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Societal Racism and Depressingly High Infant Mortality Rates Among Black Women: Is There a Link?

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In a country where more women are dying from pregnancy-related causes than in any other developed nation in the world, Black women, according to the Centers for Disease Control and Prevention (CDC), are three to four times more likely to be at risk than their white, non-Hispanic counterparts, while the death rate for infants born to black mothers is more than twice that of infants born to white, non-Hispanic infants. Researchers say this is largely due to implicit and explicit racial bias, both in the health-care system and in society.

“She was so beautiful — she reminded me of a doll. I know I was still sedated, but as I held her, I kept looking at her, thinking, why doesn’t she wake up? I tried to feel love, but after a while I got more and more angry. I thought, Why is God doing this to me?” – Simone thought after a nurse had brought her stillborn baby wrapped in a hospital blanket.

The story of Simone Landrum, a 23-year old black woman from New Orleans, told by Linda Villarosa in the New York Times Magazine on April 11th garnered an unexpected amount of attention for a problem that is increasingly becoming news but is not new: Black women and babies die at alarmingly high rates during pregnancy and childbirth. 3-4 times more than white women, to be precise.

The United States has the worst overall child mortality rate compared with those of 19 other wealthy nations in the Organisation for Economic Co-operation and Development, according to a study published in the journal Health Affairs. Across the US, infant mortality rates for full-term babies were 50% to 200% higher than in Austria, Denmark, Finland, Norway, Sweden and Switzerland, the study found. “The US is one of only 13 countries where the death rate is worse now than it was 25 years ago and among the worst of the wealthiest countries in the world. Between 700 – 900 American women die each year from the problems related to pregnancy, childbirth or complications up to a year or later. There’re as many as 50,000 cases annually when women face dangerous or even life-threatening situations,” Judy Woodruff, the anchor and managing editor of the PBS NewsHour, said.

“This study should alarm everyone. The US is the most dangerous of wealthy, democratic countries in the world for children,” said Dr. Ashish Thakrar, lead author of the study and an internal medicine resident at Johns Hopkins Hospital and Health System in Baltimore. “We were surprised by how far the US has fallen behind other wealthy countries,” he said. “Across all ages and in both sexes, children have been dying more often in the US than in similar countries since the 1980s.”

Maternal Mortality Is Rising in the US As It Declines Elsewhere (Deaths per 100,000 live births)

“Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015,” The Lancet. Only data for 1990, 2000 and 2015 was made available in the journal. Rob Weychert/ProPublica

What do the statistics say? Based on the information presented on the official website of the US health protection agency, CDC, the infant mortality rate (IMR) that refers to the number of deaths per 1,000 live births remains stable at a high level of 5.82 deaths per 1,000 births (as of 2017 Q3). Whereas, according to the United Health Foundation, the infant mortality rate among black women is estimated at 11.3 per 1,000 black babies — a racial disparity that is actually wider than in 1850, 15 years before the end of slavery, when most black women were considered chattel. In addition, roughly one out of every three babies born in the US — or about 1.3 million children each year — are delivered by cesarean section, or C-section (the surgical delivery of a baby necessary when a vaginal delivery would put the baby or mother at risk), instead of vaginally, according to data released earlier this year by the CDC.

So what’s going on?

Linda Villarosa, a contributing writer to the New York Times Magazine, who covered women's and African-American health issues, explained: “Recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions — including hypertension and pre-eclampsia — that lead directly to higher rates of infant and maternal death.” Meanwhile most research on health disparities in maternal and infant mortality focus on African American women’s greater exposure to risk factors around the time of pregnancy, including poverty and low socioeconomic status; limited access to prenatal care; and poor physical and mental health. For a very long time that vicious circle thrived: if black women without higher education in a financially precarious situation happened to have some bad symptoms during their pregnancy, the responsibility for their health automatically rested on their shoulders.

