Good afternoon, and welcome to the final installment of APA's Looking Beyond summer webinar series on maternal mental health. My name is Madonna Delfich, and I am a senior program manager in APA's Division of Diversity and Health Equity. Now, before we start, I would like to take a moment to humbly acknowledge that APA's headquarters stands on the ancestral lands of the Nacotchtank and Piscataway people. As we acknowledge and pay our respects to their elders past and present, let's take a moment to consider the many legacies of violence, displacement, migration, and settlement that bring us together here today, and commit to being a part of a comprehensive solution to address the intergenerational trauma for the descendants of these groups. I would now like to introduce our moderator, Dr. Lauren Osborne. Dr. Osborne graduated from Weill Cornell Medical College and received her psychiatric training at Columbia University New York State Psychiatric Institute. She completed both clinical research and she completed both clinical and research fellowships in women's mental health, and is an expert on the diagnosis and treatment of mood and anxiety disorders during pregnancy, the postpartum, the premenstrual period, and perimenopause. Dr. Osborne is an associate professor of OBGYN and of psychiatry, and serves as the vice chair of clinical research in the Department of Obstetrics and Gynecology at Weill Cornell Medicine. Her research on perinatal mental illness focuses on modules, models of care, and on biological mechanisms and biomarkers, with a focus on neurosteroids and the immune system. And she runs the psychoneuroimmunology and pregnancy and postpartum lab at Weill Cornell. Dr. Osborne's clinical work consists of collaborative care for perinatal mental health within OBGYN, and she's also the chair of the Education Committee for Marseilles, North America. She is the founder and chair of the National Curriculum in Reproductive Psychiatry, which is a free web-based standardized curriculum, and is an editor of the APA's textbook on women's reproductive health. Her work has been supported by the Brain and Behavior Foundation, the Doris and Duke Foundation, the American Board of Psychiatry and Neurology, the NIMH, the NICHD. So please join me in welcoming our esteemed moderator. Welcome, Dr. Osborne. Thank you so much. I'm really excited to be here today for what I think will be an invigorating discussion on a super important topic, the topic of weathering. And we have with us three amazing panelists who are going to really help set the stage for what weathering is and help us understand what its role is, particularly in maternal mental health. We're going to start off with Dr. Geronimus, who I believe is the person who coined the term weathering. So we're really honored to have her with us here today. Dr. Arlene Geronimus is a renowned public health researcher, professor, and she is the author of Weathering the Extraordinary Stress of Ordinary Life in an Unjust Society. That term weathering, which, as I mentioned, she coined, really is supposed to describe the effects of systemic oppression, which includes racism, classism, and other types of systemic oppression on the body, how that's manifested physically. Dr. Geronimus received her undergraduate degree in political theory from Princeton University and her doctorate in behavioral sciences from the Harvard School of Public Health. She also had postdoctoral training at Harvard Medical School. She is the winner of multiple awards throughout her career, most recently as the 2022 recipient of the James S. Jackson Distinguished Career Award for Diversity Scholarship from the National Center for Institutional Diversity. She serves as a professor in the School of Public Health and Research in the Institute for Social Research at the University of Michigan, and she's also affiliated there with the Center for Research on Ethnicity, Culture, and Health, and is an elected member of the Institute of Medicine of the National Academies of Science. So welcome, Dr. Geronimus, and we're all really excited to hear what you have to tell us today. Thank you very much. I'm very grateful to be here, and I'm very grateful that people are thinking about and trying to improve the concept of weathering, which I did coin about between 30 and 40 years ago and have done many studies since then that have helped me to develop the concept better and see the degree to which there is or isn't support for certain aspects of it. So I'm just going to start with just to be sure everybody knows something about weathering with just a very quick overview of what weathering is, with a specific focus on its implications for maternal health, both physical and mental. I mean, the mind-body connections are really not separable in the case of weathering, but I'll do my best to just talk about it without getting too much in the weeds, and I'm happy to answer clarifying questions afterwards if you'd like me to get more in the weeds. So simply put, weathering states or posits that the chronic stressors inherent in living in a racialized and inequitable society may cause Black Americans or other marginalized groups to experience the morbidity and mortality of white Americans or other dominant groups who are significantly older. So I do want to highlight that while in our country, and certainly my research focuses on Black Americans, weathering would happen to any member of any human member of an oppressed or marginalized group. We just happen to have an incredibly long history of severe marginalization and racism against Black Americans. And because of weathering, the other thing I want to clarify is age 20 doesn't equal 20, 35 doesn't equal 35, and 60 is even less likely to equal 60 across dominant and marginalized social identity groups. And I know that's a hard concept for people to absorb predominantly because we believe very strongly in our country that psychosocial and biological development sort of happens in a universal way. Other things can affect it, but there is some kind of true age effect that affects from immaturity to maturity to, I guess, senility, or in reproductive terms, I guess, menopause and old age. But weathering really challenges the primacy. It's not saying there aren't developmental contributors to aging, but the primacy of that in relation to what oppression does to the body for members of marginalized groups. So next slide. To give you just an illustration, we've done a lot of work since, you know, starting with data in 1976 through the present day, looking at maternal age-specific rates of very low birth weight by race in the United States. And I want to show you this slide, because I think it sort of tells you the whole story in a way. First of all, that it's not driven for Black women by our usual developmental model, which would say there'd be very high risks in the teens, and then lowest risks somewhere, say, in the mid to late 20s or early 30s, and then beginning to increase, you know, maybe in the late 30s and certainly 40s. What you see here, the Black curve is the top one, and the lowest risk age is in the teens. And then it goes up from there, so that the highest risk ages, you have a higher