Racism in Health: The Roots of the U.S. Black Maternal Mortality Crisis

Racism in Health: The Roots of the U.S. Black Maternal Mortality Crisis
Credit: Diana Ejaita

What is behind the Black maternal mortality crisis, and what needs to change? In this podcast from Nature and Scientific American, leading academics unpack the racism at the heart of the system.

[CLIP] Window rolling down

Tulika Bose [tape]: Hey, what’s that?

Protestor: It’s a brochure about all the help that’s available for pregnant women. 

Bose: I’m pulling up to one of the last clinics in Georgia where you can still get a medical abortion. 

Protestor: [tape] It’s a brochure.

Bose: [tape] What’s it a brochure about? 

On the way up the road, I’m accosted by an anti-abortion protester who starts vigorously knocking on my Uber window, thrusting a series of flyers with pictures of fetuses in my face.

Protestor: [tape] Are you here for an abortion?

Bose: [tape] Do you think I’m here for an abortion? 

Bose: After I reveal that I’m reporting for Scientific American, they try appealing to well, — science. 

Protestor: If you actually Google — like a couple of years ago, they interviewed like over 1000 biologists and 96% of them said life begins at conception. First of all you know that women getting abortions, supposedly, supposedly, for health reasons, you know, that’s less than 1% of all abortions, right?

Bose: None of this is true. But the language of science, like religion, is fast being weaponized by those opposing abortion access. And — the overturning of Roe vs. Wade is actually affecting Black pregnant people the most. 

Let me paint a picture for you. Georgia now bans abortions from 6-weeks after conception. But given that one in three pregnant people don’t actually know that they’re pregnant after six weeks, this is a problem. 

A new poll from the University of Georgia in October of last year shows that over 86% of Black voters also oppose Georgia’s new restrictions. Let’s add in something else. Of 159 counties in Georgia, 79 don’t even have access to an obstetrician. That means if you need an abortion, that puts you in a position where you might have to drive for miles.

Bose: [tape] How long you traveled from, essentially? 

Patient: About an hour and a half.

Bose: And those distances are getting further apart. A clinic manager at the Black-owned Feminist Women’s Health Center told me that pregnant people are now driving to this clinic from as far away as … 

Clinic Manager, [tape]: Mississippi, Tennessee, they still, you know. Alabama. Had a couple last Tuesday, Ohio. 

Bose:  Clinics are now being overbooked to the point of having to turn people away. More clinics are also closing under pressure from abortion bans. And if you are able to make the journey and get an appointment at a clinic, you might even be accosted by armed protestors. The clinic manager, who I’m keeping anonymous for her safety, tells me more stories about the protestors — and what pregnant people have been through with one protester in particular. One that you heard giving us some false statistics at the beginning of this episode. 

Clinic Manager: I can see it in their eyes. I say baby, don’t let that devil get to you. Don’t let what he said, hit you in your spirit. God is a forgiving God, and then I tell them about his history. You burned down a Black church and God forgave you.

Bose: [tape] Wait he burned down a Black church? 

Manager: You can google his name and the case comes up as a federal case. Down in Perry, Georgia. Houston County. And he clarified for me it was a Black church. I said, Oh, it was a Black church. Thank you, I said, because I just thought it was a regular church. But thank you, Jason, for letting me know it was a Black church.

Bose: Here’s the thing. Protestors aside, the overturning of Roe in the US added yet another hurdle for Black pregnant people seeking reproductive care. 

As you’ll find out — the weaponization of science to promote racism and control Black people’s reproductive health care isn’t new. In fact, you might even say the history of gynecology was intertwined with the desire —  once an economic need in the United States — to control Black women’s bodies, using science as an instrument. As a warning, some of the content in this podcast may be triggering for some listeners.

Harriet Washington: Horrific research, actually cutting into their skin to see where the Blackness arose, slicing into their genitalia. These profoundly painful events.

Monica McLemore: Or you could be Serena Williams and you know, you can be getting paid millions to know your own body and to know how it should function, you know, physiologically and still not have people not listen to you or believe you.

Amanda Stevenson: These are the only numbers I have ever calculated that made me cry. 

Bose: The links between science, health and racism in the United States are so deeply enmeshed, they go back to the very fabric of gynecology and reproductive health in this country. 

In this podcast, we’re going to talk about a perfect storm of factors that have led to the current disparities in maternal health — from the historical links between racism and gynecology, to the systemic erasure of America’s Black midwives, to the current reproductive rights crisis affecting the very people who were robbed of agency in the beginning.

Bose: You’re listening to Racism in Health, a new podcast from Nature and Scientific American. 

— I’m Tulika Bose 

Bose: I went to Georgia for a reason — it has the highest rate of maternal mortality in the country.  Georgia has a Black population of more than 3.6 million and according to a 2019 study, Black women accounted for 65% of all of Georgia’s abortions in that year — and stand to be disproportionately affected by the abortion ban.

