Investigating Culture and Reproductive Health

MCL Backstory

By Beth Thew and Sarah Garrett

Where do we see culture in everyday life? How does culture affect individuals, interactions, and systems? How can we shift culture to reduce suffering and promote well-being? MCL member Sarah Garrett is a cultural sociologist working to understand and induce culture change in maternity care. These are the kinds of questions she thinks about as she works to advance safer, more equitable birthing experiences in the contemporary US.

Her interest in culture and reproductive health started as a sociology major in college. Sarah focused her senior thesis on college students’ attitudes about abortion, same-sex marriage, and premarital sex, and how they came to those positions. Her research engaged the interweaving forces of perception, family dynamics, and social norms. Sarah saw students frame these controversial topics in starkly different ways and gained appreciation for theories like social constructivism, which posits that reality itself is based on individuals’ shared interpretations of social worlds. 

Sarah’s interest in these topics flourished in graduate school. She entered the PhD program at UC Berkeley’s sociology department, long a hotbed of cultural theory. There, she focused on the links between individuals’ perceptions, networks, decisions, and wellbeing. Ann Swidler, the chair of Sarah‘s dissertation committee, had pioneered work in cultural theory. In some theories of culture, people are seen as “inside” a shared culture that provides values and identifies goals to pursue. Swidler, in contrast, theorized culture as something that provides individuals with a set of tools with which to act. Sarah was particularly interested in the cultural tools people had at their disposal: specifically, their ways of understanding—and actively framing—the world around them. These tools can shape what people see as possible, desirable, legitimate, and even real. A social constructivist notices that college students forge different social worlds. A Swidlerian wants to know how they use cultural tools to do so.

In her dissertation, Sarah wanted to focus directly on these “interpretive” cultural tools and behaviors: how do people come to interpret things in a particular way? Where do these perceptions come from, and what are the effects? But these are abstract questions. Sarah had to decide what kind of experiences would help her illustrate these important principles, and she quickly returned to topic of reproduction. In part, this reflected a continuation of the work she did as a college senior, her Masters thesis on gender role ideologies, and the middle-class “Mommy wars” in popular media of the time.

But it also reflected a more personal set of experiences and insights. Sarah by then had heard enough retellings to know that when she was an infant, colicky and difficult to soothe, her mother, Pam, had interpreted the colic as a sign of her own failure as a mother. “She knew I had colic, but she felt the blame fell on her shoulders. She carried a huge emotional weight that she ‘wasn’t a better mother.’”  As Sarah grew up and saw mothers interpret infant upset and other parenting challenges differently, she had come to appreciate how powerful—and varied—individual perceptions of social phenomena could be.

Inspired by these insights, Sarah focused her dissertation on the transition to first-time motherhood. This is a period when individuals invest greatly in particular outcomes that are often not achieved. A mother may want to deliver her baby with a midwife at home or, alternatively, at a hospital with substantial monitoring and pain control. Similarly, she may have strong feelings about feeding her infant in a particular way. Of course, the baby or the birth attendants or a mother’s own body can push these cherished outcomes out of reach. “Sadly, the transition to first-time motherhood is an excellent moment to study how cultural tools equip us – or not – to navigate challenges.”

In her dissertation, Sarah surveyed and interviewed women in the Bay Area in their third trimester. She came to understand their goals for their upcoming births and infant feeding and why those goals were important. She talked to the women again about two months after birth. These interviews inevitably included stories of ruptures between what the moms wanted and the reality of what had happened. How did the mothers make meaning of these ruptures and how were cultural tools involved? Sarah found that individuals who were part of diverse social networks had more different ways of interpreting--or making sense of—different perinatal outcomes and behaviors; that new mothers in private and safety-net settings varied somewhat with regard to the interpretations they were familiar with; that the reframing of events that midwives and other support people did post-partum played a large part in mothers’ ability to cope with things having gone “wrong”; and that having more different ways of interpreting perinatal events contributed to feelings of uncertainty and anxiety in many new mothers—an unexpected emotional downside to having a diverse cultural toolkit. 

Sarah found this research fascinating for all of the reasons she expected, but it motivated her in an unexpected direction. Talking with pregnant women from a variety of socioeconomic, racial, and ethnic backgrounds had revealed to her the magnitude of problems in reproductive healthcare in the United States. In a move that would take her away from disciplinary academia, Sarah set out to investigate how she could use sociology to address suffering and inequities in domestic maternal health.

Today, Sarah’s work mostly focuses on applied maternal health research. Opportunities to delve deeply into sociological theories of culture come less frequently now than in graduate school. But what Sarah learned about perception, cognition, and culture remain substantial assets in her work. She sees culture running through many interventions designed to advance maternal health equity—even though the idea of chttps://pretermbirthca.ucsf.edu/currently-funded-projects/multi-stakeholder-engagement-state-policies-advance-antiracism-maternalulture is rarely invoked. Sarah expects that efforts to address longstanding inequities in maternal health will benefit from engaging more and more thoughtfully with how mothers, parents, and providers perceive concepts such as respectful perinatal care—culture work that she increasingly sees with the spread of community-engaged research.

In recent years, the medical profession and policymakers have turned to implicit bias training as a way to address inequities. Multiple states now require clinicians to undertake it. These mandates reflect advocates’ and lawmakers’ hopes that implicit bias training will encourage clinicians to see their historically marginalized patients differently – and to behave differently toward them as a result. Whether and how implicit bias training will help is unknown.

Sarah is currently leading work to address these important policy and equity questions. Since early 2021 she has lead the Multi-Stakeholder Engagement with State Policies to Advance Antiracism in Maternal Health (MEND) study. MEND engages community members and other stakeholders to develop guidance for effective clinician implicit bias training. Sarah and colleagues have collected a wealth of ideas for how to make change. “One thing we have heard again and again is demand for training to include real site-specific patient stories so providers can better understand how biased care is playing out where they work. Narratives – something we talk a lot about at the Medical Cultures Lab – is a well-established way to help people see and think differently. “

Sarah is also launching a three-year hospital-focused study that will allow her to investigate how maternal inequities, and interventions to combat them, connect to facility characteristics. For example, is equity work more established or effective in facilities where providers routinely encounter perinatal disparities data? or engage with community representatives? “How individual clinicians view disparities and how they see their role in helping colleagues understand and correct their biases (or not) is really important,” said Garrett.

Ultimately, Sarah hopes to use these insights – from her research and her own life — to help change clinic culture to produce better and more equitable outcomes.