risk among Black women at every age, but the gap between Black and White women, so the inequity in rates of very low birth weight, get larger and larger with age. And so the white curve, which is the blue curve, somewhat supports a more developmental model in that the teens are higher risk, and then we have a very long period of very low risk, and then a slight increase again in the late 30s. But even that's not the U-shaped curve, or some people think it's a reverse J-shaped curve, that many people, for instance, in population sciences, in developmental studies, are led to believe dominates risk of very low birth weight. And we have the very same, next slide, please. We have the very same view for maternal mortality by age of mother. Again, the low, you know, disparities between, or inequities, I would say, between Black and White mothers, lowest in younger ages, and then increasing with age, so that again, for Black women, the risk of maternal mortality by age is lowest in the teenagers, and then begins to go up in the 20s, and later 20s, and 30s, and then late 30s, very high. Whereas again, for White women, there's really no evidence of any change in risk until the late 30s, and it's much more modest than what we see for Black women. So, next slide. And this has a lot of implications, or what explains this, as we've first positive, but have studied now, and have empirical findings to support, is that instead of increased maternal age, sort of measuring how mature you are, psychologically, or reproductively, instead, for Black women, the older you are, the more likely you are to enter pregnancy with chronic diseases, or develop them during pregnancy, and also fibroids, fibroids, amazingly, something like 50% of 25-year-old Black women already have fibroids, and then they are also much, tend to be more numerous and larger than in White women. It means that if you're, during pregnancy, you're more likely, and I'll explain why in a moment, to have your fetus deprived of nutrients and oxygen, and which can result in growth retardation, or because of the stressors that affect you as you live your life. This can also lead to preterm birth. As you age, your weakened blood vessels, due to weathering, increase your risk of hemorrhage and labor, which is a major cause of maternal mortality. Your immune system becomes dysregulated, which increases your susceptibility to infections during pregnancy, but also lengthens the healing time of tears and incisions that you might have as a result of the birth and delivery. It also means that you are suffering from a longer exposure to Black carbon pollution, lead, uranium, and that those also actually cross the placental barrier, where the fetus often kind of drinks them in like a sponge, so it begins some of the problems of environmental racism in the womb. Next slide. So what is weathering? Weathering is what happens to human bodies down to the cellular level when they grow, develop, and age in a systemically racist, classist, sexist, religiously intolerant, gender binary, or xenophobic society, and weathering leaves members of oppressed populations more likely to die or suffer chronic disease and health-induced disabilities long before they are chronologically old. And I also want to highlight that no matter their work ethic or how decently they live, even in part because of how hard members of oppressed groups work in the face of system-wide barriers, members of culturally sidelined, stigmatized, exploited, or impoverished groups weather. And through weathering, members of marginalized populations age young in response to chronic physiological stressors. Next slide. And this probably doesn't surprise anybody here that stressors are important to health and to pregnancy outcomes, but I want to highlight the structured stressors. These are not just that you're having a stressful day or a rough patch or you're a little burnt out. This is the ways that your ordinary life, if you're a member of an oppressed group, has been structured in ways by society that lead you to be chronically exposed to just a multitude of stressors. Now, we know many people have studied the relationship between material hardship and deprivation and health. We call that the social determinants of health. And similarly, we have growing knowledge of how ambient or toxic physical environmental exposures can impact health of oppressed groups. And that's under the rubric of environmental racism. But what weathering adds to these, those are very important. Both of those are very important, so I'm not questioning them, but they're very incomplete. What weathering adds to this is how structurally rooted biopsychosocial stress processes, including threats to social identity safety and the high effort coping they require, also contribute to weathering and to this chronic activation of the physiological stress process. So I'll focus on that if you'll go next slide. And so you can see because of all of these things, whether it's environmental racism, social determinants of health, or what I'm calling the biopsychosocial stressors, your social positionality says a lot about whether you'll weather and how severely you'll weather. Weathering is not just on or off. It obviously happens in degrees, both across populations. And within populations, there's obviously also variability. So whether your stress response is damaging over time depends on whether the stressors you face are acute or chronic. That's key. It's the chronicity. It's the unremittingness. It's all the different fists in the face from so many different sides that leads to the most severe weathering, whether you can achieve a satisfying outcome and in short order. So we all could come home from work one day and find our heat is out and maybe we're renters. And so we're stressed by that and we're cold. We're also physically stressed by that. And we call our landlord and he says, he'll get on it right away. And the next day you have people in there fixing your furnace. And maybe you're still a little stressed because you had to miss work to let them in, but it's all over in 24 hours. Let's say you're living in a high poverty, urban disinvested area. You come home, you have no heat. It's freezing because you don't also have, probably because of disinvestment, very good insulation in your house. And you call your landlord and it takes you forever to reach them or for them to call back with your 50 messages. And then they ask dismissive, but they'll take care of it. But then weeks go by, months go by, and it hasn't been taken care of. So you are stuck in a kind of not only being cold for long periods of time, but you're stuck in this prolonged cognitive and emotional engagement and having to be vigilant to keep reminding your landlord. And that's a chronic stressor. And obviously, whether you have sufficient health, social support, resources, or power to achieve a satisfying outcome is a big part about how long you need to be cognitively and emotionally engaged and whether you have reason to believe this will ever end. Meanwhile, you're thinking you can't be too big of a pest to your landlord because there's so little affordable housing. So you can see how there are so many levels