Arak Journal

From Slavery’s Shadow to Systematic Injustice: Unmasking the Crisis of Black Maternal Mortality in the United States

By Renee DeBellis

In recent years, the United States maternal healthcare system has seen significant improvements, yet these improvements are not felt equally amongst different races. Black women are three times more likely to die during pregnancy or postpartum than their white counterparts, and are 36% more likely to have a cesarean section which increases the risk of hemorrhage, infection, and chronic hypertension (Clouser). Additionally, Black infants have a 60% chance of being born preterm and have the highest rates of low birth weight (Prather et al. 253). In the book, Under The Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation, author and activist Linda Villarosa explores these racial health inequalities and how systematic disadvantages carelessly designate the lives of Black women as less than. The crisis of Black maternal mortality in the United States, apparent in Villarosa’s work, is a reflection of healthcare disparities that stem from a deeply entrenched history of governmental neglect and abuse against Black women’s reproductive rights.  For change to begin within the reproductive healthcare system, comprehensive reform and social justice advocacy in maternal healthcare practices must elucidate how historical injustices and racial capitalism have perpetuated this disparity.   

The legacy of slavery and its effects continue to devastate the lives of Black women in America. During the 18th and 19th centuries, enslaved Black women were forced to reproduce, and an estimated 58% of enslaved women from ages 15 to 30 experienced sexual assault by slave owners and other white men, including the family of the master (Prather et al. 250). This reproductive exploitation and acts of violence resulted in “some women having to bear children every 2 ½ years” (Clouser). Black women were forced to take on the role of raising white children, including nursing, at a disadvantage to their own children. The success of slavery as an institution and economic force relied on Black women to supply future labor by reproducing at high rates. Villarosa argues that since the beginning of enslavement, “there has been a Black-white divide in who survives, how they live, and who dies, from birth to the end of life” (Under the Skin 21). Forced reproduction was justified by laws and physicians who designated Black women as hypersexual and seductive Jezebels. Moreover, the myth of Jezebel intersects with the myth of the “Strong Black Women” resulting in stereotypes about pain tolerance, fertility, and reproductive care. Doctors who inaccurately perceive pain or sensitivity cause unnecessary harm to Black pregnant women and their babies. A 2016 study conducted by researchers at the University of Virginia found that white medical students and residents believed in these assumptions because of individual prejudice and “deeply ingrained unconscious stereotypes” (Villarosa, “Black Mothers”). While slavery was abolished on the individual level, the culture of slavery and suppression of Black freedom is continually central to American identity and medical practices. 

In addition to slavery, Black women have been subjected to other forms of reproductive violence such as forced sterilization and experimentation. The birth of American gynecology and obstetrics was developed on the bodies of Black people. The “Father of Modern Gynecology” James Marion Sims “performed many reproductive experimental surgeries without anesthesia to treat various childbirth illnesses among enslaved African American women” (Prather et al. 251). The exploitation of Black women’s bodies for the benefit of the white population was also prevalent during the eugenics movement. The founder of what would later become Planned Parenthood, Margaret Sanger, fought for birth control to restrict minority groups from reproducing. In a proposal draft, Sanger deemed the South as the “‘primitive state of civilization in which most negroes… live[d]…’ beset by low intelligence, sexual carelessness, and high rates of contagious disease” (Kaplan 173). Although her work is essential to women’s reproductive rights as a whole, Sanger relied on racist stereotypes to gain financial support and openly advocated for the sterilization of certain groups of people. Throughout the 20th century, eugenics state laws were passed that legitimized the forced sterilization of people with disabilities which “disproportionality impacted young and poor Black women often diagnosed as mentally ill because they were seen as promiscuous, had children outside marriage, or engaged in interracial sex” (“Reproductive Oppression”). These involuntary procedures are further proof of how the political model of white heteromasculine power and maintenance of racial capitalism in the United States is financed by the vulnerability and control of Black women.

