Tag: Pregnancy

Being Black and Pregnant in the Deep South Can Be a Dangerous Combination

O’laysha Davis was a few weeks shy of her due date when in mid-August she decided it was time to switch doctors.

Davis had planned to give birth at a small community hospital about 20 minutes from her home in North Charleston, South Carolina. But that changed when her medical team started repeatedly calling her cellphone and pressuring her to come to the hospital and deliver the baby.

Davis said she’d told her doctor on more than one occasion that she was opposed to inducing labor early. Eventually, she reached her wits’ end.

“It was ridiculous,” said Davis, 33. “I don’t feel heard most of the time. I feel like it’s their way or no way, you know? Like you don’t have a choice.”

Davis had given birth twice before and knew from experience that Black women, like herself, and their infants face higher health risks during pregnancy and childbirth. In 2021, Davis lost a baby in the womb after a dangerous pregnancy complication in her first trimester.

“I was very fearful that the same thing would happen,” Davis said when she found out in late 2022 that she was pregnant again.

Her fears weren’t unfounded. Across South Carolina, Black infant and maternal deaths are troubling. About an hour and a half northwest of Charleston in Orangeburg County, the infant death rate was the highest in the state in 2021. Higher, in fact, than it was 50 years earlier in 1971, according to data KFF Health News obtained via a Freedom of Information Act request from the state health department. All but one of the 17 infants who died in 2021 in Orangeburg was Black.

Statistics like this scared Davis. But it was a horror story out of Georgia that really caught her attention: In July, a Black infant was decapitated during delivery by an obstetrician who allegedly used excessive force. Davis was eight months pregnant when the news broke.

“Something’s terribly wrong,” she recalled thinking.

A close-up portrait of O'laysha Davis. Her face is slightly obstructed from view by a sheer curtain.
During the final weeks of her pregnancy, Davis repeatedly refused when her doctor wanted to induce labor. (Gavin McIntyre for KFF Health News)
O’laysha Davis holds hands with her daughter, Journee.
Davis ended up switching both doctors and hospitals, found a doula, and gave birth at the Medical University of South Carolina a few days before her due date. (Gavin McIntyre for KFF Health News)

‘Moving in the Wrong Direction’

Being Black has always been dangerous for pregnant women and infants in the South. The origin story of modern reproductive medicine can be traced to experiments conducted on Black enslaved women in Alabama during the 1840s by physician J. Marion Sims, the so-called Father of Gynecology, who subjected his patients to painful pelvic surgeries without anesthesia and drugged them with opium.

Sims, a native South Carolinian who is memorialized on the Statehouse grounds in Columbia, is credited with inventing an early version of the vaginal speculum, which he designed after probing an enslaved woman named Betsey with the bent handle of a spoon.

Fast-forward nearly 200 years, following a legacy of systemic discrimination that has prevented some Black families from getting health care: Poor outcomes for Black women and babies across the United States are alarmingly high compared with white patients.

These problems aren’t unique to the South. In places such as Kansas, Arizona, and Wisconsin, for example, Black infants die at more than double the rate of white babies. In Flint, Michigan, where more than half of residents are Black, the infant mortality rate for all babies in 2021 exceeded the rate in any Southern state.

But in Deep South states like South Carolina, Louisiana, and Mississippi, infant mortality rates in rural counties, especially for Black babies, often resemble those in much poorer parts of the world.

O'laysha Davis looks out a window in her home. A sheer curtain blows in the wind in front of her figure.
“I don’t feel heard most of the time,” Davis says. “I feel like it’s their way or no way, you know? Like you don’t have a choice.”(Gavin McIntyre for KFF Health News))

Things are poised to get worse. More than one year after the U.S. Supreme Court issued its decision in Dobbs v. Jackson Women’s Health Organization, allowing state legislatures to outlaw abortion, most states in the South have passed either full or partial bans. Both research and preliminary data suggest this will further jeopardize Black women and babies.

In 2021, 42% of all reported abortions in the United States were obtained by Black women, accounting for a larger share than any other race, according to KFF data. And more than half of all Black Americans live in the South, where many of the country’s strictest abortion policies were enacted this year and last.

Already, birth rates in states that banned or restricted access to abortion have increased since the Dobbs ruling. State-level abortion bans will undoubtedly prove fatal for some people, particularly Black women and children, who are more likely to die before, during, and after childbirth than white women and children.

“There is so much anger,” said Kelli Parker, director of communications and marketing for the nonprofit Women’s Rights and Empowerment Network. “This type of legislation uniquely impacts women of color and other historically marginalized groups.”

In Texas, for example, infant mortality data from the Department of State Health Services shows the number of babies who died during their first year of life significantly increased after lawmakers passed a six-week abortion ban in 2021, according to data obtained by CNN through a public records request. In Texas, Black babies die before their 1st birthday at a rate more than twice that of white infants. That’s because the health of the mother often translates to the health of the infant, and Black women face much higher pregnancy risks, such as high blood pressure, stroke, and hemorrhage.

In South Carolina, where the state Supreme Court upheld a ban that outlaws abortion if fetal cardiac activity can be detected, non-Hispanic Black infants are also more than twice as likely to die during their first year than non-Hispanic white infants. And the state’s Black infant mortality rate increased by nearly 40% from 2017 to 2021.

Meanwhile, non-Hispanic Black women in South Carolina experienced a 67% higher pregnancy-related mortality ratio compared with their white counterparts in 2018 and 2019, according to the latest data from the state’s Maternal Morbidity and Mortality Review Committee.

“We have a lot of work to do,” said Sarah Knox, senior director of policy and advocacy at the nonprofit Children’s Trust of South Carolina. “Unfortunately, our latest data shows we are moving in the wrong direction.”

Most states haven’t released infant and maternal death data that reflects the impact of the Dobbs decision. But maternal health experts aren’t optimistic.

A KFF survey conducted this year of 569 OB-GYNs found that most doctors reported the Dobbs decision has worsened pregnancy-related mortality and exacerbated racial and ethnic inequities in maternal health.

But Dobbs isn’t the only factor. Across the South, public health experts point to a confluence of things: the closure of rural hospitals, the scarcity of doctors and midwives, the pervasiveness of obesity and chronic disease, and many states’ refusal to expand Medicaid under the Affordable Care Act.