of structural disinvestment and devaluing of you as a human being that go into this kind of chronic stress. And to the extent that you are marginalized culturally, residentially, economically, or politically, you are more likely to face chronic stressors, that is to be subject to weathering. Next slide. It's also, I wanna highlight, you cannot buy or educate yourself out of weathering completely because weathering is a function of exposure to these structurally rooted biopsychosocial stressors over time. And you're not immune to them from having a higher socioeconomic status. For one reason, your larger network and family may not have that larger status. And so, you're worrying about your mother who's living in the apartment that doesn't have enough, your elderly mother who doesn't have enough heat. And you still have to stay cognitively and emotionally engaged over a longer term. But also because there are stressors that happen within predominantly white neighborhoods, schools, and workplaces to which you're exposed. We've often called them things like microaggressions. I don't think there's anything micro about them, but it's beyond that. It's all the ways that you didn't get all the memos for how you're supposed to behave, that you have to be vigilant about your code switching. There's just a lot of ways where you, while you may yourself not be subjected to environmental racism in the nice neighborhood you can afford, you're still dealing with a whole range of stressors and you have effective ties and obligations and responsibilities to other members of your multi-generational family who are still exposed to the whole range of stressors. Obviously, weathering is a function of the strength of your autonomous protections to mitigate, resist, or undo them. It's very much a function of whether the larger society feels empathy, support, provides resources, or shares power, or validates you in the broader society. And also whether dominant groups feel any accountability as opposed to complicity in what they have done to help maintain these structures that lead to this chronic stress exposure. And so we also, when we're thinking about social justice, we have to think about the importance to health of recognition and restorative justice and not just distributive justice. We can make a dent in the worst effects of weathering through health and social policy. Certainly need to do those things, but really social change is needed for prevention. Next slide. Very quickly, the biological mechanisms through which weathering exerts its impact on people's health is that over time experience with repeated or chronic stressors and the high effort coping they require induce stress-mediated wear and tear on major body systems. Your neuroendocrine, cardiovascular, metabolic, immune, erodes your tissues, organs, and cells. It promotes plaque buildup in blood vessels, including the cardiovascular and cerebral vascular systems in the brain. It affects brain architecture and how that develops. And it may also contribute, this is still being studied, to dementia and regarding maternal health to fibroid development. Body systems become dysregulated or exhausted as cell integrity is violated, leading to accelerated biological aging and increased general physical and mental health vulnerability. And that vulnerability can be expressed, as I've noted, through many diseases, through chronic inflammation, obesity, early onset of chronic diseases like hypertension, poor maternal or infant health, autoimmune diseases, increased susceptibility to some cancers and to infectious diseases, to learning and memory problems, to depression and mood disorders. And often any individual who has been weathered suffers multiple morbidities, but in addition, there are multiple morbidities across their multi-generational families, which is its own source of stress and anxiety. Next slide. So in terms of mental health, there are some very direct impacts of weathering on mental health. Prolonged toxic stress exposure can result in a propensity toward anxiety, vigilance, and a low threshold for physiological stress arousal to become embedded. So this can result in enduring changes in brain architecture, such as enlarged amygdala, reduced hippocampus volume, and hair-triggered stress process arousal. This leaves people more susceptible to anxiety and mood disorders, including depression, and it also impairs one's ability to engage in cognitive processes and to learn. Now, we think of all of these as very bad things, and they are, but there's another way to also think about it at the same time, which is some people have forwarded the idea of having a stress-adapted brain, which can be protective if you're living or growing up in a high-risk environment. And in fact, there's many ideas that have developed across the last century or so in Black culture, which talks about how people need to have their head on a swivel, that's the constant vigilance to threat, or stay woke, which before became a more politicized term, literally just meant in sort of the late 1980s and early 1990s, that during those eras of the Black laws where you could be arrested for vagrancy just by being on the sidewalk, or you could get kidnapped and sent to coal mines and chain gangs, or terrorized through the Ku Klux Klan, et cetera, et cetera, people would admonish when others went out that they should stay woke, which again is a sign of chronic, they're telling them to be chronically vigilant to your surroundings, to what's happening around you, and to how you're code switching or how you behave in public. Next slide. Yeah, so the stress-adapted brain can lead to a low threshold for stress arousal as it increases vigilance, the recruitment of effective overcognitive neural networks on a chronic basis. It means you, in terms of when you're, say, having a baby, you have increased sensitivity to what we might call nicely poor bedside manner, and you also have increased benefit from gaining affirmation and reassurance in medical settings, and we've seen the positive effects, for instance, of doula attended births, especially doulas of the same background compared to just OBGYN attended births. As I said, the recruitment of effective neural networks over cognitive leads to susceptibility to stereo threat, which impacts your learning and performance, and over time, plaque buildup in the brain and the death of neurons, that sort of accelerated brain aging that weathering portends is problematic, and there's some evidence that Alzheimer's disease is also hastened and more prevalent among weathered people. On a societal level, this stress-adapted brain reaction can lead to negative recursive processes socially and politically as people get adversely profiled or diagnosed as angry, overreacting, or being snowflakes, especially, again, in predominantly white settings with a kind of smug naturalizing of an equity and then a feedback loop to have you need to code switch even more and remain vigilant. Next slide. Indirectly, there's all kinds of implications for weathering for mental health. It increases your risk of infertility, pregnancy loss, infant morbidity, and mortality, and all the mental health implications