Rachel is a college-educated professional pianist who lives in a middle-class leafy Cleveland suburb with her husband and their baby boy.

The 34-year-old is fit and healthy with good medical insurance and a close-knit family network, but these socio-economic advantages were not sufficient insurance to insulate her from the racial disparities that characterise America’s infant and maternal mortality rates: African American babies are twice as likely to die before reaching their first birthday than white babies, regardless of the mother’s income or education level.

A report earlier this year from Centers for Disease Control and Prevention found that over 22,000 babies died before their first birthday in 2017. But the racial disparities tell their own story: black women’s babies died at a rate of 10.97 per 1,000 births – more than twice the rate for white, Asian or Hispanic women.

And in Ohio – home to Cleveland – the situation is even worse: the mortality rate for black infants ( 15.1 per 1,000) was around three times as high as the rate for white infants. Black women are also three to four times more likely to die in childbirth in America than white women, again regardless of their socio-economic status.

It’s this terrifying reality that persuaded Rachel, who suffered a miscarriage before becoming pregnant with her son last year, that she needed an African American doula by her side during the pregnancy, delivery and after the birth.

“I was scared … I wanted someone who understood my history as a black woman to be with me during the birth and advocate for me in the hospital system where we are dismissed and not heard,” said Rachel. “Even Serena [Williams] was dismissed.”

(After giving birth in 2017, medical staff initially dismissed the tennis star’s concerns about life threatening blood clots, a condition which almost killed her in 2011.)

Facebook Twitter Pinterest Christin Farmer at the Birthing Beautiful Communities headquarters in Cleveland, Ohio. Photograph: Shooting Without Bullets/The Guardian

Rachel eventually came across Birthing Beautiful Communities (BBC) – a Cleveland-based African American doula collective that provides culturally sensitive education, advocacy and emotional support for women during pregnancy and up to a year after birth.

The not-for-profit group was founded in 2014 by Christin Farmer, a straight-talking community organiser with an entrepreneurial spirit.

“The American infant mortality crisis is driven by black babies dying. It’s about systemic racism and the lack of power sharing,” said Farmer, 34. “We have to take things in our own hands at the grassroots level because we cannot depend on the same people that enslaved and repressed us to save us.”

‘Black babies account for a third of births, but three-quarters of infant deaths’

Farmer set up BBC to tackle longstanding birth inequalities by training local black women to provide holistic attention to pregnant women in their own communities.

Birthing Beautiful Communities is among 25 inspirational people and organizations that the Guardian is highlighting as part of a week-long City Champions project in Cleveland. It is designed to showcase the upsides in a city like Cleveland where grassroots activists faced with endemic problems – like lead poisoning, infant mortality and gun violence – and few or no state solutions, are taking the initiative and helping to change lives in some of the city’s most marginalised communities.

Cleveland is the capital of Cuyahoga county located on the shore of Lake Erie in north-east Ohio, a former urban powerhouse which has suffered decades of economic decline and widespread racial inequalities. It is one of the most segregated cities in the US, a fact which directly influences the allocation of public resources for housing, health, education, infrastructure, crime prevention, parks and environmental hazards.

Q&A What is the City Champions series about? Show Hide Many cities across the US face significant challenges – places like Baltimore, Detroit, Pittsburgh and Cleveland are among them. And much has been written about how these former economic powerhouses have struggled over the last few decades. But this week in the first installment of our City Champions series, we want to highlight the remarkable people and groups working on inspiring projects that show the resilience of those wanting to improve the lives of people in one of those cities: Cleveland, Ohio. Cleveland has many challenges - inequality, structural racism, infant mortality, shamefully untreated lead poisoning - but it also has a network of people creating innovative projects that are addressing these challenges with significant success. Collaborating with the local newspaper - The Plain Dealer - and the local PBS and NPR stations, run by ideastream, we canvassed residents for their suggestions for who to recognize and received hundreds of replies. We then created an advisory panel of mostly local public figures who helped select the final 25 champions, whose stories we will be telling this week. As part of this project we have also worked with the art collective For Freedoms to create a public art expression for this project. Working with For Freedoms and local artists, we commissioned artwork for six billboards that help tell the stories of the city and the challenges the champions are addressing. –John Mulholland, editor in chief, Guardian US



Back in 1850, when the US first started collecting infant mortality statistics, the black infant mortality rate was 340 per 1,000 while the white infant mortality rate was 217 per 1,000. While deaths have fallen overall thanks to improvements in hygiene, nutrition and healthcare, the black-white disparity has grown.

