Petersen K, Phillips S. Historical context of racism in the U.S. and its impact on maternal mortality. HPHR. 2021;34.
Annually, the United States spends an excess of 3.8 trillion dollars on healthcare, accounting for about 17% of its gross domestic product. Although this is almost twice the average of other high-income nations, the U.S. shamefully ranks last among them in life expectancy (Tikkanen & Abrams, 2020). Moreover, the maternal mortality rate in the U.S. – at 17.4 deaths per 100,000 live births – is the highest among comparable countries (Tikkanen et al., 2020). However, these health disparities do not affect all women in the U.S. equally; Black women are two to three times more likely to die from pregnancy-related causes than white women (Center for Disease Control & Prevention, 2019). This article dives into these disparities and explores the role of racism and its historical context in the systems that contribute to the disproportionately high maternal mortality rate of Black mothers in the U.S.
To understand the current systems in place today, it is imperative to recognize their historical origins. The practice of modern-day obstetrics and gynecology was in part built upon the backs of enslaved Black women. In 1662, a colonial law, known as partus sequitur ventrem, established that children were to assume the legal status of their birth mother (Morgan, 2018). Although white bound labor was arguably as economically important as slavery in the colonial 17th century, this policy did not apply to the children of indentured servants (Klein, 2020). Consequently, children born to enslaved Black women were born into slavery, while children born to white indentured servants were born free. When the transatlantic slave trade was banned by the U.S. in 1808, slaveholders in the South relied heavily on exploiting the reproductive lives of Black women to acquire more slaves (Owens & Fett, 2019). This gave life to an era of unethical medical experimentation on enslaved Black women – especially in the field of obstetrics and gynecology.
Numerous medical breakthroughs have been a direct result of experimentation on this vulnerable population. Dr. James Marion Sims, often referred to as the “Father of Gynecology”, is accredited for discovering the first successful surgical technique to treat vesico-vaginal fistulas. Although admittedly a great medical achievement which has improved the quality of life for many birthing individuals, it is becoming more widely accepted that he leveraged his position of power to experiment on enslaved Black women without consent or use of anesthesia (Ojanuga, 1993). Likewise, Dr. François Marie Prevos pioneered modern techniques for the cesarean section by experimenting primarily on slaves (Owens & Fett, 2019). These historical roots of racism in medical innovation and discovery have direct consequences that shape and perpetuate modern day disparities in healthcare outcomes, particularly among Black women.
Many present-day Americans associate eugenics with the mistreatment of marginalized groups by Nazi Germany during the Holocaust. However, the history of eugenic sterilization of vulnerable populations in the U.S. is much more obscure. Eugenics is the practice of selective breeding with the goal of improving a population’s genetic composition (Merriam-Webbster Dictionary, 2018). In the U.S., white elites used the pseudoscience of eugenics to justify the sterilization of individuals deemed “unfit” for society. State-sponsored sterilization programs during the 1900’s largely targeted low-income women and women of color, and led to the permanent infertility of thousands of Black women across the country (Taylor, 2020). The coercive nature of these procedures disregarded the concept of informed consent – a pillar of modern-day medical practice. Although these unethical sterilization policies are no longer accepted as common practice today, disproportionate rates of permanent sterilization procedures among Black women continue (Shreffler et al., 2015). Erica Cohn’s documentary film Belly of The Beast details the process to unearth a legacy of coercive and illegal state-sponsored sterilization of Black women (among others) in California prisons, a practice still in existence today under the guise of “medical necessity” (Cohn, 2020).
Contextualizing modern day health disparities among Black women in America to its egregious historical origins further explains the underpinning racism built into medical systems. Black women continue to suffer the highest rate of maternal mortality rates. According to the U.S. Centers for Disease Control and Prevention (CDC), the rate of pregnancy-related mortality, calculated as deaths per 100,000 live births, was 41.7 for non-Hispanic Black women compared to 13.4 for non-Hispanic white women (2019). Distressingly, pregnancy-related deaths are largely considered to be preventable (Petersen, 2019). The cause of these stark racial disparities in maternal healthcare is attributed to the interaction of multiple complex factors – most pressing of which is systemic racism.
There is a substantial body of evidence demonstrating that unequal access to resources drives racial disparities in healthcare, particularly among birth outcomes for Black women (Bailey et al. 2017; Williams & Collins, 2001). Through inherently racist policies, Black Americans have been actively excluded from qualifying for support through social programs. One clear example of this phenomenon is the U.S.’s federally-sponsored policy of “redlining” where, starting in the 1930s, lenders were discouraged from investing in African American neighborhoods. In a striking social epidemiology study, Krieger et al. (2020) assessed the odds of living in a historically redlined district and having a preterm birth in New York City between 2013-2017. The findings were appalling and showed that living in a redlined district was associated with 1.6 times (60% greater) odds of having a preterm birth, as compared to living in a historically greenlined (most favorable) neighborhood (Krieger et al., 2020).
Even after the enactment of the Civil Rights Act of 1964, the harmful effects of redlining and residential segregation still persist in communities today. This institutionalized form of racism promoted inequities between neighborhoods, including in access to healthcare (Mendez et al., 2011). Moreover, a systematic literature review showed that race-based residential segregation was associated with an increased risk of adverse birth outcomes among Black mothers and not among white mothers (Mehra et al., 2017). Where a person lives, and the community he or she engages with, has significant consequences for health and well-being. Although some of these policy ambiguities have been addressed today, this contributed to a dangerous precedent of institutionalized racism in the U.S.