In many cases, though, the intersection of poverty and structural racism in medicine is to blame for the deaths of Black women and their infants.

A KFF survey released this week found Black patients regularly said their health care provider assumed something about them without asking; suggested they were personally at fault for a health problem; ignored a direct request or question; or refused to prescribe them pain medication they thought they needed. More than half of all Black respondents also said they prepare to visit their health care provider by expecting insults or by being very careful about their appearance — or both.

“People are tired of being bullied by their providers,” said Tiffany Townsend, a midwife and the owner of De la Flor Midwifery in Columbia, South Carolina.

In the KFF survey, Black women reported the highest rates of unfair treatment, with 1 in 5 saying a health care provider treated them differently because of their racial or ethnic background. And about twice as many Black adults who were pregnant or gave birth in the past decade said they were refused pain medicine they thought they needed compared with white adults.

The nation’s Black maternal mortality rate is almost three times as high as the rate for white women. Townsend, one of the few Black midwives practicing in South Carolina, said that’s because doctors often ignore their patients’ complaints until it’s too late.

“They don’t listen,” she said.

A portrait of infant Journee Davis in her mother's arms.
Davis had given birth twice before and knew from experience that Black women, like herself, and their infants face higher health risks during pregnancy and childbirth.(Gavin McIntyre for KFF Health News)

‘Using Their Voice’

In March 2012, Kim Smith was about 22 weeks pregnant when she felt an “unbelievable pain” in the upper-right side of her abdomen. She was immediately admitted to a hospital in Lexington, South Carolina, where she was diagnosed with HELLP syndrome, a severe case of a pregnancy condition called preeclampsia, which is marked by high blood pressure. She’d been tested for preeclampsia a few weeks earlier and the results were negative.

While the preeclampsia rate is much higher among Black women than white women, the diagnosis still came as a shock to Smith, who liked to run, taught aerobics classes in college, and thought of herself as a healthy person. She hadn’t considered the possibility of a high-risk pregnancy.

“I was placed in a wheelchair and rushed to get an ultrasound,” she remembered after arriving at the emergency room. The first ultrasound showed a faint heartbeat, but within a few minutes, it had stopped. Smith was prepped for labor and delivery, but it was too late. The baby she had named Lauren Kelly didn’t survive.

More than half of all 516 fetal deaths reported that year in South Carolina were linked to Black mothers.

The loss of her daughter devastated Smith. She has since given birth to three boys and channeled the pain of her first pregnancy into the development of a patient navigation app called “Lauren,” funded by the South Carolina Research Authority, which she hopes will be used to spare other women from a similar loss.

The app is designed to allow pregnant and postpartum women to track their stress levels and vital signs, including their blood pressure, and to automatically relay those readings to their physicians. While not a diagnostic tool, Smith intends for the app to empower patients with real-time information so they can identify potential problems early and use it to advocate for themselves.

“You have to use your voice. You have to speak up,” said Smith, who wants the Lauren app to be made available free to pregnant women enrolled in Medicaid. “I’m still finding that people are not using their voice when they go into the doctor’s.”

O’laysha Davis holds up her infant daughter. The photograph is framed so that you see O'Layasha smiling at her child, while the baby's back is to the camera.
Davis avoided an induction. She felt the first pains of labor at home and then delivered Journee at the Medical University of South Carolina on Aug. 31.(Gavin McIntyre for KFF Health News)

New Research

Across the South, researchers are trying to identify solutions to improve health outcomes for mothers and babies. “Nothing seems to be moving the needle,” said Joseph Biggio, a maternal-fetal specialist at Ochsner Health in New Orleans.

The National Institutes of Health recently awarded Ochsner Health and its partners a $16.5 million grant to establish the Southern Center for Maternal Health Equity to address Louisiana’s high maternal mortality rate. Part of that research will involve finding ways to deliver care in rural parts of the state where hospitals have closed, high-risk specialists don’t exist, and pregnant women are disproportionately Black.

Biggio said the new research center will also compare birth outcomes in Louisiana to those in neighboring Mississippi, where infant and maternal mortality rates are the highest in the country, according to the Centers for Disease Control and Prevention.

A key difference between these two Deep South states: Lawmakers in Louisiana have expanded access to the Medicaid program under the Affordable Care Act, while lawmakers in Mississippi haven’t.

Women in most states who qualify for Medicaid during pregnancy are also covered for 12 months after they give birth. But every year, many childless women in Southern states are not eligible for the low-income health insurance program until they become pregnant. Medicaid expansion, as it was designed under the Affordable Care Act, would fill this gap by loosening eligibility restrictions, but most states in the South haven’t adopted the expansion.

Some health care policy experts believe that covering women before they become pregnant and between pregnancies would reduce the burden of obesity, diabetes, and hypertension, and the risks those conditions pose to women and infants.

Tracking long-term improvement is crucial because success won’t be achieved overnight, said John Simpkins, president of the North Carolina-based MDC, a nonprofit focused on improving racial equity and economic mobility in the South.

“If we’re talking about population health improvements, then really the intervention should be beginning with kids who are being born right now, and following them through adulthood, and then probably their kids,” Simpkins said. Medicaid expansion, for example, could raise families out of poverty, but those benefits might not be realized for another generation, he said.

“I’ve found that the things that work the most are sustained investment over time,” he said.

But this work isn’t relegated to the South. In the majority-Black city of Flint, Michigan, for example, researchers are poised to launch in 2024 a multiyear project called Rx Kids to determine if direct, unrestricted cash payments to pregnant women and new moms improve birth outcomes.

“This is standard in other countries. This is common, basic sense,” said Mona Hanna-Attisha, a pediatrician and the associate dean of public health at the Michigan State University College of Human Medicine, who is leading the Flint research.

Poverty tends to peak just before a woman gives birth, she said, and the project in Flint will attempt to offset that hardship by offering every woman in the city who becomes pregnant, regardless of race, a payment of $1,500 at the halfway point of her pregnancy and then an additional $500 a month during the first year of her infant’s life, for a total of $7,500.

“This is designed to address this critical window, both economically and neurodevelopmentally,” Hanna-Attisha said. “It’s fundamentally how we are supposed to take care of each other. And it is not revolutionary.”