Stevenson: These are the only numbers I have ever calculated that made me cry.

Bose: That’s Amanda Stevenson, a sociologist from the University of Colorado, Boulder. She wrote a 2021 study in the journal Demography.

Stevenson: Because these are people who are, you know, forced to remain pregnant when they don’t want to be and then pay literally the ultimate price for that, pay with their lives.

Bose: Amanda modeled the potential impact of overturning Roe on pregnant people in the US.

Stevenson: I’m a demographer. So what we do is we count things and count them extremely carefully. Basically, we know how many people die after having an abortion in the United States. And we know how many people die while they’re pregnant or after they give birth. And so we can use those facts to estimate how many more people would die if everyone who has an abortion instead was forced to remain pregnant. 

Bose: According to Amanda’s research, if no abortions were performed in the US, the total number of pregnancy related deaths would rise from 675 to 725, and in coming years to 815. That’s a growth in death rates from 7% to 21%. But, Stevenson found something else relating specifically to Black pregnant people. 

Stevenson: Among non-Hispanic Black women, I estimate that pregnancy related deaths would increase by a third. So by 33%. People who are Black have experienced higher rates of pregnancy related death and maternal death, then do people from any other race or ethnic category. 

Bose: The CDC estimates that maternal mortality is three times higher for non-Hispanic Black people in the United States than for white people.  But not only that — 

Stevenson: Abortion services are needed at higher rates among people who are more disadvantaged. And one of the results of this is that people who are Black, have higher need for abortion services than people who are white, non-Hispanic, Hispanic or from other race-ethnic categories. And a greater fraction of people who are in those categories of needing more abortion services are forced to remain pregnant because they had needed abortion services at greater rates. 

Bose: Stevenson’s study was cited all over the news in June of last year when Roe was overturned, but she had actually been working on it since the Summer of 2019. And at that time, she said she was also facing an uphill battle with some of her peers to get it published.

Stevenson: It was rejected like six times. Because nobody, nobody believed that it was ever going to be relevant. Yeah, the reviewers were just like, this is like just absurd.

Bose: A little context around this: Stevenson is a demographer, and her study assumes zero abortions in a post-Roe world, which her peers thought was somewhat unrealistic. But Amanda was still surprised that she faced resistance to such a simple but powerful piece of demography, especially as the possibility of an outright federal ban on abortion grows increasingly plausible.

Stevenson: The point that I was trying to make was not that that is what was going to happen. I was just trying to demonstrate that like when you end abortion, more people die just because staying pregnant is deadly or like that was the whole purpose of the paper. 

Bose: It’s also important to note that when Roe legislation did come under direct scrutiny in the Supreme court, during the case of Dobbs v Jackson’s women’s health – scientists did speak up, including Stevenson. In an Amicus brief signed by over 500 public health experts – data, including Amanda’s was presented. And among its many lines of evidence, was a clear message.

Stevenson: If we actually prevent people from getting abortions, we cause more people to die. So that increase in deaths doesn’t have to happen.

Bose: Amanda’s now working on another study, using more recent data from the US as it becomes available. As are many other researchers. But, we don’t need to wait for those studies to know that there is more going on here. Amanda’s findings don’t just highlight the disproportionate impact of the overturning of Roe. There’s a deeper problem that’s existed in the USA for a long, long time. And that’s the systemic failure of medicine in the USA — and those in it — when it comes providing healthcare to Black people — especially when it comes to maternal mortality. 

Vu-An Foster: ‘My daughter arrived, and she died during birth.’

Bose: This is Vu-An Foster, a Black woman and Master’s of Public Health student — who went through two devastating pregnancy losses, before realizing that they could have been preventable. 

Vu-An Foster: I feel like my experience on the labor and delivery floor was amazing, but once they realized that my baby was going to come and was going to die, I felt like they treated me differently. I also had a nurse and I kinda said, what’s going to happen, you know, when I have my baby? And she said, well, you know your baby is gonna die, you’re gonna deliver your baby by yourself. 

Bose: For Vu-An, this was shocking and upsetting. 

Vu-An Foster: I still was in shock, I didn’t know what was going on. I hadn’t called my family or anything. Everything was happening so fast and I wasn’t even making my own decisions. I heard statistics about infant mortality. But to live it — it’s a totally different experience. The data doesn’t show you, dealing with people who are cold. And not compassionate. 

Bose: Vu-An attributes her experience to systemic racism in the health system. But it is a problem which extends even beyond this.

Monica McLemore: One in six pregnant capable people experienced mistreatment during childbirth. 

Bose: That’s Monica McLemore, a nurse-scientist at the University of Washington. In June of 2019, Monica and other researchers published a study in the journal Reproductive Health. They utilized a WHO framework, describing seven dimensions of mistreatment in maternal care that have adverse effects on quality and safety. 