Richard David, a neonatologist at the University of Illinois of Chicago, has been studying this problem for decades. In the 1980s, when scientists thought the two main culprits were poverty and lack of education, David and his colleague James Collins decided to test the theory and found that even educated, middle-class African-American women were at a higher risk of having smaller, premature babies with a lower chance of survival. “That was exactly the kind of case that made us ask the question: What else is there?” says David. “What are we missing?”

Some people suggested that the root cause may be genetics. To confirm or refute this suspicion, David and Collins looked at the babies of immigrant women from West Africa because if genes are at play, then women from Africa would also have the same risks. But as they reported in their 1997 study in The New England Journal of Medicine, those babies were more like white babies — they were bigger and more likely to be full term. So, it clearly isn't genetics, says David. Until many years later researchers noticed the startling thing: the grandchildren of African immigrant women were born smaller than their mothers had been at birth. In other words, the grandchildren were more likely to be premature, like African-American babies, which was also true of the grandchildren of black women who had emigrated from the Caribbean (unlike their European counterparts who were bigger than their mothers when they were born). David and Collins published their results in 2002 in the American Journal of Epidemiology. “So, there was something about growing up black in the United States and then bearing a child that was associated with lower birth weight,” says David.

A recent poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health showed that 92 percent of African-Americans believe that discrimination against African-Americans exists in America today. Higher education and income did not necessarily mean people experienced less discrimination, the poll found. In 2004, David and Collins published a study in the American Journal of Public Health in which they reported the connection between a mother's experience of racism and preterm birth. They asked women about their housing, income, health habits and discrimination. “It turned out that as a predictor of a very low birth weight outcome, these racial discrimination questions were more powerful than asking a woman whether or not she smoked cigarettes,” David says. Other studies have shown the same results.

At the beginning of this month National Public Radio (NPR) discussed the issue with Dr. Valerie Montgomery Rice, president and dean of the Morehouse School of Medicine, who asserted that even famous and successful black women can encounter serious pregnancy complications.

Morehouse School of Medicine

MONTGOMERY RICE: Well, one of the things that we know is that first of all, pregnancy is not without its complications. We know that they [African-American women] have a higher rate of having preterm birth. And they also have a higher rate of having any other complications of pregnancy that will cause them to have a higher mortality rate. We know that when we look at the issues that have plagued black women for many, many years, they have a higher risk of diabetes. They have a higher risk of obesity coming into pregnancy. But we also have now begun to see that they come in with a higher profile of stress and other issues that have complicated their baseline. We tend to call it microaggressions and other things that may increase their stress profile in general.

NPR: Are you saying that the actual experience of bias and discrimination in daily life is enough to affect a woman's health?

MONTGOMERY RICE: For sure. We clearly can see that when you start to interview these women, they can tell you of repeated insults that they have that raise their stress level. We've asked - and I'm pushing more research in this area to understand physiologically why that leads to some of the increased complications that we're seeing. But we do know also that when we control for socioeconomic factors such as access, when we control for factors such as no issues of diabetes or high blood pressure before pregnancy, comparing them to white women, we still see the higher rate of complications.

In the latest issue of Vogue, Beyoncé revealed that she had an emergency C-section when she gave birth to twins last year. “I was 218 pounds the day I gave birth to Rumi and Sir. I was swollen from toxemia and had been on bed rest for over a month. My health and my babies’ health were in danger, so I had an emergency C-section. We spent many weeks in the NICU. Today I have a connection to any parent who has been through such an experience. After the C-section, my core felt different. It had been major surgery. Some of your organs are shifted temporarily, and in rare cases, removed temporarily during delivery. I am not sure everyone understands that. I needed time to heal, to recover,” – Beyoncé wrote in her personal essay about her pregnancy experience for the September issue of Vogue.

Even tennis star Serena Williams — a wealthy and remarkably powerful woman — nearly died from pregnancy related complications. Earlier this year, she shared her own harrowing account of an emergency C-section and the complications that followed. “I almost died after giving birth to my daughter, Olympia. Yet I consider myself fortunate. I am lucky to have survived. First my C-section wound popped open due to the intense coughing I endured as a result of the embolism. I returned to surgery, where the doctors found a large hematoma, a swelling of clotted blood, in my abdomen. And then I returned to the operating room for a procedure that prevents clots from traveling to my lungs. When I finally made it home to my family, I had to spend the first six weeks of motherhood in bed. If it weren't for their professional care, I wouldn't be here today.” – Serena Williams shared her story with CNN.