O’laysha Davis, standing in front of a window, holds her infant daughter in a gentle embrace.
“I labored at home,” Davis says, “which is what I wanted to do to begin with.”(Gavin McIntyre for KFF Health News)

‘Extra Bad for Black Women’

Back in Charleston, the first seeds of concern had been planted during the first half of O’laysha Davis’ pregnancy when, she said, an OB-GYN prescribed a drug to control high blood pressure. She’d declined to take it — against her doctor’s guidance — because her blood pressure is normally “up and down,” she said. It wasn’t unusual for her reading to be high at the doctor’s office and normal at home, a common phenomenon known as “white coat hypertension.”

But high blood pressure during pregnancy, if left untreated, can be fatal for moms and babies. Along with medication, Davis’ doctor recommended delivering the infant a few weeks before her due date to avoid complications.

It wasn’t necessarily bad medical advice, but Davis feared the risks associated with inducing labor early, knowing that babies born after 39 weeks of gestation are generally healthier.

“I’m not getting an induction. Don’t schedule me,” she told the doctor.

Her OB-GYN scheduled one anyway. But on the morning of the scheduled induction, Davis received mixed messages from the hospital. First, there wasn’t a hospital bed available, so they told her not to come in. Later that day, though, in phone calls to Davis and her emergency contact, they advised that she come in immediately.

Finally, Davis said, she lost trust in her medical team. Compelled to find someone who would listen, she Googled the names of midwives in Charleston.

Davis reached midwife Nicole Lavallee by phone.

“I have the same conversation multiple times a week,” Lavallee said, with women who feel their medical team has stopped listening to them. “It’s extra bad for Black women.”

Lavallee connected Davis with a doula, then helped her make an appointment at another birthing hospital in Charleston.

Davis avoided an induction. She felt the first pains of labor at home and then delivered her baby — a girl named Journee Divine — on Aug. 31, a few days shy of her due date, at the Medical University of South Carolina.

“I labored at home, which is what I wanted to do to begin with,” she said. “I’m going to do it my way.”

Backlash to Affirmative Action Hits Pioneering Maternal Health Program for Black Women

For Briana Jones, a young Black mother in San Francisco, a city program called the Abundant Birth Project has been a godsend.

Designed to counter the “obstetric racism” that researchers say leads a disproportionate number of African American mothers to die from childbirth, the project has provided 150 pregnant Black and Pacific Islander San Franciscans a $1,000 monthly stipend.

The money enabled Jones, 20, to pay for gas to drive to prenatal clinics, buy fresh fruits and vegetables for her toddler son and herself, and remain healthy as she prepared for the birth of her second child last year.

But the future of the Abundant Birth Project is clouded by a lawsuit alleging that the program, the first of its kind in the nation, illegally discriminates by giving the stipend only to people of a specific race. The lawsuit also targets San Francisco guaranteed-income programs serving artists, transgender people, and Black young adults.

The litigation is part of a growing national effort by conservative groups to eliminate racial preferences in a wide range of institutions following a U.S. Supreme Court ruling that found race-conscious admissions to colleges and universities to be unconstitutional.

In health care, legal actions threaten efforts to provide scholarships to minority medical school students and other initiatives to create a physician workforce that looks more like the nation.

The lawsuits also endanger other measures designed to reduce well-documented racial disparities. Black women are three to four times more likely than white women to die in labor or from related complications in the U.S., and Black infants are twice as likely as white infants to be born prematurely and to die before their first birthdays. Racial and ethnic minorities also are more likely to die from diabetes, high blood pressure, asthma, and heart disease than their white counterparts, according to the Centers for Disease Control and Prevention.

A handful of activist nonprofit groups and law firms are leading the charge. Do No Harm, a nonprofit formed in 2022, has sued health commissions, pharmaceutical companies, and public health journals to try to stop them from choosing applicants based on race. Do No Harm claims more than 6,000 members worldwide and partners with nonprofit legal organizations, most notably the Pacific Legal Foundation, which garnered national attention when it defended California’s same-sex marriage ban.

Another nonprofit, the Californians for Equal Rights Foundation, together with a Dallas-based law firm called the American Civil Rights Project, filed the lawsuit against the city of San Francisco and the state of California over the Abundant Birth Project, alleging the program violates the equal protection clause of the Constitution’s 14th Amendment by granting money exclusively to Black and Pacific Islander women. The 14th Amendment was passed after the Civil War to give rights to formerly enslaved Black people.

The lawsuit calls public money used for the project and the three other guaranteed-income programs “discriminatory giveaways” that are “illegal, wasteful, and injurious.”

“The city and county of San Francisco crafted the Abundant Birth Project with the express intention of picking beneficiaries based on race,” Dan Morenoff, executive director of the American Civil Rights Project, said in a phone interview. “It’s unconstitutional. They can’t legally do it, and we are optimistic that the courts will not allow them to continue to do it.”

San Francisco and state officials declined to discuss the case because of the pending litigation, but the city defended the program in its initial response to the lawsuit. The Abundant Birth Project started in June 2021 and plans to make a second round of grants to pregnant mothers this fall, the response says.

The project strives to improve maternal and infant health outcomes by easing the economic stress on pregnant Black and Pacific Islander San Franciscans. People in those groups face some of the worst outcomes in the U.S., where more women die as a result of pregnancy and childbirth than in other high-income nations. The state of California last year awarded $5 million to expand the program to include Black mothers in four other counties.

But Khiara Bridges, a Berkeley law professor and anthropologist who has talked to beneficiaries of the Abundant Birth Project but is not directly involved with it, said the Supreme Court ruling on college affirmative action could actually support the argument that the program is legal.

The court struck down affirmative action in part because the majority said Harvard and the University of North Carolina failed to show measurable outcomes justifying race consciousness in college admissions. While statistics on potential benefits from the Abundant Birth Project are not publicly available, Bridges and others familiar with the program expect researchers to demonstrate it saves and improves lives by comparing the health outcomes of families who received the stipend with those of families who did not. The outcomes could justify employing race to choose program participants, Bridges said.

Bridges also drew another distinction between the role of race in college admissions and the role of race in health disparities.

“If you don’t get into Harvard, there’s always Princeton or Columbia or Cornell,” she said. “Maternal death — the stakes are a little bit higher.”