The situation in Cuyahoga county is shocking: last year African Americans accounted for just over a third of births, but three-quarters of infant deaths. This year looks set to be the worst since 2015, with black babies dying 3.8 times more frequently than white babies, according to preliminary figures.

“Everytime I hear these numbers something inside me dies,” said Margaret Mitchell, president of YWCA Cleveland. “We have suppressed the truth for too long; this is not about race, it’s about racism.”

Community leaders and health experts in Cleveland are pushing city officials to declare racism a public health crisis. At a recent city event, 400 years of Inequity: A Call to Action, some of the country’s leading racial justice researchers argued that racism – historical and contemporary – contributes to widespread health inequalities for African Americans including infant and maternal mortality.

Infant and maternal health specialist, Dr. Arthur James, of the Kirwan Institute for the Study of Race and Ethnicity at Ohio State University, said: “85% of the African American experience has been defined by slavery and Jim Crow yet we never talk about the role of history in today’s racial inequalities in gun crime, addictions, mass incarceration and infant mortality.

“Advantage and disadvantage accumulates over time, it’s time to change the narrative and shift the direction of public policy towards social determinants and achieving equity. Declaring racism as a public health crisis could change this dynamic.”

Milwaukee, Wisconsin, declared racism a public health crisis earlier this year.

Facebook Twitter Pinterest Birthing Beautiful doula Marlene Morris during a check-in at the home of Rachel in Cleveland Heights, Ohio. Photograph: Shooting Without Bullets/The Guardian

‘Black babies and black mothers are dying’

BBC is located in a cozy converted house in Hough, one of the city’s most marginalized neighborhoods, where women attend classes on breastfeeding, baby bonding and healthy eating in the open-plan lounge. (In 1966 the economically depressed and predominantly African-American neighborhood of Hough was the site of four days of rioting sparked after a black man was denied a glass of water at the white-owned Seventy-Niners Cafe at Hough Ave. The National Guard ordered in and, four days later, four people had been killed.)

The women coming to BBC can also access legal assistance, education, art therapy and entrepreneurial opportunities. In the past five years, they have trained almost 30 “super doulas” who have worked with more than 600 women. Creating jobs and reducing infant deaths marries Farmer’s two passions: community wealth-building and health equalities.

“I’m unapologetic about ensuring African Americans get opportunities first. We need space to focus on our community issues because as a culture we have so much healing to do,” said Farmer.

Doula Marlene Morris, 38, has supported 27 mothers through childbirth this year and witnessed countless examples of casual racism in hospitals such as assuming the woman’s partner is nothing more than a “baby daddy”.

“There are some awesome midwives, nurses and doctors, but too many assume that black women are angry, on Medicaid, and don’t have a birth plan, and can tolerate more pain.”

Research by the University of Virginia in 2016 found that a substantial proportion of white medical students and residents falsely believe black people have less-sensitive nerve endings, and that black skin is thicker than white.

Facebook Twitter Pinterest Myranda Majid, a community support specialist at Birthing Beautiful Communities. Photograph: Shooting Without Bullets/The Guardian

“Black babies and black mothers are dying … women come to us because they are scared,” added Morris.

To qualify for BBC help, there are some non-negotiable rules: smokers must stop smoking (which may contribute to their good outcomes), and are obligated to take anxiety management classes, known as Sisters Offering Support (SOS). Why? Toxic stress.

