In 2016, the Centers for Disease Control and Prevention reported that black women are three to four times more likely to die from pregnancy complications than white women, a stark disparity in maternal healthcare and outcomes that Angela Ferrel-Zabala, national director of Strategic Partnerships for the Planned Parenthood Federation of America, calls “unacceptable.” She points to racism and discrimination as “key factors for the disproportionately high rates of maternal death that women of color, especially black women, experience.” The racist legacy of mainstream medicine, implicit bias from individual practitioners, and structural inequalities that many women of color face can coalesce to create a toxic and even life-threatening environment for childbirth that activist communities and doulas of color are working to change. Many birth justice advocates are divesting from the existing, sometimes oppressive, healthcare model and offering their clients and communities an opportunity for guidance, affirmation, and healing.
Socioeconomic factors like geographic location, proximity to grocery stores, and access to neighborhood health centers can have an impact on a person’s health over the course of a lifetime—as well as their access to early prenatal care, says Lisa Hollier, director of obstetrics and gynecology at Texas Children’s Hospital. As Claudia Booker, a black midwife practicing in the Washington DC, Maryland, and Northern Virginia areas points out, a woman without paid leave from work who has to take “two subways, three buses, and walk ten blocks” to a prenatal care appointment might have to “make compromises” and skip visits if she can’t secure childcare or afford transportation. She says that, for some, a checkup with a doctor who might see their patients as “segments of a reproductive system instead of a whole person” can be alienating, and isn’t worth the long wait time.
Women of color are more likely to enter pregnancy in poorer health and often with chronic conditions like hypertension and diabetes, says Michael Lu, a professor in the department of prevention and community health at George Washington University. These are important risk factors for some of the leading causes of maternal mortality and complications, such as hemorrhage, sepsis, preeclampsia, and thromboembolism, Lu says. However, he adds, “the reasons why they may enter pregnancy in poorer health are complex.” Limited access to primary and preventive services, racial insensitivity, as well as the “toxic stress of poverty” and the violence some women experience can be barriers to receiving quality care before, during, and after pregnancy.
Any intervention to reduce racial disparities in maternal mortality, Hollier says, “are going to need to have their roots in a lot of these social factors,” while also addressing implicit and structural bias in the medical community. Ferrel-Zabala adds, “Racism has helped create the income inequality that makes it harder for many women of color to access healthcare; it drives medical professionals’ biases that result in women of color receiving inadequate care, and the experience of living in a racist society exacerbates stress.”
Stevie Merino is a doula, childbirth educator, and co-creator of the Long Beach Birth Worker of Color Collective in California who says that many of her clients—particularly those who are black women—experience a blatant double standard in the way they’re treated by medical professionals. Those who ask questions or push back against what they deem as unfair or insufficient care from medical professionals are often “treated as if they are being difficult, demanding, or defiant,” she says. However, white people “who go in with the same expectations and requests are applauded for their ‘due diligence,’” she asserts. Merino also mentions a 2016 study published in Proceedings of The National Academy of Sciences that indicated the prevalence of false beliefs about pain tolerance in black people—more specifically, a widespread belief among white medical practitioners and laypeople alike that black people don’t experience pain as acutely as white people.
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This racist belief, Merino says, contributes to a medical environment in which black women’s pain isn’t taken seriously or treated with compassion regardless of their socioeconomic status. She describes Serena Williams’s account of the life-threatening trauma she experienced in childbirth and published by CNN in February. “As a black woman, she was not listened to about how she was feeling about her own body, and had to walk professionals through what she needed for her life to be saved after birth,” Merino says. “If someone like her—with all of the resources and fame—can have that type of experience, how do we think that translates to other black women who may not have that type of financial access?”
“The trauma often is related, not to the birth itself, but to statements made by [hospital] staff,” says Camalo Gaskin, an educator and pregnancy/birth companion based in London and Berlin, and founder of the educational collective Birth to Birth. Gaskin says that many of the women of color she works with seek her out following a traumatic first birth experience.
“I find this to be true for birthing people of all ethnicities, but what makes it doubly problematic for women of color, particularly from the African diaspora, is that the treatment mirrors everyday instances of discrimination or violations.” Obstetrics, or any other kind of medical practice, “inherently reflects the culture surrounding it,” she says. “For that reason, any person who experiences marginalization outside, will be more likely to experience it once they step into an obstetrical environment. It’s not our bodies that are broken. We need to look at all the other external factors that are making childbirth more dangerous.”
As Merino points out, factors related to structural racism can also make childbirth more dangerous for indigenous and undocumented women of color. Those living on indigenous reservations could be faced with “an extreme lack of quality care, resources, and accessible facilities,” she says, while in some areas, a bilingual care provider may not be available, and “a phone translator just doesn't cut it.” For some, fear of deportation can also be a barrier to accessing care, sometimes preventing people from seeking out life-saving medical care and intervention. “I had a client who didn't want her partner to be at her birth because she was scared that he would be deported,” Merino says. “It’s criminal to instill that type of fear into people.”
Organizations such as the Black Mamas Matter Alliance, National Latina Institute for Reproductive Health, and Mama Maiz “are leading the work to address the root causes of maternal deaths and dismantle the structural barriers to healthcare that women of color face,” Ferrel-Zabala says, while also working to address the specific, culturally appropriate needs of their respective communities. Merino says, “it's about making a real effort to have representation and connection with the communities that you are serving.” She describes the work to “reclaim birth” as a healing process for individuals, families, and communities alike.
As a doula who works with all pregnant people—including trans and nonbinary people—Merino says, “I just try to hold space for my clients and let them know that no matter what else is going on I see them, I hear them, and I'm there to support them.” For Gaskin, the healing process involves moving away from “the paradigm of being seen as subjects of experimentation, observation, and management,” and toward “a culture of communication, being prepared to know your choices and to state your wishes.” With her clients, she facilitates “a rigorous phase of reconciliation and unlearning” patterns of institutionalized coercion and non-consent.
As Merino says, the work of birth justice activists and organizations doesn’t exist in isolation. “We can’t talk about the birth disparities or safer childbirth for people of color without also addressing the economic, social, and political issues that also create overwhelming barriers for birthing people of color.” Issues like police brutality, racism, and environmental pollution “can have a direct or ripple effect on birthing people, their children, and families,” she says. “In the words of Audre Lorde, ‘There is no such thing as a single-issue struggle, because we do not lead single-issue lives.”
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