When Briana Jones was pregnant with her second son, Adonis, a San Francisco program called the Abundant Birth Project enabled her to pay for gas for prenatal appointments, find housing, feed her toddler son, and remain healthy as she prepared to welcome her second child. The program has provided 150 pregnant Black and Pacific Islander San Franciscans a $1,000 monthly stipend. (Briana Jones)
While Briana Jones was pregnant with the younger of her two sons, she qualified through San Francisco’s Abundant Birth Project as one of nearly 150 women to receive a $1,000-a-month stipend during her pregnancy and for six months postpartum. (Briana Jones)

In California, a voter initiative, Proposition 209, has prohibited race-based selection in public education and employment since 1996. California Assembly member Mia Bonta (D-Oakland) has co-authored a pending bill that would amend the proposition to allow municipalities to grant benefits to specific groups of vulnerable people if they use research-based measures that can reduce health and other disparities.

Bonta, a law school graduate, told KFF Health News that the litigation against the Abundant Birth Project is the result of “conservative groups who want to exist in a world that doesn’t exist, where communities of color have not had to suffer the generational harm that comes from structural racism.”

Bonta has more than once been a victim of medical racism herself.

When she went to the hospital with a serious back injury, she was interrogated by a doctor who appeared to believe she was faking pain so she could obtain drugs.

“But for the intervention of my husband, who happened to be there and moved into health advocacy mode, I, as a Black Latina woman, would not have received the care that I needed,” she said. Bonta’s husband, Rob Bonta, is also a lawyer and is now California’s attorney general.

Briana Jones experiences racism every day, she said.

She was 15 when she gave birth to her first child in a San Francisco hospital. Terrified and in agonizing pain, she did what laboring mothers have always done and screamed.

A nurse ordered her to “shut up.”

In the U.S., Black women are far more likely than white women to report that health care providers scolded, threatened, or shouted at them during childbirth, research shows. They also face other forms of obstetric racism, including barriers to quality care and cumulative stress from lifelong discrimination.

Growing up Black in predominantly white and Asian San Francisco has been a struggle for Jones. But, while carrying her second baby last year, she learned from her mother of the Abundant Birth Project, and within a month, her race and address in Bayview Hunters Point, where some of the city’s poorest residents live, qualified her as one of nearly 150 women to receive the $1,000 a month during her pregnancy and for six months postpartum.

“I really did feel like it was God helping me,” she said.

For Morenoff, though, it’s just another form of discrimination, and he says the city must either open the Abundant Birth Project to all pregnant women or close it down. “The whole point of the 14th Amendment is to require America to treat all Americans as Americans with the same equal rights,” he said.

Jones had high blood pressure, leading to swollen ankles and dizziness, during both her pregnancies. In her more recent one, the birth project stipend helped enable her to quit couch surfing and move into an apartment, and she gave birth to a healthy boy named Adonis.

“It’s known that people of color struggle way harder than other races,” Jones said. “Where I live, it’s nothing but struggle here, people trying to make ends meet.”

“For them to try to take this program away from us,” she said, “it’s wrong.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

Watch: In Insurers’ Eyes, Not All Midwives Are Equal

Vanessa Garcia Clark wanted a more personal, nontraditional birth when she was pregnant with her son. She hired a midwife and gave birth at her home in California. But when she asked her insurer to reimburse her for the midwifery bill totaling more than $9,500, her claim was denied.

In the first installment of InvestigateTV and KHN’s “Costly Care” series, Caresse Jackman, InvestigateTV’s national consumer investigative reporter, explores the different types of midwives — and how not all of them may be covered by insurance.

Jackman’s story features an interview with Dr. Elisabeth Rosenthal, KHN’s editor-in-chief, who advises mothers-to-be to negotiate before paying a big bill.

Community Resurrects Colorado Birth Center Closed by Private Equity Firm

When a private equity firm closed Seasons Midwifery and Birth Center in Thornton, Colorado, in October, the state lost one of its few non-hospital birthing centers and 53 families with pregnancy due dates in November and December were left scrambling to find providers.

But then staffers and community advocacy groups stepped in to fill the void for the suburban Denver community and its patients, many of whom rely on Medicaid, the federal-state insurance program for people with low incomes. They reorganized Seasons as a nonprofit organization and struck a note of triumph and defiance in announcing its reopening in January as the free-standing Seasons Community Birth Center. Seasons has five deliveries scheduled in February and 30 in March.

“With the closing, we decided we’re not going to let capitalism take us down,” said Justina Nazario, a Seasons birth assistant. “We’re going to bring these really important qualities that you don’t get in the medical-industrial complex.”

Over the past two decades, the number of at-home and birth center deliveries nationwide was on the rise — until the covid-19 pandemic hit. The number of out-of-hospital births increased 22% from 2019 to 2020 and an additional 12% from 2020 to 2021, according to a Centers for Disease Control and Prevention report.

Nationally, birth centers — medical facilities for labor and childbirth that rely on midwives to help with healthy, low-risk pregnancies — have lower rates of preterm births, low birth weights, and women transferred to hospitals for cesarean sections.

While C-sections can be lifesaving, they are major surgeries that come with significant risk and cost. A 2013 study of about 22,400 women who planned to give birth at a birth center found that 6% of those who entered labor at such a facility were sent to a hospital for a C-section. By contrast, about 26% of healthy, low-risk pregnancies in hospitals end in C-sections.

Before Seasons closed, staffers transferred about 8% of patients to a hospital for a C-section.

The funding model for birthing centers is complicated: In Colorado they are regulated and licensed by the state health department, yet because they’re not hospitals, they can’t bill insurance in the same way as a hospital. So Seasons, for example, receives about $4,000 per birth from private insurance, said Heather Prestridge, the clinic’s administrative director, while a hospital birth costs on average $19,000 and is reimbursed by insurance for about $16,000.

The only option for patients who don’t have private insurance and cannot pay out-of-pocket is to deliver in a hospital. Most birth centers don’t accept Medicaid, but Seasons is different. Before its closure, about 40% of its clients were on Medicaid, which reimburses less than other insurance providers, Prestridge said.

“Every time we take a Medicaid client on, we lose money,” Prestridge said. “It’s so important for everyone to have access to this kind of care, so we continue to do it anyway.”

Medicaid’s restrictions and low reimbursement rates have led to financial problems for birth centers, including Seasons, despite their being inundated with patients. In Colorado, 19% of the population and 36% of births were covered by Medicaid in 2022.