Monica McLemore: That was everything from being shouted at and scolded, you know, by a healthcare provider, violations of privacy. People feeling ignored by their healthcare team, failing to respond to requests for help in a reasonable amount of time. As a nurse, that’s people dinging the call bell light and nobody’s coming to answer, right? That’s directly in the purview of nursing. Threatening to withhold treatment, or forcing people to accept treatment maybe that they didn’t want, right? That was one in six people. 

Bose: This study — which they called Giving Voice to Mothers — documented this treatment utilizing a survey of — 2,700 people from varying racial and socio-economic backgrounds. The study found that being a person of color resulted in higher rates of mistreatment. But, it didn’t stop there.

McLemore: What we found was proximity to Blackness was enough for people to be mistreated, even if they themselves were not Black. So, you know, if you had a mom with a mixed race baby and a Black father, there was mistreatment that occurred. So at some point, we have to talk about the proximity to Blackness, being one of those risk factors from this treatment, irrespective of you yourself are or are not Black. 

Bose: There have been other studies that also show how racism and anti-Blackness – can affect health outcomes in a maternal setting. 

McLemore: That has to do with the fact that there’s anti-Blackness embedded in how people think about other humans in our country.

Bose: This anti-Blackness manifests in a host of ways, for example, a 2020 study published in the journal of racial and ethnic health disparities found that Black women were more likely to undergo unnecessary C-sections — which have greater risks of complications for pregnant people. 

Bose: Many chalk these disparities up to socio-economic status, and the quality of hospitals. And it’s true that these factors play an important role. But it’s far from the whole story. Monica told me about someone she admired, but never got to meet. Shalon Irving, who collapsed and died three weeks after giving birth. 

Monica McLemore: For a lot of people who’ve read about it, they know she was a dual doctorate, I knew her work, she was working at the CDC studying this exact issue. For me it was not hypothetical.

Bose: The Scientific community was shocked. After Irving’s initial C-section, she made several visits to her primary care providers — for hematoma, spiking blood pressure, headaches, blurred vision, rapid weight gain, and swelling legs. Her clinicians allegedly told her to “wait it out,” according to her mother. But after taking a prescribed blood pressure medication, she collapsed and died soon after. 

Monica McLemore: I thought to myself, Wow, if you can have two PhDs or Dr, pH and doctorate and really be working on this issue, and still have clinicians, not pay attention to your symptoms, still have multiple visits to health care providers where things got missed, and then to end up dying from the very condition that you were studying. 

Bose: And — Shalon Irving was far from the only wealthy, informed Black woman who experienced trauma while giving birth. For example tennis pro Serena Williams almost died when doctors didn’t believe her when she said she was having a pulmonary embolism. These stories are reflected in data, too. According to a 2016 study Black, college educated mothers who gave birth were more likely to suffer complications than white women who never graduated from high school. 

Monica McLemore: I can’t believe we have lost an iconic leader, a thought leader, a scholar, you know, in this work, for the very reasons why people can’t clearly see why structural racism in healthcare is such a problem and why health equity is so necessary and crucial. Because if we don’t rethink  training, our clinical health care workforce, this will continue to happen. That, to me, was a huge wake up call.

Bose: Given that wealthy, informed Black women are experiencing this level of difficulty, Monica’s really worried about groups that are even more vulnerable. 

Monica McLemore: Poor women have no chance. 

Bose: As we heard in the last episode, there are a myriad of ways that people have injected racism into the healthcare system — including among practitioners themselves. But — to get to the root of the problem, you have to dig deeper. To find the rot at the heart of the system. And one core example of this can be seen in a particularly insidious concept in the medical literature. It’s one that still manifests now when Black people ask for help in a clinical setting, and are denied. That’s the myth that Black people do not feel pain.

Washington: That claim is not peculiar to Black women, it was ascribed to all African Americans. All African Americans were judged to not feel pain.

Bose: This is Harriet Washington, a medical historian and ethicist who wrote the book Medical Apartheid.

Washington: The rather shaky theory being that their nervous systems are too primitive and poorly organized to register pain. 

Bose: And historically, the concept of pain was quite different. 

Washington: In the 19th century, to say that someone didn’t feel pain was to say other things as well. It was believed then that anxiety, heart disease, these things are predicated on the same neurological insufficiencies. So not just he didn’t feel pain, the belief was that they didn’t feel mental illness. They didn’t commit suicide, they didn’t feel anxiety, as whites would. 

Bose: This myth was heavily leaned on to justify slavery.