African-American moms who are middle class and upper-middle class, who have resources, education, access to good health care, also lose their babies at higher rates than white mothers. Their babies are being born prematurely, or with low birthweight, or both, at a higher rate than white babies from all income backgrounds. A recent NPR story also indicates that even if an African-American mother has a good home and job, racism can have deadly effects.

sistersong.net

Monica Simpson, an executive director of SisterSong, the country’s largest organization dedicated to reproductive justice for women of color,  reached the same conclusion during her work in the organization. “We were picking up different stories and hearing this across the board from so many black women across the country. But it didn’t matter what their socio-economic status was, it didn’t matter what their education level was. Here we are looking at Serena Williams in particular who was the world’s best athlete. She definitely has support, she’s definitely not dealing with economic issues and she still was dealing with the fact that she almost lost her life after giving birth,” – she said to PBS NEWS in April.

researchgate.net

Keisha Bentley-Edwards, a co-author of the report ‘Fighting at Birth: Eradicating the Black-White Infant Mortality Gap’ and an assistant professor of general internal medicine at Duke University, says she was herself surprised with the results of the investigation she held with her colleagues. “It’s amazing. The disparity widen as education levels increase for black women and really that is a big part of the question. Once you take away age as a factor, you take away medical status as a factor, this gap still remains. And the one thing that you have to look at is racism as a contributing factor for these disparities, particularly for people who have higher degrees. We should know that among white women the higher the education level the lower the infant mortality rate,” – she told to CBSN. Black women who live in affluent neighborhoods, receive prenatal care in the first trimester, are normal weight, and have advanced degrees are still more likely to die or have their baby die than white women in poor neighborhoods, with no prenatal care, who are obese, and don’t have a high school diploma.

So if even factors like education, age and socio-economic status fail to impact the racial disparity, what does not?

The Nonprofit Quarterly (NPQ) gives a strong response to the answer: “Racism, not race, causes health disparities for black mothers.” After having examined the findings of numerous researches, they came to conclusion that it is racism that causes black women dying at disproportionately high rates. “Whether it is from invisible bias leading to sub-par care, or a lifetime of discrimination leading to chronic stress, racism seems to be the culprit,” – the NPQ concludes.

At the same time Reuters found it “hard to say exactly why infant mortality rates are so much lower in Connecticut than in Mississippi” (6.45 deaths for every 5,000 full-term births in Connecticut versus 19 deaths for every 5,000 in Mississippi), suggesting that “this may be more due to mothers’ education and income levels rather than disparities in health care after birth.” Well, maybe it’s because of the higher density of the black population in Mississippi?

Let’s take a look.

Societal Racism and Depressingly High Infant Mortality Rates Among Black Women: Is There a Link?

A map of the free and slave states in USA in 1861 before the American Civil War (free states in blue, slave states in red). Wikimedia.org

As we see, the infant mortality rates are much higher in the south-eastern states where historically there are more African Americans. Is it just a coincidence that the second largest black population state is the first by infant mortality rate?

Societal Racism and Depressingly High Infant Mortality Rates Among Black Women: Is There a Link?

The health disparities that exist for Black mothers in America are well documented. Dr. Joia Crear-Perry, founder of the National Birth Equity Collaborative, asserts, “Knowing the risk factors allows patients to do things like get tested earlier for an illness or, for example, participate in a smoking cessation program. Risk factors can include attributes like fair skin for melanoma, which you can’t modify but you can cover or add sunscreen. But no one’s saying that whiteness is a risk factor for melanoma.” Seeing race as a risk factor for maternal death would suggest that there is some genetic predisposition that has been passed to Black mothers. This is not the case, however. A growing body of research indicates that, in fact, the stress caused by discrimination plays a noteworthy role in both maternal and infant mortality, it is not that Black women are somehow biologically doomed to have this condition.