As a nonprofit, Seasons will need to lean on fundraising to fill the gaps, Prestridge said.

A photo shows workers at Seasons Community Birth Center.
Seasons Community Birth Center in Thornton, Colorado, rebranded and reopened in January as a nonprofit after a private equity firm closed it in October. Seasons is one of the state’s few non-hospital birthing centers.(Aubre Tompkins)

Colorado has seven birth centers, including Seasons, which often have rooms that look more like bedrooms than hospital rooms, and bathtubs as an option for delivery.

In 2018, two other Colorado birth centers — associated with hospital groups but owned by a for-profit parent company — closed. The two Denver-area practices primarily served patients who had low incomes or were refugees, according to The Colorado Sun.

“It came as a shock to us, but unfortunately it has become our reality,” Miki Tynan, co-founder and managing director of Colorado Birth and Wellness said of the birth center closures.

When Seasons closed Oct. 4, Colorado Birth and Wellness, a collaboration between two birth centers in the Denver area, took on more than 60 of its clients.

The physicians group that started Seasons in 2019, called Women’s Health Group, partnered with a private equity group, Shore Capital Partners, in late 2020 and became Elevate Women’s Health. Executives there determined that Seasons was unprofitable and closed it, said Aubre Tompkins, clinical director at Seasons Community Birth Center, and others who worked for Seasons at the time.

“It was pretty devastating,” Tompkins said. “There were a lot of tears, there was a lot of anger, there was a lot of confusion.”

After the closure was announced, Elephant Circle, a reproductive justice organization, reached out to Tompkins with a plan to raise money for Seasons to reopen as a nonprofit. The organization’s founder, Indra Lusero, said members wanted to save Seasons but also wanted to invest in making the nonprofit model work more broadly.

“There’s been some investment, there’s been federal studies, there’s great data — all the things saying, ‘Hey, I think this model looks like it could work. We should invest in this model,’” Lusero said.

As a nonprofit, Seasons plans to expand its services to include gender-affirming care and train more people as midwives and doulas to increase diversity in the field. Seasons offers annual gynecological exams, contraceptives, lactation services, and newborn care through the first two weeks of life.

Tompkins is a member of what she described as an emergency and temporary task force that reopened the facility with a reproductive justice mission. Nazario will also sit on the board, along with representatives from the Colorado Organization for Latina Opportunity and Reproductive Rights, or COLOR; Elephant Circle; and Soul 2 Soul Sisters, a racial justice organization.

Nazario, who describes herself as Afro-Latina, has experienced firsthand how essential her identity and experiences are to her work in birthing. Potential clients often reach out to her saying they had been looking for someone like her, someone like them.

Katherine Riley, who gave birth to her daughter at Seasons last year, is policy director at COLOR and a member of the Seasons Community Birth Center board. She said she’s excited to advance Seasons’ mission and expand teaching opportunities for future midwives.

“The practice of midwifery, I think, in itself is an act of resistance,” Riley said. “There’s a long history of racism and patriarchy in ousting midwives, and so I think returning as a community to that is so important.”

Part II: The State of the Abortion Debate 50 Years After ‘Roe’

The Host

The abortion debate has changed dramatically in the seven months since the Supreme Court overturned Roe v. Wade and its nationwide right to abortion. Nearly half the states have banned or restricted the procedure, even though the public, at the ballot box, continues to show support for abortion rights.

In this special, two-part podcast, taped the week of the 50th anniversary of the decision in Roe v. Wade, an expert panel delves into the fight, the sometimes-unintended side effects, and what each side plans for 2023.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN.

Among the takeaways from this week’s episode:

  • Exemptions to state abortion bans came into question shortly after the Supreme Court’s decision to overturn Roe, with national debate surrounding the case of a 10-year-old in Ohio who was forced to travel out of state to have an abortion — although, as a rape victim, she should have been able to obtain an abortion in her home state.
  • The restrictions in many states have caused problems for women experiencing miscarriages, as medical providers fear repercussions of providing care — whether affecting their medical licenses or malpractice insurance coverage, or even drawing criminal charges. So far, there have been no reports of doctors being charged.
  • A Christian father in Texas won a lawsuit against the federal government that bars the state’s Title X family-planning clinics from dispensing birth control to minors without parental consent. That change poses a particular problem for rural areas, where there may not be another place to obtain contraception, and other states could follow suit. The Title X program has long required clinics to serve minors without informing their parents.
  • Top abortion opponents are leaning on misinformation to advance their causes, including to inaccurately claim that birth control is dangerous.
  • Medication abortion is the next target for abortion opponents. In recent months, the FDA has substantially loosened restrictions on the “abortion pill,” though only in the states where abortion remains available. Some opponents are getting creative by citing environmental laws to argue, without evidence, that the abortion pill could contaminate the water supply.
  • Restrictions are also creating problems for the maternal care workforce, with implications possibly rippling for decades to come. Some of the states with the worst maternal health outcomes also have abortion bans, leading providers to rethink how, and where, they train and practice.
  • Looking ahead, a tug of war is occurring on state and local levels among abortion opponents about what to do next. Some lawmakers who voted for state bans are expressing interest in at least a partial rollback, while other opponents are pushing back to demand no changes to the bans. With Congress divided, decisions about federal government spending could draw the most attention for those looking for national policy changes.

And for extra credit, the panelists recommend their most memorable reproductive health stories from the last year:

Julie Rovner: NPR’s “Because of Texas’ Abortion Law, Her Wanted Pregnancy Became a Medical Nightmare,” by Carrie Feibel

Alice Miranda Ollstein: The New York Times Magazine’s “She Wasn’t Ready for Children. A Judge Wouldn’t Let Her Have an Abortion,” by Lizzie Presser

Sandhya Raman: ProPublica’s “’We Need to Defend This Law’: Inside an Anti-Abortion Meeting with Tennessee’s GOP Lawmakers,” by Kavitha Surana

Sarah Varney: Science Friday’s and KHN’s “Why Contraceptive Failure Rates Matter in a Post-Roe America,” by Sarah Varney

Also mentioned in this week’s podcast:


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Part I: The State of the Abortion Debate 50 Years After ‘Roe’

The Host

The abortion debate has changed dramatically in the seven months since the Supreme Court overturned Roe v. Wade and its nationwide right to abortion. Nearly half the states have banned or restricted the procedure, even though the public, at the ballot box, continues to show support for abortion rights.

