Crisis in the Crib:
The Struggle for Justice in Black Maternal Health
by Zion Brannon, Department of Pharmaceutical & Biomedical Sciences
Black maternal mortality, the disproportionately high rate of pregnancy related deaths among Black women, is a multilayered public health crisis with deep historical and systemic roots. From the exploitation of their bodies during slavery to healthcare segregation in the 1960s, history has put Black women at a disadvantage. This continues today through residential discrimination, resulting in resource deserts and extreme poverty rates. Furthermore, many providers have formed implicit biases that influence their care of black women. As a result, Black women are three to four times more likely to die during childbirth than their white counterparts.
This paper explores the connection between systemic issues and the Black maternal health crisis. It explores potential solutions, including medical education reform, implicit bias training, and increased advocacy for Black mothers. This research aims to inform policies to ensure race does not predispose women to negative outcomes.
maternal mortality, health disparities, Black women
Introduction
Having a baby is typically associated with joy, celebration, and excitement for the new life ahead. Most people do not go into the hospital room wondering if they will leave with their newborn after delivery. However, for many Black expectant mothers, this is a reality they must face. Black women are three to four times more likely to die during childbirth than their white counterparts (Hailu et al., 2022). When confronted with this alarming statistic, a seemingly straightforward question arises: why does this inequality exist?
Unfortunately, this question does not have a simple answer. Black maternal mortality —the death of Black women during pregnancy, childbirth, or postpartum— stems from both structural racism (an intricate web that connects historical injustices to modern-day disparities) and implicit bias in medical care. What began with unethical medical experiments on enslaved Black women has evolved into inequities in pain management and quality care access and continues to systemically place Black mothers at risk. Confronting these issues requires medical education reform and public health initiatives that empower Black women in healthcare settings.
Despite the severity of Black maternal mortality, the medical and science community has struggled to reach a consensus on its root causes. Difficulties in standardizing the research on this topic coupled with limited studies on how the intersectionality of race, socioeconomic status, and education level affect health outcomes have prevented the development of a comprehensive model of maternal racial disparities (Hailu et al., 2022).
However, some researchers are taking on this challenge. One of these scientists is Dr. Sheree Boulet from Emory University. After experiencing postpartum issues, she pursued a Master’s in Public Health, where her research showed that many Black women’s birthing experiences were worse than hers. After two decades of study, Dr. Boulet argues that structural racism is one of the main contributors to maternal health disparities (S. Boulet, personal communication, November 4, 2024). Structural racism is the combination of cultural, social, legal, and political systems that marginalize and unfairly treat racial minorities. In the United States, this manifests as historical discrimination, residential segregation, and over-policing.
Historical Foundations of Black Maternal Mortality
Of these, Dr. Boulet believes that historical racism is the most crucial component (S. Boulet, personal communication, November 4, 2024). While, on the surface, our society has progressed towards equality, Black communities are still dealing with the residual effects of slavery and the Jim Crow era.
For instance, J. Marion Sims, the “father of modern gynecology,” derived many of his practices from experimenting on enslaved women, often without anesthesia (Minehart et al., 2021). Although society today recognizes these practices as unethical, these studies have left lasting impacts, such as medical providers’ belief that Black women have a higher pain tolerance than white women. This bias continues to affect modern healthcare, as evidenced by a 2021 study on Black maternal experiences, where one participant described being forced to have a C-section without proper anesthesia. Despite communicating her pain by screaming and crying throughout the procedure, the doctors continued the procedure, leaving her traumatized (Canty, 2021). This scary parallel to the antebellum period is a clear depiction of slavery’s lingering effects.
Just as the legacy of slavery continues to shape biased perceptions of Black women in healthcare, the repercussions of the Jim Crow era—particularly healthcare segregation and unethical experiments —have deepened Black mistrust in the medical system, with lasting effects on maternal health. Black Americans over the age of 60 experienced healthcare segregation and restricted access to care during the Civil Rights Era (Alson et al., 2021). Many people in this age group also witnessed the impacts of the Tuskegee Syphilis Study. In this CDC experiment, Black men with syphilis were promised treatment but instead given placebos to observe the effects of the disease’s progression. Living through these problems increased Black Americans’ suspicion of doctors and the medical system. This mistrust has been passed down generationally, and now, Black patients, especially expectant mothers, often avoid medical care unless it is an emergency.
Modern Day Barriers to Maternal Healthcare
Even for Black women who seek medical care, residential discrimination poses additional barriers. In 1968, the Fair Housing Act outlawed housing discrimination. However, the communities formed before this law passed remain marginalized, facing “isolation, resource deprivation, and exposure to poverty, violence, and environmental toxins” (Alson et al., 2021). The concentration of railroads and industrial plants, along with the lack of access to parks and healthy grocery stores, increases the risk of health conditions like asthma and hypertension for those living in predominantly Black neighborhoods (Hailu et al., 2022). Structural racism in the form of over-policing exacerbates this issue. When community members constantly feel watched by police, their stress levels often increase. This can contribute to early aging and potentially asthma, diabetes, and high blood pressure.
Despite their higher risk of poor health conditions, Black women in these communities often do not have access to adequate healthcare. Poverty within the community increases its citizens’ reliance on government assistance. According to Dr. Boulet, this causes healthcare providers to avoid practicing in these areas because of lower compensation rates. The combination of an increased predisposition to poor health and a lack of satisfactory care sets potential mothers up for failure before their pregnancy process even begins.