of those experiences. It means you may experience prolonged disability or members of your networks experience prolonged disability, and that increases your caretaking obligations and anxiety about their well-being. It means you're likely to be widowed or orphaned at much younger ages than the typical white American. It means you have to endlessly engage in high-effort coping, which leads often to a loss of resilience, reserve, and just sheer exhaustion. It means sleep disturbances and frequent experiences of loss, grief, and disruption of your autonomous protections. Next slide. And so I'm just gonna end without going more into weeds that I'm, again, happy to go into if people would like me to, that an important thing to remember is that in addition to material resources, health also comes from a sense of rootedness in an affirmation of cultural values, practices, effective ties, and beliefs that give life purpose and meaning, and also to have access, if you're a member of a marginalized or oppressed population to an alternative cultural framework to the dominant culture that marginalizes you. Next slide. So I wanna thank you, and again, if you'd like to know more beyond today, there are many scientific articles, and I've also written this book that came out last year that is meant to be accessible to a broad range of readers about weathering. So thank you. Thank you so much, Dr. Geronimus. What a wonderful introduction to the topic and to your fundamental work on this issue. I think what we're gonna do is go ahead and proceed to our other two speakers, and then we'll have time for discussion and questions at the end. Folks can be putting questions in the Q&A. I see we have a couple there already. Madonna, would you like us to do a few questions now or save them all to the end? We can save them to the end. Okay, so I'll keep track of them, and we'll have a discussion section at the end. So we're gonna proceed now to Dr. Baker as our second speaker, and I'm really thrilled to be able to introduce Dr. Baker, who's the executive director of the Center for Parent and Teen Communication at Children's Hospital of Philadelphia. She is leading that center as it continues working to ensure that every caring adult has the knowledge and skills to promote positive youth development and foster the kind of strong family connections that will position parents to raise youth with character. Dr. Baker holds a doctorate of public health degree from Drexel University, and she's trained as a community mental health counselor with her BA degree from the University of Pennsylvania and a master's in education from Temple University. She completed her postdoctoral training at the National Center on Fathers and Families at the Graduate School of Education and the School of Nursing also at the University of Pennsylvania. So I think you've hit every Philadelphia area institution. I can't go to any more Philadelphia schools. She's also working on a certification in health and wellness coaching from Rowan University. She has over 24 years of experience in designing, implementing, and evaluating community-driven and evidence-based prevention programs for vulnerable populations, both nationally and internationally. Her research has examined cultural and social phenomena of vulnerable populations and the ways in which health risks are defined and experienced. More specifically, her scholarship explores how community spaces are crucial for the implementation and sustainability of community health programs. Finally, as if that wasn't enough, she's also the CEO of a coaching company, a tribe called Fertility LLC for couples of color who need infertility and prenatal support. And she has a podcast, Maternal Health 911, which is a support system for BIPOC women and families who have endured fertility and maternal health issues. So I'm really excited to hear your contributions to this conversation on weathering. Thank you, Dr. Osborne, for the amazing introduction. I'm going to try my best to follow Dr. DeRonomis. I'm going to share my slides now. There might be some overlap between some of the things that I have here for us to discuss. So I'm probably going to pass along some of those things and go through them kind of quickly. The goal here is for us to do kind of a more, a case study discussion on how weathering actually affects black women in their daily lives. So I'm going to start my screen and I hope everybody can see it. So we're going to take, I want to do a case study with you all on a black woman whose name is Kim Anderson, and she is from Atlanta, Georgia. And really kind of demonstrating how weathering affects black women on a daily basis. So I always try to ask, why is this important? Why is this work important for all of us that are here on the panel? And infant mortality itself is one of the most important indicators of health with a variety of factors such as maternal health, quality and access to medical care, socioeconomic conditions, and public health practices. And I think a lot of us would think, okay, well here in the United States, that's one of the best countries that we could potentially be in, that we should kind of be leading with having less infant mortality in our society. But the reality is, and Dr. Jeronimus also displayed this, is that United States is not doing well at all regarding having these disparities for infant mortality decrease. And as you can see here on this slide, that of women of color have the highest infant mortality rates where black women are the highest. And if we go to the next slide in terms of pre- Dr. Baker, we're not seeing the screen. We're not seeing it. Oh no, wait a minute. Let's see. What about now? No, nothing. Oh, what is happening? It worked in our test run. It sure did. Hold on a second. Gosh, hold on. What is going on? Okay, hold on. Maybe that's why. Okay, what about now? Yep, yep. There we go. Okay, everybody can see it now? Yeah. Yes. Okay, yay. Okay, so let me go back. So infant mortality here in the United States. So we have 10% of black women who experience infant mortality. And these disparities have continued to actually increase. And if we look at preterm birth specifically, again, black women are at the highest with about 14%, close to 15% of live births. And so, and this is also new data from March of Dimes. So we wanna ask ourselves, what is actually happening in the daily lives of black women that when black women get pregnant that we have these potential outcomes that outcomes that we don't want to have when we get pregnant with our children. And so I'm going to play this video for you all. This is Kim Anderson's story on what happened when she was pregnant with her first child and then what was the outcome for her. The story of Kim Anderson, a successful Atlanta executive and lawyer illustrates exactly what David and Collins are talking about. We know that a healthy lifestyle should lead to a healthy baby. Women who eat well, exercise, get prenatal care, avoid alcohol and drugs and cigarettes are more likely to have a good pregnancy. But one of the best predictors for a healthy pregnancy outcome is higher education. This is a picture of me, May, 1984, when I graduated from Columbia