 For generations, the U.S. government has punished Black women because of their race and gender.  In the ‘60s and ‘70s sterilization took on a different form but was legitimized by welfare policies. To receive government assistance, “Black women who had more than one child were also required to “consent” to sterilization” (“Reproductive Oppression”). The term “welfare queen” rose to popularity in the 1980s and was a derogatory and racially charged depiction of women who allegedly exploited the welfare system. The reliance of Black mothers on public assistance is not the result of hypersexuality, but rather the fact that “poverty rates are about 28 percent for Black women compared to 10 percent of White women” (Clouser). Regardless of education or income, Black women are also “more likely to reside in lower socioeconomic status communities” (Clouser). Villarosa’s book, Under the Skin, which was born from her 2018 New York Times article “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis,” tells the unfortunate story of Simone Landrum who “lost her baby daughter and almost lost her life” due to the harsh and dismissive way physicians treated her (Under the Skin 20). Laundrum’s treatment demonstrates that a combination of personal-level internal biases and systematic racist principles contribute to this crisis. This raises the question: Is it possible for Black women to reconcile with the prospect of accepting assistance from the government and institutional entities that have historically marginalized and mistreated them? Furthermore, is it even possible for an institution rooted in racist ideology to be reformed on a wide-scale level? These questions reveal the complex dichotomy of establishing solutions to this crisis that are effective and contend with the fact that wide-scale Black reproductive control has been essential to the reproductive liberty of white, middle-class women.  

As a whole, the medicalization and capitalization of birth in the United States has resulted in poorer maternal outcomes for all women, but especially for those most vulnerable in society.  During the late 19th century, the outlook on childbirth and pregnancy risks shifted with the growth of “sanitary science and the germ theory of disease” and pain relief drugs which in turn positioned physician-attended births and hospitals as safer than midwifery (Goode and Rothman 80). Additionally, the inequalities of America’s private insurance system disproportionately leave Black women with unequal access to reproductive care, including fertility treatments, family planning services, and abortion access. Villarosa eloquently points out in her book that a physician’s “denial of racial bias can be so extreme that no one believes you even when you have the evidence” (Under the Skin 20). With no regard for the effects of institutional racism, doctors believe that the death of Black mothers and babies can solely be changed through better education, or the actions of Black mothers themselves. However, it should be the basic practice for, “public health researchers [to] be familiar with the histories and lived experience of their African American patients to appropriately design collaborative prevention efforts that ameliorate racism and its health-related impacts among African American women” (Prather et al. 256). Additionally, physicians should be aware of the theory of “weathering” developed by Dr. Arline Geronimus at the University of Michigan School of Public Health. She linked that the stress caused by repeated exposure to discrimination triggered the premature deterioration of the bodies of Black women which could lead to poorer pregnancy outcomes (Villarosa, “Black Mothers”). A 1997 study conducted by a team of female researchers from Boston and Howard Universities on almost 60,000 Black women found, “higher levels of preterm birth among women who reported the greatest experiences of racism” (Villarosa, “Black Mothers”).  As researchers continue to fill in the gaps caused by a bias toward conducting long-term medical studies about white women, it is becoming more evident that the accumulation of traumatic life experiences can cause sustained levels of stress that make the body more physically vulnerable. One of those traumatic experiences is racism. Because of the centuries of mistrust Black women have experienced at the hands of predominantly white doctors, it is necessary for more OB-GYNs in the United States to be people of color. Although affirmative action has been deemed unconstitutional by the Supreme Court, medical admissions need to consider that, “patients rate their healthcare experience higher when they see a provider who resembles how they themselves look” (LoGiudice 3). A survey conducted by healthcare company Press Ganey with over 117,000 responses found that “racial/ethnic concordance between a patient and their provider greatly improved the patient experience” (LoGuidice 3). By funding scholarships aimed at increasing diversity and shifting the attitudes amongst medical professionals, diversity among maternal health providers will improve Black women’s outcomes. 

On the other hand, revolutionary change can only truly begin with the de-medicalization of birth. Less than 10% of births in the U.S. are attended by midwives in comparison to 50-70% of births in other developed nations that have more positive health outcomes. When midwives attend births there are “significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death” (Vedam et al. 2). The role of Black women in birthing as doulas can be traced back to the period of enslavement. Women of color (WOC) doulas, particularly, play an important role in the birthing experiences of Black mothers, and when supported by state governments they can mitigate high rates of Black maternal mortality. Doulas are a presence in the birthing room that create a sense of togetherness, however, “that same ‘togetherness’ often shores up the black reproductive body as a site of both profound political desires and intense struggle, and helps to produce the temporality of crisis that doulas also attempt to ameliorate” (Nash 32). Currently, there are nationwide initiatives focused on providing reproductive justice to women of color, such as SisterSong and Birthmark Doula Collective. SisterSong is the largest organization in the country that advocates for the elimination of racial discrimination in healthcare and recognition of this injustice as a violation of international human rights. In the state of Louisiana, where black mothers die at 3 ½ the rate of white mothers, Birthmark doulas have seen significantly lower rates since their founding  (Villarosa, “Black Mothers”). Other groups like Birthmark have formed in places such as Brooklyn, Memphis, Dallas, Atlanta, Los Angeles, and more. In New York City, the By My Side Birth Support Program offers free doula services for mothers in Brooklyn’s predominantly black and brown neighborhoods. From 2010 to 2015, the mothers who received the support had “half as many preterm births and low-birth-weight babies as other women in the same community” (Villarosa, “Black Mothers”).