In the interview for PBS NEWS Linda Villarosa answered the question of “what is going on in America, in the lives of black women, in the medical communities that’s causing this”: “What I found in my reporting were really two things both related to race. The first was that simply the experience of living in America as a black woman does something to your body that causes low birth weight babies, maternal mortality, and infant mortality. Second, is that there is a kind of racism in the healthcare system and most of it unconscious. It’s a kind of bias, that’s existed for a long time that is affecting birth experiences of black woman in America.” She also emphasized that really toxic stress black women have to face has no common with ‘Oh, I feel really stressed out’ or ‘I just need to kind of take a chill pill or relax’, it is the result of aggressions and insults that happen to them every day. It can be anything from ‘I think that I’m treated differently, people think I’m less intelligent’ to ‘I’m being discriminated by the police, in housing, and in my workplace’. Linda called “toxic physiological stress” that can result in conditions — including hypertension and pre-eclampsia — that lead directly to higher rates of infant and maternal death.” And that’s a real point.

“Prolonged elevation and circulation of the stress hormones in our bodies can be very toxic and compromise our body’s ability to regulate key biological systems like our cardiovascular system, our inflammatory system, our neuroendocrine system. It just gets us really out of whack and leaves us susceptible to a bunch of poor health outcomes,” Amani Nuru-Jeter, an epidemiologist at the University of California, Berkeley, who is researching how chronic stress from discrimination causes biological changes that lead to health disparities, confirms.

Today a growing body of research suggests that stress induced by this discrimination plays a significant role in maternal and infant mortality. Those problems are amplified by unconscious biases that are embedded throughout the medical system, affecting quality of care in stark and subtle ways. In the more than 200 stories of African-American mothers that ProPublica and NPR have collected over the year 2017, the feeling of being devalued and disrespected by medical providers was a constant theme. Over and over, black women told of medical providers who equated being African American with being poor, uneducated, noncompliant and unworthy. “Sometimes you just know in your bones when someone feels contempt for you based on your race,” said one Brooklyn woman who took to bringing her white husband or in-laws to every prenatal visit. Black expectant and new mothers frequently told us that doctors and nurses didn’t take their pain seriously — a phenomenon borne out by numerous studies that show pain is often undertreated in black patients for conditions from appendicitis to cancer.

“I'm just thinking that it's just me, and it is — it was my body — but the care that I was given in that process could have, maybe if it was in a different situation, it would have been a different outcome. I'm just not sure that we're aware that this is an issue beyond just our bodies,” – Nicole Neely, who lost her babies nearly 20 years ago, shared her thoughts.

Racism, an evergreen toxin in American society, has long served as the primary ingredient of racial inequality. This year marks the 50th anniversary of the Kerner Commission, a bipartisan group created by former President Lyndon B. Johnson to investigate the country’s seemingly endless civil unrest. The commission’s final report identified “white racism” as the main source of unrest in communities across the country. The commission stated, in no uncertain terms, that “our nation is moving toward two societies, one black, one white — separate and unequal.” Fifty years later, the United States has yet to sufficiently take on the toxin of racism. Current data reveal that it not only continues to divide communities and promote unrest, but the daily exposure to racism is literally killing black women and infants.

So what has to be done to address the problem? There are many different proposals, from elevating the role of doulas as a potential intervention for Black mothers and babies to setting up various funding programs to help Black mothers. Nevertheless, the question is still remains an open one.

Linda Villarosa proposed: “I think that what we have to do is change the medical system. Individual people are racist this is something that’s embedded in the system, it’s baked in and we have to start in the medical school and before to start getting doctors and other medical providers to face unconscious bias that’s affecting the care of women of color. I think that’s a very-very important first step.”

In conclusion, as long as the root cause for the United States’ depressingly high infant mortality rate is not addressed, there is no sense in “testing” any other measures.

Author: Christine Petrova