Law School. People would think I'm living the American dream, a lawyer with two cars, two and a half kids, you know, the dog, the porch, a good husband, great family. I've always been lucky to have good health. Always ate well, exercise, never smoked. So when we look at Kim Anderson, a well-paid lawyer in good health, we would expect her newborn to be a healthy full-term baby. It didn't turn out that way. Back in 1990, when she was pregnant with her first child, Kim went into labor two and a half months early. I just wanted to know at least that if she was born alive, that at least we had a fighting chance. I heard her cry, thank God. But she was so small. I mean, you could like hold her in the palm of your hand. Kim's baby, Danielle, weighed only two pounds, 13 ounces when she was born. She joined the ranks of almost 300,000 low birth weight infants born in the U.S. that year. About one out of every 14 babies, all of them at a high risk of dying before their first birthday. I remember getting home and being in the bathroom and just, I fell apart. You know, because it's like, I didn't get to take my baby home, you know? I remember just sort of falling apart. In the terminology of social scientists, Kim Anderson's family enjoys high socioeconomic status, which increases the odds for overall good health. Persons who are higher in socioeconomic status, persons who have more income or more education or better jobs or more wealth, live longer and have fewer health problems than those who are lower in socioeconomic status. Education, for example, predicts infant mortality for both black women and white women. And the more educated you are, the less likely you are to have a low birth weight baby, a preterm baby, or an infant death. Women who are poorest and least educated are those whose babies are at greatest risk in any racial group. But the babies of African-American mothers with higher education are still at greater risk than we'd expect. Infant mortality among white American women with a college degree. Okay, I'm going to stop it there. So I wanted to, hold on a second. Let me pause that. Okay. Can everybody see my slides? I'll bring them back. Okay, here we go. Here we go. So in that particular story, some of the things that you hear from Kim are that she was educated. She went to Columbia Law School. She was married. She lives in a very affluent neighborhood. So all these protections that we think in everyday life, also that Dr. Geronimo has talked about, would you think would protect you and mean that your baby would be the healthiest as possible? But the kind of opposite is occurring for black women in our society to the point that where we are now is that regarding pregnancy related mortality in this country, black women are the most likely to die post childbirth and recent CDC data having black women at 41%. And this number is also not going down. It's still going up. And when we look at disparities over education level, pregnancy mortality rate for educated black women is higher in comparison to white women who have less education. So when we talk to people about these students, when I've had conversations with other kind of public health professionals, I think this particular phenomenon is really kind of hard for people to grapple with. And that makes a lot of sense. But what is really happening for black women and what all of us are in agreement in is that we're experiencing daily racism and stress. We are also experiencing structural racism and discrimination. And there are also social and economic factors that play a role. And as Dr. Geronimo also talked about higher rates of perinatal depression and also these higher rates of preterm birth among black women and black infants. And so these experiences are also for me was one of the reasons of why I started my podcast, Maternal Health 911, because I just found that the more black women that I've talked to that there was this kind of experience of with going to doctor's appointments kind of being dismissed by our nurse practitioners or OBGYNs or when you're pregnant and experiencing pain and your pain kind of being dismissed. And then just finding that this was something that experiences that were shared because sometimes you do feel like you're alone, but that these are collective experiences that black women are having when we do get pregnant. And so being mindful of these things are very important so that when we are pregnant and black women are pregnant that there can be some advocacy and that you can have a support system while you're pregnant. I have to also talk about the role of social determinants of health. So there are, as Dr. Ron has talked about as well, so if you live in a neighborhood where you don't feel safe and you're told to exercise and walk while you're pregnant, you may not be able to do that. If you have to take two buses to get to your doctor's appointment, then that might affect your prenatal care, how often you go, the quality of prenatal care. So these are a lot of things that always are not the fault of the individual or black women or black families, but realities that have to be considered when thinking about the fertility and maternal health outcomes of black women and black families and some of the struggles that they are dealing with and trying to navigate. Also in terms of just on a daily basis, Dr. Camara Phyllis Jones, who was one of my favorite researchers who was also in the video, she also talks about the different levels of racism that we experience, black women experience and people of color on a daily basis. So there's the institutionalized racism and that's differential access to services, the feeling of this being an inherited disadvantage. So again, it could be lack of access to prenatal health or to getting a doula that you don't have to pay for yourself, which doulas are game changers for birth outcomes of black women. Also personally mediated experiences. So if you go into a store and you're followed by someone because they think you're going to steal, so that's a personally mediated experience of racism. And then also just internalized of whether you feel hopelessness or the society's beliefs about black women and whether you're taking that internally, all those things have an impact on you every single day. So that by the time that you're pregnant, your baby in utero is experiencing and is affected by these racist and discriminatory experiences that women of color and black women in particular are having on a daily basis. And so if we really, I think together, together I think that it's going to be nurses, doctors, social workers, psychologists, public health professionals, community leaders. I mean, in order for us to really make a change in these disparities for black women and babies, the need for preconception care, improving the quality and access of prenatal care, expanding healthcare access over the life course. So really helping black women before they get pregnant, increasing involvement of black fathers, investing in community building, urban renewal and closing education gap, and also increasing the amount of doulas covered by insurance. Because as we all talked about, doulas are really making a difference in