In the first few months of BBC, Farmer noticed an odd phenomenon among pregnant women coping with tough situations such as domestic violence, poverty, homelessness and family incarceration – they consistently denied feeling stressed.

To find out why, Farmer approached Angela Neal, a professor, clinical psychologist and director of the Program for Research on Anxiety Disorders among African Americans at Kent State University.

The findings show a link between the extent of racism a woman has experienced and low cortisol levels – which is associated with anxiety and PTSD.

“The cause of toxic stress is American racism, and that is the principal social determinant of infant mortality disparity,” added Neal. “Part of the solution to infant mortality is making sure emotional care is part of antenatal care.”

Farmer added: “Black women have been normalizing and internalizing stress and trauma for so long … this is a big deal in prematurity which is killing our babies.”

Toxic stress contributes to conditions like hypertension and pre-eclampsia, which increase the risk of premature birth and its complications -– the largest contributors to infant death globally. In the US, one in 10 babies were born premature last year, signalling the fourth consecutive annual increase, according to new figures by March of Dimes, a not-for-profit that works to improve the health of women and babies. The premature birth rate among black women is 49% higher than for white women.

For black women in America, the grind of institutional and societal racism generates physiological stress which directly increases the risk of life-threatening conditions for them and their babies.

In a 2010 paper on the complex web of factors which contribute to racial inequalities in infant mortality published in the Maternal and Child Health Journal, academics at the University of South Florida concluded: “In addition to infant, maternal, family, community and societal characteristics, we present research linking racism to negative birth outcomes and describe how it permeates and is embedded in every aspect of the lives of African American women.

“Understanding the contribution of history to the various factors of life of Black women in the United States will aid in developing more effective policies and programs to reduce Black infant mortality.”

But sometimes nothing is enough.

Facebook Twitter Pinterest Jazmin Long , Vice President of Fund Development, nurses a baby at the Birthing Beautiful’s headquarters. Photograph: Shooting Without Bullets/The Guardian

‘Grassroots is what’s going to save our babies’

Romanique Rice did everything right. She read countless pregnancy books, ate well, attended classes and antenatal appointments, and called upon doula Morris for support and advice.

“I wanted someone to have my back in the hospital … a doula the same race as me, who understood my experiences, the inequalities and circumstances of my life without judgment,” said Rice, 26.

Everything seemed fine. Rice went into labour at full term, but by the time she got to the hospital her daughter, Riley, had died in utero. She wouldn’t, couldn’t believe it until Morris arrived to relay the news. A placenta abnormality was the probable cause. Rice and her partner were devastated, and so was Morris and the whole BBC family. “I’m just trying to help her process the grief and find the answers she needs,” said Morris.

It’s the first time Rice is back at the BBC house since the stillbirth, and it hurts. “I was so angry, full of emotions, but Marlene has helped keep me calm and give me clarity.”

Farmer is an optimistic changemaker with ambitious plans to extend the super-doula model across America. So far she’s opened a second BBC centre in the neighbouring city of Akron; developed standardized training and care protocols to ensure fidelity to their model; is writing a book and working towards opening the state’s first midwife- and doula-run community birthing centre

To do this work, BBC receives financial support from the state government and the Cleveland Clinic, a world-class medical system with health centres and hospitals across north-east Ohio where health and wealth inequalities are stark.

Farmer has no qualms about this juxtaposition. For her, the infant mortality divide is systemic, but the solutions are local.

“Grassroots is what’s going to save our babies and everyone else should be supporting partners in that work including hospitals and government.”

She added: “I don’t focus on what we can’t do, only what we can do and know that we can solve infant mortality so that’s my goal. I won’t stop until that goal is realised, and if that means I have to figure out other strategies, well bring it on, that’s what I do.”

These photographs were a collaboration between Jasmine Banks, a student photographer at Shooting Without Bullets, Amanda D. King and McKinley Wiley.

Follow Guardian Cities on Twitter, Facebook and Instagram to join the discussion using #citychampions, catch up on our best stories or sign up for our weekly newsletter.