good data will be equally important for its growth.
Kathryn Hall Trujillo has lived much of her adult life walking between two worlds: The L.A housing project and Arkansas fields of her youth, and the windowed office of her work in public health. Long a translator between worlds, she has a created a program that allows black women all over America to take on similar roles. Kathryn was born to teenage parents and felt the strong pull of community in both L.A and Arkansas, where she was raised. By the age of fifteen, she was fully immersed in the civil rights movement, which had come right to her door; literally. Her uncle was the state coordinator for the Student Non-Violent Coordinating Committee and the Arkansas movement was directed from her grandmother’s kitchen. Kathryn spent the tenth grade on picket lines, in court, and in jail.
Soon after, Kathryn married and began having children. While still a teenager, she escaped from an abusive relationship and found herself living in a bus station with her two children. With time she pulled herself up, got a job, and eventually completed a Masters in Public Health at UCLA. This gave her a new world view, one that integrated economic, social, and political factors into health care. She began her professional life working for the California State Department of Health but quickly recognized its inefficiency and inability to bridge the gap between policy and reality: State programs are mandated to set policy, fund programs and collect data, but were not able to work directly with pregnant women to understand the barriers to care and prevent deaths and illnesses of black babies. She started the Birthing Project as a test initiative for the government to eventually fund. But the funding never came, and one day Kathryn found herself so involved in the Center for Community Health and Wellbeing, of which the Birthing Project was a part, that she never returned to her state job. The center grew into a robust one-stop location for clinic and social services under a single roof, and a Sacramento-wide public health program.
The Birthing Project was only one element of Kathryn’s successful work reforming the health care infrastructure of Sacramento, but it was an element that spread through word of moth and attention from the likes of Essence Magazine. For eighteen years, Kathryn has provided structure to the ad hoc expansion of the Birthing Project at 82 sites in response to requests that poured in from all over the country. Now, having established the needed health care structures for Sacramento and reached a new stage in her own life, Kathryn is preparing for the next stage in her work. In 2007, Kathryn left the operation of her Sacramento clinic and program to devote herself full-time to a strategic expansion of Birthing Project across the U.S.