The practice of midwifery and the doula industry has faced the extraction of profit by America’s capitalist economy which in turn highlights the tension between economic greed and societal progress. Therefore, advocates must “interrogate how doulas are called upon by the state even as they are uncompensated by the state, as evidence of a state effort to ameliorate medical apartheid” (Nash 46-47). It is also crucial to understand that the imagination of un-institutionalized medical practice is unrealistic; therefore, there must be more private, state, and federal funding and support for WOC birth-worker labor. It is almost impossible for public funding and grants to compete with privatized doulas so it is also necessary for doula support covered by Medicaid and private insurance in every state. If Black women are not making as much as other doulas then this is not an accessible option. The state of Black women’s bodies is not the crisis. It is the overmedicalization of birth connected to the privatized profits of the healthcare system that are supporting systems of racism and poverty that put the lives of Black women at risk. Medicine has historically been the site of antiblack misogynistic violence and bringing Black women into that space with proper support is required if there is to be any change in their maternal outcomes. 

The history of slavery, medical experimentation, and inadequate health care have exacerbated Black women’s sense of mistrust and complexity with maternal healthcare systems. It is vital for medical professionals to examine these historical factors and their effects to address this health crisis properly. Research and information on racial inequalities within the United States healthcare system should be a mandatory part of training for medical students regardless of their specialties. To ignore how past influences shape current outcomes is to neglect how the contextual factors of racism contribute to inequalities. For groups that have faced historical oppression and marginalization, liberty cannot solely rely on the power of government. It is inhibited by the members of society, and until those members view America’s historical acts of violence as tools for education and progress, there cannot be collective advancement forward. 

Works Cited

Clouser, Gillian. “Blackness, Maternal Mortality, and Prenatal Birth: The Legacy of Slavery.” Yale School of Medicine, 16 May 2022, medicine.yale.edu/news-article/blackness-maternal-mortality-and-prenatal-birth-the-legacy-of-slavery/.

Goode, Keisha, and Barbara Katz Rothman. “African-American Midwifery, a History and a Lament.” The American Journal of Economics and Sociology, vol. 76, no. 1, 2017, pp. 65–94. JSTOR, http://www.jstor.org/stable/45129363. Accessed 18 Apr. 2024.

Kaplan, Sara Clarke. The Black Reproductive: Unfree Labor and Insurgent Motherhood. University of Minnesota Press, 2021. JSTOR, https://doi.org/10.5749/j.ctv1ns7ndt. Accessed 17 Apr. 2024.

LoGiudice, Jenna A. “Reducing Racial Disparities in Maternal Healthcare: A Midwifery Focus.” SAGE open nursing vol. 8, 6 Nov. 2022, doi:10.1177/23779608221138430.

Nash, Jennifer C. “Birthing Black Mothers: Birth Work and the Making of Black Maternal Political Subjects.” Women’s Studies Quarterly, vol. 47, no. 3/4, 2019, pp. 29–50. JSTOR, https://www.jstor.org/stable/26803260. Accessed 18 Apr. 2024.

Prather, Cynthia, et al. “Racism, African American Women, and their Sexual and Reproductive Health: A Review of Historical and Contemporary Evidence and Implications for Health Equity.” Health Equity, vol. 2, no. 1, 2018, pp. 249-259. ProQuest, doi:https://doi.org/10.1089/heq.2017.0045.

“Reproductive Oppression Against Black Women.” Women’s Leadership and Resource Center University of Illinois Chicago, The Board of Trustees of the University of Illinois, wlrc.uic.edu/reproductive-oppression-against-black-women/. Accessed 17 Apr. 2024. 

Vedam, Saraswathi et al. “Mapping integration of midwives across the United States: Impact on access, equity, and outcomes.” PloS one vol. 13,2 e0192523. 21 Feb. 2018, doi:10.1371/journal.pone.0192523

Villarosa, Linda. “Everything I Thought Was Wrong.” Under The Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation, Doubleday, 2022, pp. 1–21. 

—. “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis.” The New York Times, 11 Apr. 2018, www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html.