Medicaid, a government-sponsored health insurance program for low income individuals, is a crucial source of health care access for many reproductive age women, particularly Black women. Black Americans are disproportionately affected by poverty; according to U.S. Census Bureau data, the poverty rate in 2019 was 21.2% for Black Americans and only 9% for white Americans (Kaiser Family Foundation, 2013). In addition to being the largest payer of family planning and maternal health services in the U.S., medicaid also covers almost half of all births (Markus et al., 2013). Along with the qualification based on income (<138% of federal poverty line), the Affordable Care Act’s Medicaid expansion allowed states the opportunity to offer coverage to more families in need. Unfortunately, the failure of states to expand Medicaid programs has further increased racial health disparities. Expanding Medicaid improves women’s health outcomes and reduces maternal mortality rates. In states that have not expanded programs (largely concentrated in the South) the uninsured rate among Black Americans was 14% compared to 8% in expanded states (Adam Searing & Cohen Ross, 2019). This pointed example of the connection between race and lack of insurance coverage leading to adverse maternal outcomes clearly demonstrates institutionalized racism in today’s society.
To make matters worse, having access to services does not necessarily guarantee that the care received is of high quality. Wealthier neighborhoods have access to more advanced medical facilities and improved standards of care. The inequitable distribution of wealth between neighborhoods, even within the same cities, bolsters racial disparities in health outcomes. For example, New York City houses both some of the richest and poorest neighborhoods in the country. Black women in New York City have a twelve-fold higher risk of pregnancy-related deaths, again compared to the national average of a two to three-fold increased risk (Howell & Zeitlin, 2017).
Although structural racism facilitates large-scale harm through racist policies and systems, individuals’ implicit bias also contributes to racial disparities in maternal health outcomes. In contrast to overt and intentional discrimination, implicit biases are the unconscious thoughts and feelings an individual holds about a group of people and are formed through repeated exposure to racist stereotypes propogated by systemic discrimination. These biases can influence physicians’ decision making processes – especially in high-stress environments, such as maternal healthcare units (Saluja & Bryant, 2021). In 2012, a study found that Black women sustain the highest rate of cesarean deliveries, even after adjusting for medically necessary procedures (Roth & Henley, 2012). Three of the six leading causes of maternal morbidity and mortality are associated with cesareans: hemorrhage, complications of anesthesia, and infection (Saluja & Bryant, 2021). Therefore, this association details a proposed mechanism for how implicit bias in part contributes to the increased risk of pregnancy-related death for Black women.
Under the guise of scientific methods, the medical community has historically attempted to biologically differentiate between Black and White individuals, strengthening the effects of implicit bias further. Over the years, myths about Black bodies have been perpetuated even against scientific reasoning. For example, some physicians still hold the false belief that Black people have less sensitive nerve endings, thicker skin, and stronger bones (Saluja & Bryant, 2021). Consequently, health care providers tend to perceive Black patients’ pain as lower than other races and ethnicities. In a 2004 study, researchers found that laboring Black mothers had significantly lower rates of epidural analgesia use than white women, when controlling for socioeconomic factors, age, rural-urban residency, and availability of anesthesiologists (Rust et al., 2004). All healthcare providers must strive for an active awareness of their own implicit biases or racist tendencies before making critical patient care decisions.
The historically erroneous understanding of race as a biological construct has permeated to the present day use of clinical tools, such as those that predict medical risk like the Vaginal Birth After Cesarean (VBAC) calculator. The VBAC calculator was established in 2007 through a large-scale prospective observational study analyzing factors predicting a successful vaginal birth following a previous cesarean delivery (Grobman et al., 2007). The final VBAC calculator incorporates biological items with a plausible application to childbirth (age, height, weight) and also includes African-American (and Hispanic) race/ethnicity with no explanation, falsely suggesting that there may be a physiological difference to being African American or Hispanic. Moreover, the final calculator neglected to consider the multitude of other social factors that decreased the success of a vaginal birth after a cesarean. As previously stated, Black women face the highest rates of cesarean sections in the U.S., contributing to increased risks of adverse outcomes and built upon a foundation of racism. There has been a recent movement to challenge the inclusion of race in the VBAC calculator and recognize “racism” not race as the underlying driver of adverse outcomes (Vyas et al., 2019; Rubashkin, 2020).
The health disparities experienced by Black women in the United States are a reflection of broad social and economic inequities rooted in historical and ongoing injustices. The sobering statistics discussed in here were exposed years ago, yet little progress has been made. In the nation that spends more money on healthcare than any other country, we should not struggle with such vast racial inequities. The United States is currently in the midst of a revitalized social justice movement that will give rise to leaders in healthcare who are committed to improving health equity for all. We can do better and we will.
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Kevin Petersen (he/him), MPH, is a medical student at the University of Central Florida College of Medicine and recently completed an MPH in Health and Social Behavior at Harvard T.H. Chan School of Public Health. He plans to pursue a career in Obstetrics and Gynecology after medical school. His advocacy and research interests include health equity and transgender healthcare within the field of OB-GYN.
Sara E.K. Phillips (she/her/hers), MPH is a recent graduate of the Harvard School of Public Health and is now completing her MD at the University of Washington School of Medicine. A budding OBGYN, Sara is a womxn’s health advocate, health equity researcher, and social justice organizer.