outcomes for black mothers and babies. So in closing, understanding the impact of weathering on the reproductive health of black women is critical in order for community, clinical health professionals, all of the leaders to develop effective solutions. And there really have to be policies, civic engagement, racial justice movements in order for us to see changes in birth outcomes for black women and babies. So thank you everyone. Thank you so much, Dr. Baker. It was a wonderful and powerful presentation. And we're gonna turn now to Dr. Ibrahim, and we do wanna make sure we have some time for discussion at the end. So we will try to stay on until a few minutes after the proposed end, which was one, we're gonna try to stay on till 110 to try to get some of that discussion time in. I'm really thrilled to introduce Dr. Ibrahim, who is a nurse scientist with over a decade of clinical experience working as a family nurse practitioner, providing primary care to underserved communities in urban and rural areas of the US and Canada. She's also a registered nurse in inpatient pediatric oncology and stem cell transplant. Dr. Ibrahim has experienced caring for women and their families as a doula and is a certified breastfeeding specialist. So rounding out many different roles in reproductive health. Prior to entering nursing, she worked as an anthropologist on international development projects funded by agencies such as the World Bank and the USAID. She holds her PhD from Yale University, a master's in nursing from the University of California and Los Angeles, a bachelor's in nursing from the Johns Hopkins University and a BA and MA in anthropology from Boston University. She completed an NIH funded Rural Health Equity Postdoctoral Fellowship at the University of Minnesota School of Public Health. And I'm really thrilled to introduce her today and get a third take on weathering. Thank you. Thank you so much for that nice introduction. And I'm so pleased to be here today with such an esteemed panel and thank you so much. So before I get started, I wanted to just say a word about language because we as clinicians and health equity scholars, what we say and how we say it is so important. So in order to ensure that everyone is represented and included, we use a gender additive approach to language such as using women and pregnant people in the hysteria lab, which is the lab I direct. And after a lot of listening to community members and exploring policies from leading organizations in multicultural societies, we heard many times that if we only use gender neutral language, we risk marginalizing or erasing the experiences of some women, millions of whom around the world still lack basic human rights. And we believe in human rights-based care and that we can add inclusive language to our current language without subtracting anybody. So sometimes for brevity, I will use only women, but it is used in the most inclusive of intentions. And so at this point, we know well about the maternal health crisis occurring in the United States. United States leads high income nations in rates of maternal mortality and severe maternal morbidity and women and birthing people from communities that have been historically marginalized such as black and indigenous women and those with low socioeconomic status are at disproportionately higher risk for negative birth outcomes for both women and their babies. And also right now, the leading cause of maternal mortality in the U.S. is maternal mental health conditions. And while black women are twice as likely to experience maternal mental health conditions, they are only half as likely to receive care. Other studies have reported similar data for other groups of racialized and low-income women. And one of the explanations for the inequities in maternal and infant birth outcomes is called weathering. And a huge thank you to Dr. Geronimax for her excellent introduction to weathering just now. I'll try to summarize very briefly that weathering refers the biological processes through which exposure to chronic stress for marginalization and discrimination and racism causes accelerated wear and tear on the body, essentially causing individuals from oppressed, marginalized and exploited groups to age faster on a cellular level. So their bodies are biologically older than their chronological age. This places them at a greater vulnerability to chronic disease, disability and shorter life expectancy. So importantly, an individual's health status depends more on their experiences and their interactions with others as well as the physical environment in which they live rather than on their DNA or their individual lifestyle choices. And this was sort of brought to light as well in Dr. Baker's case study. And one type of experience that is unfortunately too common is mistreatment of pregnant and birthing women and people. And this mistreatment can range from, as Dr. Baker spoke of, dismissing people's concerns, lack of caring as all the way to physical or sexual assault by care providers. And the rates at which marginalized folks were likely to experience the highest rates of maternal mortality and severe morbidity. And I would include under that maternal mental health conditions. Those people are the people who experienced weathering the worst. And they're also the same people who experienced mistreatment from their care teams during pregnancy and birth at the highest rates. For example, a couple of recent studies found that 20% of participants in a study of mistreatment across the perinatal period, so prenatal birth and postpartum care, reported mistreatment in their maternity care. But it was 30% of black, Latina and multiracial participants as well as 30% of participants with public insurance or no insurance. And another study that was looking specifically at mistreatment in the birth admission or birth period, found 13.4% of participants experienced mistreatment, but these rates went up exponentially for those who were LGBTQ+, those with Medicaid, those who were obese before pregnancy and those who were racialized. So a large cohort of folks who would be marginalized and experienced weathering experienced much higher rates of mistreatment. And so thinking about the experiences during pregnancy and birth, thinking about weathering, thinking about maternal mental health as the leading cause of death for moms in the United States right now, I developed a scoping review study to look at how life experiences during pregnancy and birth, how do they get under the skin and cause biological changes and cause weathering and contribute to maternal mental health conditions. So we really looked across three buckets, the experiences during the pregnancy and birth period, indicators of weathering, which I'll talk about a little bit later, but these included telomere length, epigenetic age and allostatic load and maternal mental health. And we focused really on postpartum anxiety, postpartum depression, and birth-related post-traumatic stress disorder, PTSD. So with the help of two medical librarians, we developed a scoping review search strategy, and my co-author and I screened 1,100 articles at the title and abstract level, 120 full-text