In this special two-part podcast, taped the week of the 50th anniversary of the Roe decision, an expert panel delves into the fight, the sometimes-unintended side effects, and what each side plans for 2023.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Sarah Varney of KHN.

Among the takeaways from this week’s episode:

  • Exemptions to state abortion bans came into question shortly after the Supreme Court’s decision to overturn Roe, with national debate surrounding the case of a 10-year-old in Ohio who was forced to travel out of state to have an abortion — although, as a rape victim, she should have been able to obtain an abortion in her home state.
  • The restrictions in many states have caused problems for women experiencing miscarriages, as medical providers fear repercussions of providing care — whether affecting their medical licenses or malpractice insurance coverage, or even drawing criminal charges. So far, there have been no reports of doctors being charged.
  • A Christian father in Texas won a lawsuit against the federal government that bars the state’s Title X family-planning clinics from dispensing birth control to minors without parental consent. That change poses a particular problem for rural areas, where there may not be another place to obtain contraception, and other states could follow suit. The Title X program has long required clinics to serve minors without informing their parents.
  • Top abortion opponents are leaning on misinformation to advance their causes, including to inaccurately claim that birth control is dangerous.
  • Medication abortion is the next target for abortion opponents. In recent months, the FDA has substantially loosened restrictions on the “abortion pill,” though only in the states where abortion remains available. Some opponents are getting creative by citing environmental laws to argue, without evidence, that the abortion pill could contaminate the water supply.
  • Restrictions are also creating problems for the maternal care workforce, with implications possibly rippling for decades to come. Some of the states with the worst maternal health outcomes also have abortion bans, leading providers to rethink how, and where, they train and practice.
  • Looking ahead, a tug of war is occurring on state and local levels among abortion opponents about what to do next. Some lawmakers who voted for state bans are expressing interest in at least a partial rollback, while other opponents are pushing back to demand no changes to the bans. With Congress divided, decisions about federal government spending could draw the most attention for those looking for national policy changes.

Also this week, Rovner interviews Elizabeth Nash, who tracks state reproductive health policies for the Guttmacher Institute, a reproductive rights research group.


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In North Carolina, More People Are Training to Support Patients Through an Abortion

Lauren Overman has a suggested shopping list for her clients preparing to get an abortion. The list includes a heating pad, a journal, aromatherapy oils — things that could bring physical or emotional comfort after the procedure.

Overman is an abortion doula.

She has worked as a professional birth doula for many years. Recently, Overman also began offering advice and emotional support to people as they navigate having an abortion, often a lonely time. She makes her services available either free or on a sliding scale to abortion patients. Other abortion doulas charge between $200 and $800.

Overman is one of around 40 practicing abortion doulas in North Carolina, according to an estimate from local abortion rights groups — a number that could soon grow. North Carolina groups that train doulas said they’ve seen an uptick in people wanting to become abortion doulas in the months since Roe v. Wade was overturned.

Every three months, the Carolina Abortion Fund offers free online classes for aspiring abortion doulas. Those sessions used to have 20 sign-ups at most, according to board member Kat Lewis. Now they have 40.

“It’s word of mouth. It’s people sharing ‘This is how I got through my abortion or miscarriage experience with the help of a doula.’ And someone being like, ‘That’s amazing. I need that. Or I wanna become that,’” Lewis said.

Demand for training has also surged at the Mountain Area Abortion Doula Collective in western North Carolina, which started in 2019. Ash Williams leads the free four-week doula training and includes talks on gender-inclusive language and the history of medical racism. The course also includes ways to support clients struggling with homelessness or domestic violence.

“The doula might be the only person that that person has told that they’re doing this. … That’s a big responsibility,” Williams said. “So we really want to approach our work with so much care.”

Going to the clinic and holding a patient’s hand during the procedure are among the services abortion doulas can offer, but some clinics don’t allow a support person in the room. So doulas like Overman find other ways to be supportive, such as sitting down with a woman afterward, to listen, share a meal, or just watch TV together.

It’s “holding space — being there so that they can bring something up if they want to talk about it. But also, there are no expectations that you have to talk about it if you don’t want to,” Overman said.

The photograph shows Lauren Overman's notebook, which she holds as she draws a simple diagram of the female reproductive system. The drawing has clearly labeled where a fertilized egg is located in the uterus and the location of the cervix.
Lauren Overman uses sketches to walk her clients through the abortion procedure.(Max Posner / NPR)

Overman uses Zoom to consult with people across the country, even in states where abortion is restricted or banned. She can help them locate the closest clinics or find transportation and lodging if they’re traveling a long distance.

Overman makes sure her clients know what to expect from the procedure, like how much bleeding is normal after either a surgical or medication abortion.

“You can fill up a super maxi pad in an hour. That’s OK,” she explained. “Fill up one or more pad every hour for two to three hours consecutively, then that’s a problem.”

Abortion doulas are not required to have medical training, and many do not. It’s not clear how many work across the U.S., because the job is not regulated.

There has been a jump in the number of people requesting her abortion doula services over the past several months, Overman said, from around four people a month to four every week.

If people are afraid to talk to their friends or relatives about an abortion, she said, sometimes the easiest thing to do is reach out to someone on the internet. A doula may start out as a stranger but can become a person who can be relied on for support.

This article is from a partnership that includes NPR, WFAE, and KHN.

“Cuarto trimestre”: período clave para prevenir las muertes maternas

Durante varias semanas al año, el trabajo de la enfermera-comadrona Karen Sheffield-Abdullah es detectivesco. Con un equipo de investigadores médicos del Departamento de Salud Pública de Carolina del Norte examina los registros hospitalarios y los informes forenses de las madres que murieron después de dar a luz.

Estos comités de revisión de la mortalidad materna buscan pistas sobre lo que ha contribuido a estas muertes —recetas que nunca se recogieron, faltar a citas médicas postnatales, señales de alerta que los médicos pasaron por alto—, para averiguar cuántas podrían haberse evitado y cómo.

Los comités trabajan en 36 estados, y en la última y mayor recopilación de datos de este tipo, publicada en septiembre por los Centros para el Control y Prevención de Enfermedades (CDC), un sorprendente 84% de las muertes relacionadas con el embarazo se consideraron prevenibles.