Washington: The practical advantage of this belief, which of course is untrue, but was widely embraced by medicine was that if you had a being that didn’t feel pain, one could ethically justify, in their minds at least, subjecting them to pain – You could take this person and work them in mercifully in the hot subtropical sun, you could never do that to a white person who might suffer sudden stroke who might feel pain and exhaustion. But African Americans were supposedly exempt from that.

Bose: And this myth was also capitalized on by scientists — including Marion Sims, a white man who many have referred to as the quote “father” of gynecology. Sims rose to fame by developing a treatment for a condition called Obstetric Fistula. Obstetric Fistula, by the way, is a tear between the birth canal and rectum, caused by prolonged, obstructed labor which often results in infection and urinary incontinence. It’s important to note that it’s a preventable medical condition that is disproportionately experienced by people without access to good healthcare. Globally, the majority of those are people of color. And, enslaved Black women suffered from it in the 19th century.

Washington: Dr. James Marion Simms very typically said he had cured vaginal fistula by his experimental surgeries on enslaved Black women. Enslaved black women simply could not say no.

Bose: Sims, as Washington told me, had a very specific economic reason for wanting to cure obstetric fistula in Black women. 

Washington: The problem with Black women from the medical point of view was that they couldn’t work if they had this. So Simms knew that curing this would make his fame and fortune.

Bose: And to seek this fortune – Sims experimented on enslaved Black women, many of them multiple times. And he did it without the use of anesthesia. I’ll stop right here for a trigger warning. This might be hard for some listeners.

Washington: Horrific research, actually cutting into their skin to see where the blackness arose, slicing into their genitalia. To try to find a treatment for vestical vaginal fistula. These profoundly painful events could be justified by these doctors, in their view, at least, because subjects didn’t feel any pain.

Bose: There’s a famous painting showing Simms work, by Robert Thom. It depicts a Black woman, fully clothed, her hand to her breast, surrounded by a few attending doctors. And Sims. But that picture doesn’t even begin to represent the experiments that Sims actually carried out.

Washington: In reality, according to Simms own writings,  the women were naked, and the two men and the other surgeons were there, in part to hold them down. As they screamed and tried to get away — while Sims sliced into their genitalia, a very ugly, horrific scene.

Bose: But these horrific experiments did lead Sims to a discovery.

Washington: Eventually, Sims hit upon the idea of using silver sutures to sew the wounds together. He’d sew the holes together, and the silver sutures did not harbor bacteria, did not harbor bacteria, and they actually worked.

Bose: These young women were teenagers. Their names were Lucy, Betsey, and Anarcha. Anarcha alone was experimented on without anesthesia 30 times. Despite the pain that they endured, Sims never treated them as people.

Washington: He did not linger to suture the other openings and cured women. He immediately left for Paris and New York City where he made a medical fortune. He was lionized there, adulated and became the President of the American Medical Society.

Bose: It was through research by prominent figures like Sims that the idea that Black people didn’t feel pain became accepted within scientific circles. Even though men were literally employed to hold Black women down as they screamed.

Washington: So, it was a false belief, but it was too profitable to abandon.

Bose: And the myth that Black women don’t experience pain — 

Washington: Yes, it exists today.There have been a bevy of well conducted studies showing that if you take Black people and white people with the same medical profile — the same medical history, whites will be offered effective analgesia and Black people are not only denied painkillers, because they don’t feel pain. Their claims of pain are not believed. But they also are labeled as drug seeking.

Bose: This misconception also persists among those that work in the medical sector. For example, a study from the University of Virginia in 2016 asked medical students about their understanding of pain and race.

Washington: Half of all medical student respondents did not believe the Black patients felt pain the way whites did. So did a lot of practicing physicians. And so this belief has been remarkably persistent.

Bose: Monica Mclemore too has seen this on the clinic floor and even in textbooks. Over and over and over again.

McLemore: I started my baccalaureate degree in nursing in 1988. And I have been asked to review nursing textbooks that, you know, have been in print since I was a nursing student that still recycle, you know, stereotypes and myths about Black people, Black patients.

Bose: That same study from the University of Virginia highlighted racialized myths — medical students believed that Black people’s skin was thicker, or that their blood coagulated more quickly, which resulted in less accurate recommendations for treating Black patients in regards to pain.  

McLemore: This notion that we would even think that race would somehow mediate pain is odd. Pain is a universal human experience, right? So this idea that somehow some members of our species actually wouldn’t experience pain. It’s just so odd to me. And yeah, I know that that’s taught to people.

Bose: Monica’s a scientist, but she’s also been a nurse since 1993. And since racism has been happening for so long in our society, there’s something that people — and sometimes the medical community itself —  do to justify it when the elephant in the room is as deeply embedded in something we hold as sacred as healthcare. 