articles, and ended up including 74 articles, which would have included at least two of those three buckets that I spoke about earlier. The exposures that we looked at were really the social context of pregnancy and birth. Did the participants have a birth companion? So it could have been a trained doula, could have been just another person, but someone dedicated to supporting the pregnant person during birth. Their birth experiences, their perception of their birth experiences, were they positive, were they negative? Did they feel like they experienced discrimination within the perinatal period? Their interactions specifically with their maternity care team, experiencing mistreatment, again, this was maternity care-specific mistreatment, as well as obstetric violence, which is often used in certain countries more so than mistreatment, but is similar in that it's negative care and negative treatment by the maternity care team, as well as stressors in the perinatal period or socioeconomic disadvantage. And we really looked at disadvantage, not just articles or studies that stratified by income. And the maternal outcomes we looked at, as I said, were postpartum anxiety, depression, and birth-related PTSD specifically. So on the next few slides, the solid blue circle indicates a study that had strong evidence for associations between the exposure and the outcome, which in this case is postpartum anxiety. So two studies had strong evidence between birth experiences and postpartum anxiety and showed that negative birth experiences increased rates of postpartum anxiety symptoms or diagnosis, and stressors in the perinatal period also increased rates of postpartum anxiety. On the next slide, you'll see there are these empty circles. So those are articles that looked at the associations, but did not find anything. So for postpartum depression, we also looked at what measures were used to identify the outcomes. And for postpartum depression, the most common measure used was the Enembra, the EPDS. And so there was pretty strong evidence for associations between negative birth experiences, experiencing mistreatment or obstetric violence, and increased stressors and decreased socioeconomic status were all associated with increased postpartum depression. And interestingly, discrimination was not associated with postpartum depression, but I think this is potentially due to the fact that those who were discriminated against would be less likely to go to their postpartum appointment because of a lack of trust in their care team, and so be less likely to be diagnosed with PPD rather than actual rates being lower. And then for birth-related post-traumatic stress disorder, PTSD, the most common measure used was the Citi Birth Trauma Scale. And increased PTFD symptoms or diagnoses were associated with negative birth experiences, experiencing mistreatment or obstetric violence, stressors and lower SES, and conversely having a birth companion or doula, or a supportive hospital staff during the birth decreased rates of birth-related PTSD. So that also goes back to the stress-trained brain and being more susceptible or amenable to support and care during a medical encounter. And so we also looked at measures of stress and weathering, looked at allostatic load, epigenetic age, and telomere length. There were many fewer studies looking at these, and the results were a little more mixed, but we did find that postpartum depression did have an association in some studies with telomere length and also inflammation, which is related to weathering and increased stress and allostatic load. Postpartum anxiety had associations with inflammation. And so these are like biological markers for inflammation. And then epigenetic age and stress also had associations, but there's definitely a lot more work that can be done in the biological measurement area. But in summary, the review presented evidence for associations between experiences in the perinatal period, indicators of weathering and maternal mental health conditions. And from here, we can really go on to explore further causes of maternal mental health inequities, as well as to develop interventions and policies to reduce weathering and its resulting effects on the health and life expectancy of our most marginalized folks. So thank you so much, and I will stop sharing and pass it back to Dr. Osborne. Wonderful, thank you so much. And I think you played right into one of the questions that we had in the chat, which was to think about what are the, how do we specifically link this to maternal mental health as opposed to those physical health conditions? And so I think you gave us a compelling case for that, which is great. There are a few questions in the chat. I'm going to encourage folks in the audience to put things into the Q&A, not the chat, but the Q&A. And I'm going to start off with those questions that we have there. And we may, if we don't get to all of them, we can jump in and answer some of them online. But one intriguing question, this happened during Dr. Geronimus' talk, was whether we see parallel data when we look at native populations affected by European colonization. And I'm curious of what we know about that evidence. There is less study of that for a whole range of reasons, including issues with data and the limitations of studying things scientifically or quantitatively. However, there's some evidence for it. Theoretically, one would expect it. And there's a lot of qualitative evidence to suggest whether it's through historical trauma, whether it's through poverty, whether it's through having many reservations near things like uranium mines. I mean, so it's such a range of things that would weather, that one would expect to weather, and there's some evidence of weathering of native populations. Thank you. We have another question that says, the theory of the wide physiological and psychological effects of weathering is quite convincing, but what is the evidence? And I think that came relatively early on. You all did cite a bunch of the evidence that supports this, but I wonder if any of you could expound a little bit more on the specific evidence tied to these specific psychological and physiological markers. Well, as I mentioned, I've been studying this for almost 40 years. I have probably more than a hundred scientific articles. And I tried to summarize a lot of that in an accessible way in my book. It would be hard to just pick up one thing to tell you the evidence. Someone had asked, I think, in the chat before about some of the evidence on the maternal age patterns of birth outcomes. I can put in the chat, the most recent study, which was published last year in health affairs on the low birth weight parts. And then another study is embargoed at the moment, but it shows some maternal mortality research, but those are also covered at least to a degree in the book. So there's actually a lot of evidence, but people haven't done, there's been a real shift in people being interested in actually reading the evidence or in contributing to the evidence. And so I think that itself is structurally, one could argue is structurally racist. It's a kind of complete erasure of the lived experience of