Last week, the world got to learn a little bit more about pro-tennis player Serena Williams’s experience giving birth to baby girl Alexis Olympia, through her interview with Vogue magazine. That little bit is now shining a big spotlight on the American health-care system and the hurdles and dangers women face bringing life into the world.
Williams delivered Alexis Olympia by emergency C-section after the baby’s heart rate declined. All was well until the next day, when Williams felt short of breath. She immediately brought this to the attention of her care providers and requested a CT scan because of her history of pulmonary embolism—that is, blood clots in her lungs—but they thought her pain medication was making her confused. Nonetheless, she was able to insist on a CT scan and get an accurate diagnosis and appropriate treatment.
Williams is an international superstar, a sports phenom, and is on track to set a new record for Grand Slam victories. But for all her celebrity and status she is, still, a black woman in America. And as such her birthing experience can’t be separated from the birthing experiences of so many black women in America, who are far likelier than white women to suffer serious complications or die as a result of childbirth. When discussing Williams’s maternal-health emergency, it’s vital to address the role played by racism and racial discrimination—a requirement to sustainably address the United States’ growing maternal-health problem.
Black women are nearly four times more likely to die from pregnancy and childbirth than white women, and are also more likely to experience a severe maternal morbidity such as a heart attack, hemorrhage, sepsis, or blood clots like Williams did, regardless of their level of education or income. In fact, data from the New York City Department of Health show that black college-educated women were more likely than white women who hadn’t completed high school to experience adverse maternal-health outcomes.
Knowledge and money aren’t enough to save black women, because racism trumps all.
Denying that fact, or failing to mention it when the opportunity presents itself, hinders meaningful progress on maternal health in the United States, where maternal mortality is rising, instead of declining as it is in the rest of the developed world. We won’t go far in solving the American maternal-health problem without first acknowledging and then addressing how racism—both inside and outside the health-care setting—harms black moms.
Racial discrimination within the health-care setting is a modern problem built on the legacy of slavery, reproductive oppression, and control of medicine and black bodies. It’s important to remember that the white medical establishment worked hard to eliminate black midwives through smear-messaging campaigns claiming they were “dirty” and by passing laws restricting their practice. Today racial discrimination in clinical care presents in a variety of ways. Research has shown that implicit racial bias may cause doctors to spend less time with black patients and that black people receive less-effective care. Doctors are also more likely to underestimate the pain of their black patients. And anecdotes of disrespect and mistreatment abound.
To those familiar with this history and research, the fact that Williams’s doctors didn’t initially take her calls for care seriously isn’t surprising. Williams knew her history with blood clots and knew what she was experiencing, but her providers weren’t inclined to trust her. How many other black women have died or nearly died because their providers refused to listen to them or because these women didn’t have the power to insist?
Beyond that, racism outside of the clinical setting is a much broader problem that influences health even before people can interact with the health-care system. Black people experience chronic stress resulting from exposure to overt and covert racism and micro-aggression, which can range from something as basic as intentionally avoiding eye contact to the extreme of being harassed, abused, or killed by police. And racist policies—like those dictating where our children go to school, whether we can vote, how clean the water in our communities needs to be, who patrols our neighborhoods, and on and on—create structural inequalities that disadvantage black people and set us up to fail.
The chronic stress arising from racial discrimination and racist policies targeting those both black and female takes a toll on the body and disrupts normal biological processes necessary for optimal health. Decades of research has established a link between stress and health, specifically the negative health consequences of living while black in America, regardless of socioeconomic status.
Nation contributor Dani McClain described for this magazine her experience dealing with this knowledge while pregnant with her daughter. She wrote, “You might think that I don’t need to worry: I eat a healthy diet; I don’t have high blood pressure or diabetes. I am not poor; I have private insurance and a master’s degree. I started prenatal appointments at 10 weeks and haven’t missed one. But I’m under no illusion that my class privilege will save me.”
Dani also shared that she stopped watching the news during her last trimester—the accounts of police violence against black bodies was just too much. She wasn’t wrong in doing so. Research by Dr. Fleda Mask Jackson found a connection between perceived police violence and depressive symptoms among pregnant black women. The risk of depressive symptoms was higher in those pregnant black women who also already had a male child. Yet much of the discourse from care providers and public-health professionals has neglected to explicitly name the role of racial discrimination and systemic oppression in black maternal outcomes.
California is considered a leader on maternal health because it has succeeded in reducing maternal mortality for all moms in the state, mostly through enhanced safety protocols that help hospitals manage emergencies during labor and delivery and provide higher-quality care. The maternal-mortality rate declined from 10.9 deaths per 100,000 live births in 2000 to 7.3 deaths per 100,000 live births in 2013. Despite these gains, the maternal-mortality rate for black women in California is 26.4 deaths per 100,000 live births. When Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative, was asked in a November 2017 interview about ongoing disparities in maternal health, he failed to explicitly mention racism or racial discrimination, focusing instead on differential treatment and resources at hospitals where black women give birth.
As a public-health professional, I have attended dozens of conferences, meetings, and briefings on maternal health. I have often been disheartened to hear public-health leaders and researchers neglect to explicitly call out the role of racism on maternal health, even when asked about it directly. Providers, researchers, and public-health professionals are more inclined to point to the high prevalence of chronic diseases such as high blood pressure and diabetes, and to the epidemic of obesity in the black community. This places the onus for large-scale change on individuals rather than the systems that we know cause harm. Neither does it acknowledge how racial oppression contributes to the overrepresentation of chronic disease and illness among black people.
To advance maternal health in the United States, we have to address our race problem, and that starts by naming it. We must acknowledge that racial discrimination affects black mothers, even those as celebrated as Serena Williams. Over Monday, Williams acknowledged the outpouring of stories that followed her going public with her own, writing on Facebook, “I didn’t expect that sharing our family’s story of Olympia’s birth and all of complications after giving birth would start such an outpouring of discussion from women—especially black women—who have faced similar complications and women whose problems go unaddressed.” She encouraged women to “continue to tell those stories. This helps. We can help others.” That’s the first step, yes—but providers, researchers, and public-health experts also need to hear our stories and acknowledge the role of racism.