McLemore: We were called, you know, crack Mamas, you know, welfare queens in the 80s. And for some people, those structural racist stereotypes continue to perpetuate; it’s easy to blame Black mothers for their health outcomes and further death. Oh, well, if she wasn’t obese, oh, well, if she wasn’t, you know, it’s older, sicker, fatter, right? It’s that whole paper that I wrote about this. When any individual level risk factor alone is not sufficient to explain poor outcomes at a population level.

Bose: In the US, blaming Black pregnant people starts to look a lot like mass gaslighting. From a scientific perspective, risk factors for individual cases just don’t result in population level disparities like this – that’s just not how statistics work. And that’s before we consider that many individual risk factors that cause poorer health outcomes for Black women while giving birth aren’t actually in control of patients at all.  

McLemore: When you think about food apartheid, or having access to, you know, fruits and vegetables and healthy food, right? I mean, that is contingent upon if you can afford it.

Bose: And this is especially important to pregnant people — who are carrying a child for months in the environment that they live in. 

McLemore: We act like the only environment that matters is the uterus, or the body of the pregnant person, when we live in a whole world that has other kinds of exposures that we know that influence pregnancy outcomes. If you’re in, you know, Flint, Michigan, or you’re in Mississippi, and you have no clean water, or as all of us are going to painfully find out, if we don’t do something about climate crisis — we know that heat exposure, you know, is associated with prematurity. 

Bose: Monica says these external factors are often disregarded as soon as a person becomes pregnant. 

McLemore: For too long pregnant people have been thought about as vessels or some, you know, means to an end, where pregnant people are exclusively responsible for the environment in which we gestate new humans. Why are Black women being blamed for their obstetric outcomes? Because I would argue that we have a health system that blames pregnant people as individuals, for their outcomes, instead of the structural problems.

Bose: There’s actually a phenomenon that’s been studied called “Mother Blame” that illustrates this perfectly — and in studies about Mother Blame, healthcare providers are pointed to as people who often blame women for maternal outcomes. That’s before you consider the effect of racism on the body itself. There’s also the idea of something  called allostatic load — it’s the “wear and tear” on the body caused by stress. Also called “weathering” — it actually increases biological aging, and an earlier decline in overall health. And there is a growing body of evidence suggesting Black women are affected more than people of other races. Studies have also shown that the experience of racism and the compounding stress can actually lead to poorer health outcomes — in particular cardiac health. 

And here’s the thing — cardiovascular conditions are among the biggest risk factors for people giving birth. They’re also cited as a reason Black pregnant people have higher rates of maternal mortality. As we’ve seen, there are compounding factors stacked against Black pregnant people. In addition, the tendency to blame women, especially Black women, for their outcomes extends even further to their chances of getting pregnant in the first place. Here’s Jennifer Barber, a researcher who focuses on racial disparities and something called contraceptive deserts.

Barber: I collected data on 1,000 18 and 19 year old women in a county in Michigan, Genesee County, it’s where Flint, Michigan is located… One thing we found in this study is that the pharmacies that the Black women in the study live close to are open fewer hours per week than the pharmacies that the young white women move close to. And so that overall makes them less convenient.

Bose: According to Jennifer’s study, these pharmacies also had fewer female pharmacists and also tended to keep condoms and other methods of birth control behind glass. Young Black and white women in this study also tended to favor different types of contraceptives.

Barber: So young Black women in our study tended to choose condoms over oral contraceptive pills, while the young white women tended to choose oral contraceptive pills over condoms.

Bose: And Barber has a few ideas as to why. 

Barber: Black women are less likely than white women to have insurance that covers prescription contraceptive methods. [and] They have good reason to be wary of the whole healthcare, medical establishment. You know, there’s a long history of abuse of the Black population by that system. And so I think they have reasonable worries about having to interact with clinicians in order to get contraception — and so it makes sense that they would want to rely on methods that don’t require a clinical visit. 

Bose: And what all this translates into is more unwanted pregnancies, because Black women are more likely to have to rely on contraception methods like condoms.

Barber: Those methods are just difficult, because they require the cooperation of a partner. And they have to be implemented sort of, in the moment at the time of intercourse. They’re tedious for one or another reasons, condoms are messy. They’re sort of, I would say, not cheap, if you have intercourse relatively frequently, like young women tend to do. You know, for a variety of reasons, it’s just more difficult to use those methods. And so if we saw white women needing to rely on those methods like Black women do, we would see higher rates of unwanted pregnancies among white women as well. 

Bose: Jennifer’s study isn’t isolated. According to CDC data from 2017-2019, Black women in the US are more likely to use condoms than white women. A 2011 study published in perspectives in sexual and reproductive health found that of a group of one million low-income women in California, Black women were also more likely to be given condoms by a family planning service than oral contraceptive pills. There are also socio-economic reasons for this — such as barriers to accessing insurance that are more likely to affect Black women. And, as Jennifer found, there are also contraceptive deserts. 