certain people in the United States and the sort of dominant ideas that all that matters are things like development or money, income and education. Again, all those things do matter. Not trying to say everybody was wrong before, but they're not the only and maybe not even the dominant issues that affect the health and wellbeing of marginalized groups. Great, we've got another question about the immigrant health paradox and studies that have shown that individuals who immigrate to the U.S. have relatively better health outcomes than U.S. born individuals. And I know that there's been studies showing that it gets worse and worse the more generations you have in the U.S. So how does weathering play or not play a part here? It plays a profound part. And we studied this and some of our studies are directly about this. For one thing in terms of the immigrant health, first original immigrant health paradox which was that the immigrants are less likely for instance to have low birth weight babies than native born Americans. That reflects weathering because people for several reasons, including that immigrants are, first of all, they tend to be selected for people who are healthy and who have the means, either psychosocial means or material means and practical means to immigrate. It also is because they have grown up in a, there may be different kinds of racism and discrimination in their native countries but it's not the American version. So they have developed, they're a little bit not fluent in American racism and they also tend to live in ethnic enclaves where they're protected a lot from American racism but their children and grandchildren start looking more and more of having the outcomes of black Americans. And so a theory, and we've done some research on this, is that sort of exposure, the more you've been socialized and become fluent in American racism, the longer you've been in the country, these original protections get overrided or have less impact on you when you start to see, and we've done a lot of work. While we haven't done a lot on native Americans, we have done quite a bit on Latinx populations and there's a lot of evidence that they, whether to including the original immigrants, if they've been in the United States a long time, despite having, despite they and their children and grandchildren having higher socioeconomic status than your typical first, newly arrived immigrant. So I don't think it's despite it, I think it's partially because of that, because of becoming more fluent in American racism and facing more need to be vigilant by being in more predominantly white situations. Okay, thank you. All right, we're gonna close up with one last question, which is a question about whether there are any protective factors. So childhood's a unique place, the brain is developing, are there, is there evidence about the protective effect of safe nurturing relationships in weathering? So I think we saw from Dr. Baker some evidence that there's a lot of things that we might expect to be productive, like education, supportive marriage, that don't necessarily have a protective effect, but is there any evidence about protective effects? Should I just keep answering for it? Go ahead, Dr. DeRoges. Yes, is the short answer, but it's not necessarily the dominant model of what nurturing is. There's cultural differences and also class differences what's possible for being nurturing and who you can depend on in part because of weathering. So that for instance, if you're raised in a nuclear family, in a very weathered population, I know this will sound again, a lot of things about weathering are counterintuitive. And I think that's because of, we've erased other lived experiences and just don't see or acknowledge them. But where you need to look for that nurturing may be an extended kin network, may be a multi-generational family rather than just the mother and father. So a lot of interventions that are meant to teach parenting and teach that to just the mother and father will probably miss the mark, at least in part. The other thing is a kind of nurturing black children need is different in the sense of not just because their family structure may be different, but also because they're dealing with racism. So probably everybody here understands about the talk and the things you have to include if you're gonna be a nurturing caregiver to a black child. But there's more than that. You need to help with instilling pride. You need to help in having what I called an alternative cultural framework to the one that marginalizes you. You have to have your networks, not weather as much so they can live till you grow up. There's just, it's just, again, nurturing is obviously incredibly important, but we have to define it more broadly and more so in a more socially situated and culturally situated way. I agree with Dr. Animas wholeheartedly. And I think just in terms of just the lived experiences of black parents and black families. And it's not to say that when you're pregnant that having a partner doesn't matter because having a partner, of course, does matter because you need somebody to be able to support you, maybe somebody to go to your doctor's appointments with you, but it's just the regular, I guess, everyday checkbox items that don't necessarily protect you from the risk of dying or your baby dying. But what is needed is that there is support, there is social support. If you need to have someone go with you to every doctor's appointment so that if you can't advocate for yourself, if it's your partner, your mother, your mother-in-law, your best friend, your aunt, someone, your auntie, I think those things are also critical. And that also with people of color having to deal with their own daily experiences of racism and discrimination on top of everything else that they're doing. And also as Dr. Giroir said, also now you have to teach your children on a daily basis how to manage racism and discrimination. And be able to cope with those on a daily basis as well. Great. All right, I see we have one more question about the immigrant paradox, but we'll have to answer that by typing the answer. I think we are out of time. I'm gonna turn it back over to Madonna to close us out here. Thank you, Dr. Osborne. Thank you all for joining us this afternoon for sticking with us for the extra time that we added on. And a very, very special thank you to our esteemed panel of experts. This was an amazing, amazing webinar. You've all shared some invaluable insights with us today that I'm sure our attendees will find as a value add and they'll be able to take it on and put it into the work that they're doing. So again, thank you all for joining us this afternoon. And if you missed any of the maternal mental health webinars this summer, they will be available for free on www.psychiatry.org. And you can also access the entire Looking Beyond catalog through APA's Learning Center. So again, thank you so much and enjoy the rest of your afternoon. Take care.

maternal mental health

weathering

systemic oppression

Dr. Arlene Geronimus

chronic stress

Black Americans

systemic racism

maternal mortality

mental health challenges

Dr. Marsha Baker

Dr. Nadia Ibrahim