Black women have long faced higher odds of pregnancy and delivery complications—and many have died as a result. In 2018, the issue received headlines when two celebrities experienced life-threatening childbirth complications: professional tennis player Serena Williams developed blood clots in her lungs following an emergency C-section while superstar singer Beyoncé Knowles-Carter was on bed rest due to preeclampsia prior to her own emergency C-section.
Alarming stories like Knowles-Carter’s and Williams’ are more than familiar to Leanne Yinusa-Nyahkoon, a clinical assistant professor of occupational therapy who has devoted her career to health disparities research.
Yinusa-Nyahkoon (CGS’98, Sargent’01,’03,’09) began her career in pediatric occupational therapy serving diverse urban communities. Early on, she noticed the children she treated were predominantly Black. She wondered, “Is this just a coincidence that all these children have these learning, physical, or intellectual disabilities? Or, is there an underlying factor?”
—Leanne Yinusa-Nyahkoon
During her doctoral studies at Sargent, Yinusa-Nyahkoon investigated the ecological barriers contributing to racial disparities in childhood asthma. She uncovered a common, underlying thread of social forces that include systemic racism, discrimination, and judgment from healthcare providers, and clients feeling alienated within healthcare settings. Those findings launched a career devoted to studying health disparities that disproportionately affect urban Black communities.
A FAMILIAR CHALLENGE
After graduating with her doctoral degree, Yinusa-Nyahkoon shifted her focus—slightly. “The opportunity arose to do similar work, but to look at birth outcomes and the factors that have plagued Black women for decades,” she says.
Pregnancy and birth outcomes, including maternal mortality, preterm birth, low birthweight, and infant mortality, disproportionately afflict Black mothers and babies in the United States. After studying developmental disabilities and asthma, examining birth outcomes “was just continuing the thread,” says Yinusa-Nyahkoon. “It’s still the same underlying factors.”
Yinusa-Nyahkoon says her work is guided by the American Occupational Therapy Association’s Occupational Therapy Practice Framework, which emphasizes addressing the natural and physical environment. It also encompasses attitudes, products and technology, support and relationships, and services, systems, and policies. “It’s not just about the environment in your home or the physical structures that surround you. But really, in the social environment that you interact with every day,” Yinusa-Nyahkoon says. Income and educational inequities, the criminal justice system, racist housing policies, poor infrastructure in neighborhoods, and the dearth of Black healthcare providers are some of the many social factors that lead to disparities in maternal, infant, and child health. These forces, she says, contribute to young Black women having little to no access to needed products and technology, inadequate supports and relationships, skeptical attitudes about healthcare, and services, systems, and policies that were designed without them in mind.
MEET GABBY
Yinusa-Nyahkoon’s opportunity to study birth outcomes came in 2009, when she joined the Gabby System project. Gabby is an embodied conversational agent: an animated, virtual character that assesses the health of young Black women and delivers evidence-based health information to address individual needs and guide health behavior change. When the program first launched, the Gabby team recruited Black women who were healthcare providers or students in health professions to test the system. “We really needed someone with some perspective about health to give us concrete information about what to add, what to fix, and how to tweak it,” Yinusa-Nyahkoon says. Gabby is now being implemented in 12 urban and rural communities across the United States.
The Gabby System project uses an embodied conversational agent to address maternal and infant health needs earlier in pregnancies.
One of the motivating factors for creating Gabby is that prenatal care may be addressing maternal and infant health too late. Health behavior change often takes longer than the prenatal period, and according to the United Health Foundation’s America’s Health Rankings, an estimated 30–45 percent of pregnancies are unintended or mistimed. That means that the preconception care provided by the Gabby System presents an opportunity to intervene during a critical window.
The goal of the Gabby System is to improve young Black women’s overall health and the likelihood of having a healthy pregnancy and delivery. “The point of Gabby is not to replace the provider, but to facilitate conversation and fill in the gaps in the clinical encounter,” Yinusa-Nyahkoon says. It empowers women and “provides them with evidence-based information to get them thinking about their health or potential questions they could ask providers.”
—Leanne Yinusa-Nyahkoon
“One of the key strengths of Gabby is how comprehensive it is,” says Kylie Woodall (’21), an occupational therapy doctoral student on Yinusa-Nyahkoon’s research team. “There’s over 100 different factors that it can assess for, and then it has the ability to figure out which factors may be most relevant.”
The program is currently focused on three main birth outcomes: infant mortality, preterm birth, and low birthweight. “We’re making a transition to also focus on maternal mortality, because those numbers are appalling,” Yinusa-Nyahkoon says.
In the United States, Black women are currently three to four times more likely to die of pregnancy or delivery complications than white women. These stark disparities in adverse birth outcomes are inextricably linked to implicit bias and poorer quality of medical care. The healthcare field needs “to recognize that anti-Black racism, not race, is the driving factor behind these health inequities and that this health crisis cannot be addressed without critically working to examine and dismantle racism and bias in healthcare and society at large,” says Woodall.
Adverse birth outcomes among Black women are also linked to stress caused by the cumulative impact of repeated exposure to racial discrimination, commonly known as weathering.
“A huge contributing factor is a lifetime of stress and just the burden, to be very frank, of being Black in America,” Yinusa-Nyahkoon says. “That just weighs on the body’s system and unfortunately affects birth outcomes.” This complex problem even extends across income and education levels. “Recent data tell us that the worst stats are of Black women who have a master’s degree or higher, which negates the argument that it’s just a socioeconomic issue,” she says.
Yinusa-Nyahkoon’s interest in this research is, in part, personal. “As a woman who identifies as Black and has given birth four times, I feel the burden and I felt the pressure every time because I knew my outcome was never supposed to be good,” she says. “I would like all of us, in light of COVID-19, in light of Black Lives Matter, to actively demonstrate that, from the womb, Black lives do matter. We all need to work toward creating equitable outcomes.”