Barber: It’s not a failure of Black women to use contraception as well as white women, it’s that they use contraception that is much more difficult to use consistently, correctly, and all the time.

Bose: And this has devastating and unequal results.

Barber: Black women who want to avoid pregnancy are getting pregnant at three times the rate of the white women who want to avoid a pregnancy.

Bose: Which means that these new state-wide abortion laws  — often made by white men — will be affecting the bodies of Black women who often never had a choice.

Barber: The combination of Black women having more pregnancies that they might like to abort, and the danger of giving birth for black women means that the striking down of Roe versus Wade is literally a life and death situation for Black women.

Bose: We’ve seen that racism has impacted almost every part of the American healthcare system, resulting in devastating outcomes. But what about the formation of the American medical establishment itself? For example – the maternal healthcare system in the United states, looks distinctly different from many other high income-countries. For example – the US doesn’t really use midwives anymore. And if you look back through history – that also has everything to do with racism. Here’s Harriet Washington again.

Washington: There were actually no gynecologists in the 19th century. 

Bose: You see, before the formal field of gynecology there was still maternal healthcare. Some of it was performed by poorly trained white male doctors, but also by enslaved Black midwives. These women brought their practices to the United States, and their skill was specifically revered.

Washington: Black midwives, Black healers were so successful, and helping women bear children without horrible after effects like obstetric fistulae, and without child death, that not only Black women, but also white women would often prefer their administrations.

Bose: Remember – fistulae was exactly the conditions that emerging white doctors in the field — like Simms — sought to cure – to make their fortune. As an aside, we now know that white doctors at this time actually created fisulaes in women by attempting to speed up the birthing process. But anyway – You can probably guess what happened next. 

Washington: And white doctors responded by vilifying Black midwives. They were not white. That was an indictment in itself. They also were African, unChristian. They also were uneducated. That was a common criticism. But if you’ve looked at training of white doctors, it was actually rather brief, especially when it came to women’s issues, so they weren’t terribly well educated themselves. 

Bose: The vilification of Black midwives and healers grew over the coming decades — eventually, spreading to all female clinicians. 

Washington: And this competition, it became increasingly bitter. After a while Black midwives and other Black healers were at risk of being punished and executed when their patients didn’t fare well. They’d be accused of poisoning. They’d be accused of killing patients.

Bose: Doctors like this formed part of an intentional erasure of Black people from medicine that continued throughout US history. Take the Flexner report of 1910 — an influential medical document that evaluated all of the US’s medical schools, written by educator Abraham Flexner. You can thank the Flexner report for the fact that only two historically Black medical schools remain in the US. And in turn —  for the lack of Black medical doctors in the US, which have barely increased over 120 years to only 5%. In the report, Flexner argued that the  Black physician should be trained in hygiene, not surgery, and serve as quote “sanitarians” to prevent exposure to things like Tuberculosis for neighboring white people. Let’s note that obstetrics qualifies as surgical. What’s more the American Medical Association, which was heavily influenced by Flexner and lionized characters like Sims, also prevented Black doctors from joining. 

Meanwhile, the discrediting of Black midwives continued, during and after the Flexner report. Throughout the early 20th century, American Obstetricians continued to lobby policymakers to help ban midwifery and also prohibit abortions. This was compounded by immigrant quotas and legally enforced segregation. Physicians and public health officials published studies claiming that midwifery led to quote “illiteracy, carelessness, and general filth.” By the 1960s, the practice was almost completely obsolete in the US.

To this day, midwives continue to be barred from practicing in many hospitals in the United States, or without the supervision of a physician. In the US, it can also be difficult to get insurance to cover the cost of midwives. Let’s note The World Health Organization recommends midwifery care as an evidence-based approach to reducing maternal mortality. And some experts note that the high-income countries with the lowest intervention rates, best outcomes, and lowest costs have integrated midwifery-led care. 

In Sweden, for example, a study in the Journal of the European Economic Association found that doubling trained midwives led to a 20-40% decrease in maternal mortality.

While we can’t say to what extent this is down to the use or non use of midwives —  what we can say is that, if it wasn’t for the racist, self-interested motivations of early 19th century white doctors, and the subsequent erasure of Black medical practitioners — the landscape of maternal healthcare in North America might look quite different today. Something to think about. We’ve talked a lot about Black maternal mortality rates. But — to get a really clear picture, it’s also really important to take a look at the raw numbers. Let’s take a look at the actual number of women that die per year from childbirth. Here’s Henning Tiemeier, a Professor of Social and Behavioral Science at the school of Maternal and Child Health at Harvard University, explaining an exercise he uses with his students.

Henning Tiemeier: I asked the students to guess how many women die per year in absolute numbers in during childbirth, and the year after, or ask them in the first 42 days, which is often the definition used. And then I asked them to think whether it’s 808,000 or 80,000 per year. And believe it or not, many of my students say it’s 8000, or even more, why is actually 800, I can use 800. So, but this is important for the students to realize that something which is so much of the media is actually 800. And then I, we I say is it as overplayed that we make all this fuss for something which is so rare events?  