Lo que resulta aún más alarmante para enfermeras-detectives como Sheffield-Abdullah es que el 53% de las muertes se produjeron mucho después de que las mujeres fueran dadas de alta del hospital, entre siete días y un año después del parto.

“Estamos muy centrados en el bebé”, afirma. “Una vez que el bebé está aquí, es casi como si la madre fuera descartada… Y en lo que realmente tenemos que pensar es en ese cuarto trimestre, ese tiempo después del nacimiento del bebé”.

Las condiciones de salud mental fueron la principal causa subyacente de muertes maternas entre 2017 y 2019. Las blancas no hispanas y las hispanas fueron las más propensas a morir por suicidio o sobredosis de drogas, mientras que los problemas cardíacos fueron la principal causa de muerte para las mujeres negras no hispanas.

Ambas circunstancias ocurren desproporcionadamente más tarde en el período posparto, según el informe de los CDC.

Los datos revelan múltiples deficiencias en el sistema de atención a las nuevas madres, desde los obstetras que no están adiestrados (o bien pagados) para buscar signos de problemas mentales o de adicción, hasta las pólizas que despojan a las mujeres de la cobertura médica poco después de dar a luz.

El principal problema es que el típico control postnatal de seis semanas es demasiado tarde, según Sheffield-Abdullah. En los datos de Carolina del Norte, las nuevas madres que murieron más tarde no acudieron a esta cita porque tenían que volver al trabajo o tenían otros niños pequeños, agregó.

“Tenemos que estar realmente en contacto mientras están en el hospital”, dijo Sheffield-Abdullah, y luego asegurarnos de que las pacientes reciban la atención de seguimiento adecuada “una o dos semanas después del parto”.

Otra de las recomendaciones de los CDC es más pruebas de detección de depresión y ansiedad posparto, durante todo el año posterior al parto, así como una mejor coordinación de la atención entre los servicios médicos y sociales, según David Goodman, que dirige el equipo de prevención de mortalidad materna de la División de Salud Reproductiva de los CDC, que publicó el informe.

Una crisis frecuente es que la adicción de uno de los padres se agrava tanto que los servicios de protección infantil se llevan al bebé, lo que precipita una sobredosis accidental o intencionada de la madre. Tener acceso al tratamiento y asegurarse de que las visitas a los niños se produzcan con regularidad podría ser la clave para prevenir estas muertes, apuntó Goodman.

El cambio político más importante ha sido la ampliación de la cobertura sanitaria gratuita a través de Medicaid, indicó. Hasta hace poco, la cobertura de Medicaid relacionada con el embarazo solía expirar dos meses después del parto, lo que obligaba a las mujeres a dejar de tomar medicamentos o de acudir a un terapeuta o a un médico porque no podían pagar el costo sin seguro médico.

Ahora, 36 estados han ampliado o tienen previsto ampliar la cobertura de Medicaid hasta un año completo después del parto, en parte como respuesta a los primeros trabajos de los comités de revisión de la mortalidad materna.

“Si esto no es una llamada a la acción, no sé qué es”, señaló Adrienne Griffen, directora ejecutiva de la Maternal Mental Health Leadership Alliance, una organización sin fines de lucro centrada en la política nacional. “Hace tiempo que sabemos que los problemas de salud mental son la complicación más común del embarazo y el parto. Solo que no hemos tenido la voluntad de hacer algo al respecto”.

El último estudio de los CDC de septiembre analizó 1,018 muertes en 36 estados, casi el doble de los 14 estados que participaron en el informe anterior. Los CDC están dando aún más fondos para las revisiones de la mortalidad materna, dijo Goodman, con la esperanza de captar datos más completos de más estados en el futuro.

El aumento de la concientización y la atención sobre la mortalidad materna les ha dado esperanza a activistas y médicos, especialmente por los esfuerzos para corregir las disparidades raciales: las mujeres negras tienen tres veces más probabilidades de morir por complicaciones relacionadas con el embarazo que las blancas.

Pero muchos de estos mismos partidarios de una mejor atención materna dicen estar consternados por la reciente decisión del Tribunal Supremo de Estados Unidos de erradicar el derecho federal al aborto; las restricciones en torno a la atención de la salud reproductiva, dicen, erosionarán los avances.

Desde que estados como Texas empezaron a prohibir los abortos en etapas tempranas del embarazo y a hacer menos excepciones para aquellos casos en los que la salud de la embarazada está en peligro, a algunas mujeres les resulta más difícil recibir atención de urgencia por un aborto espontáneo.

Los estados también están prohibiendo los abortos —incluso en casos de violación o incesto— en chicas jóvenes, que afrontan un riesgo mucho mayor de complicaciones o muerte por llevar un embarazo a término.

“Cada vez más el mensaje es que ‘no eres dueña de tu cuerpo’”, dijo Jameta Nicole Barlow, profesora adjunta de redacción, política y gestión sanitaria en la Universidad George Washington.

Según Barlow, esto no hará más que agravar los problemas de salud mental que experimentan las mujeres en torno al embarazo, especialmente las mujeres negras, que también se enfrentan a la larga historia intergeneracional de la esclavitud y el embarazo forzado. Sospecha que las cifras de mortalidad materna empeorarán antes de mejorar, debido a la interrelación entre la política y la psicología.

“Hasta que no abordemos lo que está ocurriendo políticamente”, dijo, “no vamos a poder ayudar a lo que está ocurriendo psicológicamente”.

Esta historia es parte de una alianza que incluye a KQEDNPR, y KHN.

KHN’s ‘What the Health?’: Biden Declares the Pandemic ‘Over’


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President Joe Biden’s declaration in a national interview that the covid-19 pandemic is “over” has complicated his own administration’s efforts to get Congress to provide more funding for treatments and vaccines, and to get the public to go get yet another booster.

Meanwhile, concerns about a return of medical inflation for the first time in a decade is helping boost insurance premiums, and private companies are scrambling to claim their piece of the health care spending pie.

This week’s panelists are Julie Rovner of KHN, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico, and Lauren Weber of KHN.