Healthcare Providers’ Implicit Bias
Sadly, no matter how many of these barriers a Black woman overcomes, there is one that she cannot escape—her race. Race is an unavoidable factor that independently “places women at risk for poor maternal outcomes” (Canty, 2021). Despite her affluence and resource access, Serena Williams had a challenging birthing experience demonstrating this unfortunate reality. After delivering her baby, she experienced intense coughing and trouble breathing. Knowing her medical history, Williams believed she was experiencing a pulmonary embolism, a life- threatening blood clot in her lungs. She asked the nurse for a CT scan but was dismissed. When she finally spoke to her doctor, after continual efforts to be heard, he confirmed her suspicions and immediately provided treatment. Williams’ story highlights that even access to quality healthcare and wealth does not prevent Black mothers from being unheard, and thus endangered, by medical professionals.
To address the cause of experiences like these inside doctors’ offices, we must look towards a different type of racism—implicit bias. The American Psychological Association defines implicit bias as a “negative attitude, of which one is not consciously aware, against a specific social group” (American Psychological Association, n.d.). We all have implicit bias, but in the medical
field, it can be deadly. According to Dr. Boulet’s research, a surprising number of medical professionals have negative beliefs about Black women, such as being less knowledgeable about their conditions, less likely to be cooperative, and less likely to adhere to treatment plans. These assumptions show up in the care, or lack thereof, that Black mothers receive. For example, Black women are assessed and prescribed opioids less frequently than white women (Minehart et al., 2021).
Implicit bias can also appear in more covert ways. One study participant recalled her doctor assuming she needed food stamps and other government assistance despite her education and wealth level (Canty, 2021). The doctor meant well but still made harmful assumptions about his patient’s economic status because of her race. Doctors often fall back on societal stereotypes and previous negative experiences in stressful situations, even if this implicit bias is unintentional. While most medical practices try to counteract this with implicit bias training, Dr. Boulet said bias awareness alone is insufficient. Making lasting changes requires action steps. Unfortunately, learning these steps takes time, and many well-intentioned doctors are too busy to acquire and implement them. A simple solution is for medical schools to incorporate implicit bias training into the curriculum. Unfortunately, this is not always the reality. A third-year medical student at The Medical College of Georgia explained that she was only offered one cultural competency lecture throughout her time at the institution. To make matters worse, she estimated that only 15% of the students were attentive. (Anonymous student, personal communication, October 31, 2024). Refusing to accept that this should be the standard, I set out to find an institution that equipped its students to be culturally competent doctors with minimal implicit bias.
Pathways to Change
Morehouse School of Medicine embodies this approach. It is a Historically Black College (HBCU) whose mission is to “increase the diversity of the health professional and scientific workforce, ultimately advancing social equity (MSM website).” Piper Harper, a student at this institution, shared how the school practices its mission. She boasted of its ability to design classes dedicated to studying societal factors affecting health and select case studies representing diverse populations. She also highlighted how Morehouse engages its large population of Black students in service initiatives to foster relationships and increase trust between the Black and medical communities (P. Harper, personal communication, November 5, 2024).
Along with changing the healthcare providers’ behavior through early training, empowering Black women before and during their pregnancies can also help reduce their maternal mortality. For example, the CDC launched Hear Her®, a campaign dedicated to sharing the stories of women and their pregnancy-related complications. The goal is to educate women on ways to make their voices heard and listen to their bodies during their medical experiences. Other experts suggest that developing patient education programs can help women understand what conditions may develop during or after pregnancy. Together, these strategies can help women regain agency in the delivery room, ensure they know what standard of care to expect, and equip them to hold doctors accountable.
Conclusion
Understanding the Black maternal health crisis requires reflecting upon systematic policies and how they have shaped medical professionals’ opinions of Black women. To address these problems, training culturally competent medical students and empowering expectant mothers are two promising solutions. While more research is still needed to determine the exact causes and most effective solutions to maternal disparities, one thing is clear. A Black woman bringing new life into the world should never come at the expense of her own. Therefore, we must help raise awareness and support changes to ensure that every mother, regardless of race, receives the care and support she deserves.
References
Alson, J. G., Robinson, W. R., Pittman, L., & Doll, K. M. (2021). Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review. Health Equity, 5(1), 49–58. https://doi.org/10.1089/heq.2020.0081.
Awards and recognitions | Morehouse School of Medicine. (n.d.). Retrieved November 1, 2024, from https://www.msm.edu/Community/awards.php.
Canty, L. (2021). The lived experience of severe maternal morbidity among Black women. Nursing Inquiry, 29(1). https://doi.org/10.1111/nin.12466.
Hailu, E. M., Maddali, S. R., Snowden, J. M., Carmichael, S. L., & Mujahid, M. S. (2022). Structural racism and adverse maternal health outcomes: A systematic review. Health & Place, 78, 102923. https://doi.org/10.1016/j.healthplace.2022.102923.
Hear personal stories of pregnancy-related complications. (2024, July 9). HEAR HER Campaign. Retrieved November 2, 2024, from https://www.cdc.gov/hearher/personal- stories/index.html.
Implicit bias. (n.d.). https://www.apa.org. Retrieved November 3, 2024, from https://www.apa.org/topics/implicit-bias.
Minehart, R. D., Bryant, A. S., Jackson, J., & Daly, J. L. (2021). Racial/Ethnic Inequities in Pregnancy-Related Morbidity and Mortality. Obstetrics and Gynecology Clinics of North America, 48(1), 31–51. https://doi.org/10.1016/j.ogc.2020.11.005.
Acknowledgements: I would like to thank Dr. Gallagher for mentoring me through this paper writing process. She encouraged me along the way and offered valuable feedback. I would also like to thank Dr. Sheree Boulet and Piper Harper for allowing me to interview them.
Citation Style: APA