Bose: It’s true – the numbers on the face of it may not look high, especially when looking at the mortality rates around diseases like Covid, for example. But Henning has a response. 

Tiemeier: It’s not a disease, it should not be a single. It’s, it’s all unnecessary.

Bose: Henning has another exercise he likes to use, as well. 

Tiemeier: I start with a slide which gives the terminal mortality per 100,000 per race. This is always a shock. But actually, most students know it, and we start a conversation. And then I tell them that this slide is actually not from the US, but from the UK. And it is the same, it’s the same, it’s exactly the same.

Bose: Now, rates of maternal mortality overall are much, much lower in the UK than in the US. But — Black people in the UK are facing a maternal mortality rate that’s also four times that of white women, just like the rates in the US.

Tiemeier: The UK has definitely very strong elements in maternal care. So the midwifery system, so midwives, is spectacularly well organized, it’s very successful, and is one of the reasons that they have a reasonably low mortality rate. So let’s give them credit for that. But the racial differences, equally dramatic. So that’s indeed a problem.

Bose: The UK has a different healthcare system, and one that’s Nationalized. And, it has an active network of midwives, present at almost all births. Yet, we still see a very similar discrepancy. Why?

Tiemeier: So, um, I think, um .. I think we have to start with, um, racism and discrimination?? We know that discrimination does cause poor health and not only mental health, but also physical health in many different ways . 

Bose: The fact is that, although we focus on the US in this episode, – systemic racism impacts and is interwoven with systems around the world. The UK, however,  like the majority of other wealthy nations, does still provide access to free abortions. And in the United States — more Black women will require abortions. Black women are being set up to fail, through a system that has failed them from the very beginning.

Here’s where we stand. Since the overturning of Roe v. Wade, people can now be effectively forced to give birth without their consent. 13 states have already moved to ban abortion entirely without exceptions for rape or incest, and 14 other states are looking to create restrictions. 

And all of this is occurring against a backdrop of the highest rate of maternal mortality of all high-income nations, one that’s increased through COVID,  and one that disproportionately affects Black pregnant people regardless of status.  This takes place within a medical system that has itself been shaped by centuries of racism, economic incentives and active erasure. Now, things are changing. As our broader society learns more about its history, large institutions — like the Academy of Medicine — are reckoning with their role in the world that we live in. 

But it is a slow process. It wasn’t until 2018 that the statue of J Marion Sims in Central Park was removed. Harriet took me back. 

Washington: I had given a talk at the Academy of Medicine right across the street. And when I finished the talk a medical student jumped her feet and said we have a tear that statue down. It took 10 years. I was there when it was carted away.

Bose: But the removal of the statue is far from a sign that the problems — the lionization of Simms — and the legacy of the racist bias in medicine – are over.

Washington: And I was struck by the fact that there were many people there, who were angry about the fact the statue had been taken down, defending Sims.

Bose: Harriet wrote an article in Nature in response to one such poorly worded and racist editorial, also published by Nature in 2017.

Washington: There had been other reports, you know, essays written in journals like Nature of people defending Simms, and complaining that the statue shouldn’t be taken down because you’re trying to rewrite history. And I thought, you know, in a way, they’re right, we are trying to rewrite history, we’re trying to correct it.

Bose: Rewriting history also means challenging our medical system. Only 5% of Black doctors remain in the US, and yet studies have shown that Black patients fare better when they have Black doctors. In the wake of this information and the Supreme Court’s decision on Roe — things may look dire. 

Yet while early practitioners like Sims and his research caused immense harm, researchers like Amanda Stevenson, Harriet Washington, and Monica Mclemore are raising the profile of these issues through their work to quantify these disparities. Part of this podcast has also been about the mission of re-platforming scholars and activists.

McLemore: We have technologies and tools that we didn’t have prior to Roe. We have an activated and educated populace. We have reproductive justice and reproductive justice informed clinicians and advocates and strategists and community organizers. 

Bose: The fall of Roe, just like Covid, has created a lens that zoomed in on existing inequalities. And it’s up to many in science and medicine to fix it, and it’s up to those of us in science journalism to amplify people that are. Not only that — but publications like Nature and Scientific American need to look back through their pages, and learn from their mistakes too. 

Bose: Maybe science can be a force for good, this time. 

This has been Racism in Health, a podcast from Nature and Scientific American. This episode was produced, narrated, and reported by me, Tulika Bose, with additional reporting from Megan McDonough and Nick Petric Howe. Sound design was by me, with editing help from Noah Baker, Jeff DelViscio, and Chrissy Yates. We’d also like to thank guest editor Melissa Nobles who has provided invaluable advice and guidance in the production of this podcast.