Among the takeaways from this week’s episode:

  • Biden’s comment to “60 Minutes” that the pandemic was over — even though covid is still an issue — highlights the difficulty in communicating to the public how to transition from a public health crisis to a public health problem.
  • Much of the country may agree with the president, as evidenced by fewer people using face masks regularly and a decreased number of commercial restrictions related to covid. But several hundred people are still dying each day, a high toll often overlooked.
  • Insurance premiums appear to be on the upswing this fall, even though medical costs have not been rising as quickly as other parts of the economy in recent months. The increase may reflect insurers’ concerns that, coming out of the covid crisis, consumers will be seeking more medical services.
  • One aspect of health business that is driving up costs is the increased investment by private equity companies, which are expanding their reach beyond emergency room doctors and a few other specialties to a wider range of medical services, including gastroenterology and ophthalmology.
  • Another concern for the future of health costs is the move toward consolidation in health care. Among recent developments on that front were Amazon’s announcement it is moving into primary care with the purchase of One Medical and CVS’ decision to buy home health care company Signify Health.
  • Abortion policies continue to make news in various states. West Virginia passed a law that restricts nearly all abortions; several Utah Republican legislators sent cease-and-desist letters to abortion providers in their state; and Puerto Rico has a new political party campaigning on the issue of trying to curb the commonwealth’s liberal abortion law.
  • While Democrats hope the issue of abortion will swing more voters their way in the midterm elections, it’s not clear whether overall support for abortion will be a deciding issue for voters in more conservative states and bring any changes.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The Anchorage Daily News’ “Many Alaska Pharmacies Are Understaffed, Leading to Sporadic Hours and Patients Turned Away,” by Annie Berman

Joanne Kenen: Capital B’s “Clinicians Dismiss Black Women’s Pain. The Consequences Are Dire,” by Margo Snipe

Anna Edney: The Guardian’s “Fury Over ‘Forever Chemicals’ as US States Spread Toxic Sewage Sludge,” by Tom Perkins

Lauren Weber: KHN’s “Doctors Rush to Use Supreme Court Ruling to Escape Opioid Charges,” by Brett Kelman

Also mentioned in this week’s episode:


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KHN’s ‘What the Health?’: Graham’s Bill Recenters Abortion Debate


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Sen. Lindsey Graham (R-S.C.) put abortion back on Republicans’ agenda this week with a legislative proposal calling for a national ban on most abortions after 15 weeks of pregnancy. For many in his party, it was an unwelcome intrusion that could add to public unease with the party’s efforts to limit access to abortion as they look toward the midterm elections.

The World Health Organization suggested this week that the end of the covid-19 pandemic is within sight, but that doesn’t mean there’s an end to second-guessing about how public health officials reacted or their plans going forward.

This week’s panelists are Mary Agnes Carey of KHN, Rachel Cohrs of Stat, Sandhya Raman of CQ Roll Call, and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s episode:

  • Graham appeared to be trying to build consensus among conservatives with his bill. Republicans have been startled how the Supreme Court’s decision this summer ending a constitutional right to abortion has energized voters opposed to the move. In some red states, confusion has arisen over how strict a ban lawmakers can support. Graham’s bill would allow states to enact abortion laws that are more restrictive but would cap efforts by more progressive states to keep abortion legal later in pregnancy. He had the backing of several influential anti-abortion groups.
  • That didn’t seem to matter to many Capitol Hill Republicans. Senate Minority Leader Mitch McConnell was dismissive of the proposal, saying the issue needs to be dealt with on a state level, and refused to commit to bringing up the bill if Republicans capture the Senate in the fall elections. Conservatives have long argued that abortion access should be a state decision.
  • Graham’s announcement was inconvenient for Capitol Hill Republicans. Much of the political debate on abortion access had been focused on state races, but his bill allows Democrats to make it an issue in congressional races, too.
  • Groups that oppose abortion say that Graham’s effort is a good first step toward setting policy for the country, especially since states may continue to be more restrictive.
  • In the past, the 15-week gestational ban has been fairly well supported by the public, according to opinion polling. But new surveys suggest Americans’ views may be shifting as they witness the consequences of the Supreme Court decision and tragic stories appear about pregnancies in which fetal anomalies are discovered late or a mother’s health is impaired in late pregnancy.
  • On the covid-19 front, World Health Organization Director-General Tedros Adhanom Ghebreyesus told reporters Wednesday that the covid pandemic is not over but was upbeat about the fight against the virus. “The end is in sight,” he said.
  • His comments came as a group of world health experts, the Lancet Covid-19 Commission, blamed the WHO, the U.S. government, and others for insufficient coordination in fighting the disease. And a report by Politico and the German newspaper Welt looks at four non-governmental health organizations that had an influence on pandemic efforts.
  • Despite Adhanom Ghebreyesus’ comments, public health officials in the U.S. are pushing hard for Americans to get another covid booster this fall. And the situation points out that public health officials may not have a good handle on how to transition from treating covid as an emergency to an ongoing health threat.
  • The outlook is also muddled because the Biden administration has asked for more money from Congress to continue to fund vaccination and testing efforts, but congressional Republicans appear unlikely to support that effort. They believe it is time for the government to move out of that effort and allow the regular health industry to take over.
  • The latest statistics from the Census Bureau show a near-record low in the number of people who are uninsured. But most experts are concerned because once the covid emergency ends, states will again be allowed to recalibrate their Medicaid rolls and many people who have been covered by the federal-state health program during the pandemic could be pushed off government coverage.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Mary Agnes Carey: KHN’s “As State Institutions Close, Families of Longtime Residents Face Agonizing Choices” by Tony Leys

Rachel Cohrs: Politico’s “A New Approach to Domestic Violence” by Joanne Kenen

Sandhya Raman: The Philadelphia Inquirer’s “Philly’s Kids Are Grieving Alone From the Far-Reaching Trauma of Gun Violence, Advocates Say” by Abraham Gutman

Margot Sanger-Katz: The New York Times’ “Despite Their Influence and Extensive Access to Information, Members of Congress Can Buy and Sell Stocks With Few Restrictions”  and “These 97 Members of Congress Reported Trades in Companies Influenced by Their Committees” by Kate Kelly, Adam Playford, and Alicia Parlapiano

Also discussed on this week’s podcast:

Politico and Welt’s “How Bill Gates and Partners Used Their Clout to Control the Global Covid Response — With Little Oversight” by Erin Banco, Ashleigh Furlong, and Lennart Pfahler

The Census Bureau’s “Income, Poverty, and Health Insurance Coverage in the United States: 2021


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