[The above is a transcript of this podcast] 


PEW Research Center: The Growing Diversity of Black America

Reuters: Georgia Allows Georgia ‘Heartbeat’ Abortion Ban to Take Effect

Advancing New Standards in Reproductive Health: One In Three People Learn They’re Pregnant Past Six Weeks’ Gestation

Georgia Recorder: New Poll Finds Nearly Two-Thirds of Georgia Voters Object to State’s New Abortion Restrictions

Atlanta: In Much of Rural Georgia, Maternal Health Care Is Disappearing

TIME: Armed Protestors And Far Right Groups Are Escalating Protests At Abortion Protests

Grady Newsource: In Georgia, The Most Dangerous State for Pregnant Women, Policy Change Could Save Lives

KFF: Reported Legal Abortions by Race of Women Who Obtained Abortion by the State of Occurance

Demography: The Pregnancy-Related Mortality Impact of a Total Abortion-Ban in the United States: A Research Note on Increased Deaths Due to Remaining Pregnant

CDC: Maternal Mortality Rates in The United States, 2020

Nature: ‘We Are Bearing Witness’ Health Researchers Navigate a Post-Roe World

Reproductive Health: The Giving Voice to Mothers Study: Inequity and Mistreatment During Pregnancy and Childbirth in the United States

Journal of Racial and Ethnic Health Disparities: Racial and Ethnic Disparities in Cesarean Delivery and Indications Among Nulliparous, Term, Singleton, Vertex Women

American Journal of Obstetrics and Gynecology: Site of Delivery Contribution to Black-white Severe Maternal Morbidity Disparity

Harvard School of Public Health: America is Failing its Black Mothers

Vascular Cures: Serena Williams and her Experience With Pulmonary Embolisms

History Channel: The ‘Father of Modern Gynecology’ Performed Shocking Experiments on Enslaved Women

World Health Organization: Obstetric Fistula

The History of Medicine: J. Marion Sims: Gynecologic Surgeon

The Atlantic: The Surgeon Who Experimented on Slaves

PNAS: Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites

UVA Today: Study Links Disparities in Pain Management to Racial Bias

Journal of Racial and Ethnic Health Disparities: Acknowledging and Addressing Allostatic Load in Pregnancy Care

Cleveland Clinic: Heart Disease and Pregnancy

Penn Medicine News: Pregnancy-Related Heart Failure Strikes Black Women Twice as Often as Those of Other Races

Journal of Racial and Ethnic Health Disparities: Contraceptive Desert? Black-white Differences in Characteristics of Nearby Pharmacies

CDC: Current Contraceptive Status Among Women Aged 15–49: United States, 2017–2019

Perspectives in Sexual and Reproductive Health: Race, Ethnicity and Differences in Contraception Among Low-Income Women: Methods Received by Family PACT Clients, California, 2001–2007

WebMD: Black Women and Birth Control

The Journal of Perinatal Education: Where Have All the Midwives Gone?

AMA Journal of Ethics: How Should We Respond to Racist Legacies in Health Professions Education Originating in the Flexner Report?

Medpage Today: Racial Bias in Flexner Report Permeates Medical Education Today

US News: Stop Meddling With Midwives

ACLU: The Racist History of Abortion and Midwifery Bans

Columbia Mailman School of Public Health: End Racial Disparities in Maternal Health, Call a Midwife

The American Journal of Nursing: The Midwifery Problem

Kaiser Health News: Doctors, Hospitals Tussle Over Role of Nurse-Midwives

World Health Organization: Nursing and Midwifery

The Commonwealth Fund: Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries

Journal of the European Economic Association: Midwives and Maternal Mortality: Evidence from a Midwifery Policy Experiment in 19th-century Sweden

The Guardian: Black women in UK four times more likely to die in pregnancy and childbirth

Nursing Times: Only half of babies in England now delivered by midwives

Economics Observatory: Does access to abortion vary across the UK?

NPR: Supreme Court Overturns Roe v. Wade, Ending Right to Abortion Upheld for Decades

Reuters: Factbox: U.S. Abortion Restrictions Mount After Overturn of Roe v. Wade

The Washington Post: Majority of women ages 15 to 44 would face new post-Roe abortion limits

The Commonwealth Fund: Health and Health Care for Women of Reproductive Age

US News and World Report: The U.S. Maternal Mortality Rate Surged by Nearly 20% in 2020

Clinical Obstetrics and Gynecology: Reducing Disparities in Severe Maternal Morbidity and Mortality

The Guardian: J Marion Sims: Controversial Statue Taken Down but Debate Still Rages

JAMA Network: Black Representation in the Primary Care Physician Workforce and Its Association With Population Life Expectancy and Mortality Rates in the US

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