Disparities in Infant and Maternal Mortality: Examining Obstetric Racism in the United States

By Maria Murphy

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Photo by Christian Bowen on Unsplash

Serena Williams, well-known American tennis champion, is one of countless black women to experience racism in the delivery room. While in labor, she began to feel short of breath and immediately recognized her symptoms from prior complications with pulmonary embolisms. Williams notified the doctors and nurses about what treatment was effective in the past, a computerized tomography (CT) scan and a blood thinner, but her suggestions were quickly dismissed, attributing her advice to confusion from the pain medication. The doctors chose a different route, resulting in a dead end. Again, Williams insisted “I told you, I need a CT scan and a heparin drip,” (Scutti, 2018). Finally, they sent Williams for the CT scan, revealing blood clots in her lungs. In just a few short minutes, she was on the blood thinner she had previously requested. Williams had several more problems after this incident, eventually returning home with an order for six weeks of bed rest (Lockhart, P.R.). Like many other birth complications, Williams was left in a vulnerable position from a preventable situation—disregard for her prior knowledge and experiences. Her reflections on this incident, showcased in a Vogue profile, highlight the dangers of racial bias in the medical field.

Although traumatic and physically painful, Williams’ complications were not fatal, but not all Black women are as fortunate. When compared to a White woman, a Black woman is 3.2 times more likely to die from complications of pregnancy (Petersen et al., 2019). Her infant is 2.3 times more likely to die (Wallace et al., 2017). These figures come from the infant and maternal mortality rates, defined by the death of a mother or child within one year of delivery. The racial disparities these data show hold true among all ages, education levels, and socioeconomic statuses, just to name a few. For a developed nation such as the United States, these statistics indicate the presence of underlying racial components rather than the need for medical advancements.

Before examining the deeper societal roots of the racial disparity in maternal and infant mortality, the acute causes must first be addressed. Grimm and Cornish define obstetric racism as discrimination during pregnancy, childbirth, and postpartum leading to an increased occurrence of adverse birth outcomes for Black women and infants (2018). Obstetric racism does not, however, have an immediate effect on obstetric mortality. No woman or child dies directly from racism, but instead of the secondary medical conditions it induces. Long-term exposure to and interaction with racism manifests itself physically, which, in turn, raises the likelihood of adverse birth outcomes (Grimm & Cornish, 2018). Because the mother and child exist in an interconnected system, maternal complications often have accompanying effects in the fetus. Chronic maternal stress, a condition closely tied to a Black woman’s constant interactions with racism, is directly correlated with hypertension, which leads to a host of cardiovascular issues (Grimm & Cornish, 2018). Hypertension, otherwise known as high blood pressure, and its secondary medical disorders, such as cardiomyopathy and other cardiovascular conditions, account for almost forty percent of maternal deaths (Petersen et al., 2019). Although stress is the most common, any maternal complication, such as having twins or triplets, a controversial term due to problems with the cervix, or premature rupture of the amniotic sac, leads to a higher risk of infant mortality. The acute stressors for newborns come from preterm birth and a low birthweight. Any child born before 37 weeks of gestation is considered to be preterm, a condition that accounts for nearly 35 percent of infant deaths. Preterm infants carry much greater risks because they did not develop completely in the womb. Moreover, preterm births are more likely to weigh less than a full term baby, so any premature child often carries both of the major risk factors. A low birthweight, less than 5.5 pounds, puts an infant at an increased risk of both short- and long-term health issues. The severity of its effects are related to the specific weight, as a decrease from 5.5 to 3.3 pounds increases its mortality rate from 25 to 100 times that of a healthy child (Grimm & Cornish, 2018). By understanding how each of these medical conditions leads to adverse birth outcomes, one can begin to analyze how societal factors influence the maternal and infant mortality rates.

Despite the medical advancements of the twentieth century, Black women and their infants in the United States remain at a higher risk of pregnancy-related death due to the pernicious effects of institutionalized racism, sub-par medical care, and racial stereotyping in the medical field. Many women’s narratives serve as a testament to the unfair treatment they have received, and data from research studies support their claims. Because racial inequality puts both mothers and children at a disadvantage, its transgenerational effects perpetuate racism in the United States. As a means of quantifying the pervasiveness of racism’s effects, this paper will examine how structural racism, societal and community factors, lack of consistent pre- and post-natal care, and implicit racial bias contribute to infant and maternal mortality rates.

Structural Racism

Structural racism, an indication of an individual’s daily interactions with racial inequality, as stated above, is a large contributor to maternal stress. According to Wallace et al., structural racism is characterized by a state’s ratios of Black to White educational attainment, median household income, unemployment and level of employment, imprisonment, and juvenile custody. States with greater racial gaps for positive factors, such as Black employment in a managerial role or median household income, had corresponding differences in infant mortality (Wallace et al., 2017). Because these factors indicate a socioeconomic advantage, greater educational opportunities, healthier neighborhoods, better access to healthcare, and more political power, they also predict the degree to which Blacks are disadvantaged in a state or community. As the psychological stress of this inequality builds up over time, physical health is impacted, too. Duke University conducted a study of the effects of racial stress following the “Lacrosse Scandal,” a case in which three White males were accused, and eventually acquitted, of raping a Black woman. The study revealed heightened cortisol levels, an indication of high blood pressure, after students of color were exposed to racial triggers and other racially stressful situations. Interestingly, the black female students experienced even higher cortisol levels than the males, demonstrating the dangerous effect racial stress can have on women and, in turn, maternal hypertension (Richman & Jonassaint, 2008). The Center for Disease Control and Prevention refers to this phenomenon as the “weathering effect,” supporting the idea that Black women age more quickly due to emotional, psychological, economic, and environmental stressors related to racial inequality (Petersen et al., 2019). The effects of structural racism may not be apparent in day-to-day life, but their presence slowly and consistently damage Black mothers’ health, thus supporting the racial disparity in maternal and infant mortality.

Societal and Community Factors

Unlike the state-wide spread of structural racism, societal and community factors induce stress in a more localized fashion. Some areas of the United States experience more explicit racial prejudice and discrimination than others, and studies have shown that this also has an effect on maternal stress and infant mortality. Counties exhibiting this racial tension are observed to have a larger gap between Black and White preterm births and infants with low birth weight (Grimm & Cornish, 2018). Racial prejudice manifests itself in a variety of ways, each of which serves as a source of maternal stress. One of the most well-known examples of discrimination comes from redlining, which Grimm and Cornish define as an “institutional practice in which banks and other financial institutions deny loans to communities and individuals based on race,” (2018). A Pennsylvania study found Black Americans to be less likely to be granted a loan, even when the gender, income, and loan amount were the same as a Qhite applicant. As a result, Black women are more likely to find themselves in neighborhoods with lower-quality public education, healthcare, and businesses (Grimm & Cornish, 2018). Although results of redlining are not surprising, Grimm and Cornish also reveal a more interesting source of maternal stress: higher education. Workplaces that require more education are more likely to be dominated by White males, making the environment somewhat isolating and hostile for Black women. Even if the company exhibits no explicit racism, the racial disconnect may result in a lack of connection to coworkers and the perception of racial discrimination (Grimm & Cornish, 2018). Maternal stress comes as a result of continued stress, and analyzing how the specific societal and community dynamics play a role leads to greater understanding of their effects on obstetric mortality.

Pre- and Post-natal Care

Yvette Santana, a 40-year old black woman, became pregnant with twins through in vitro fertilization after two fibroid removals. Due to her age and fibroid troubles, Santana believed herself to be high-risk, but her White, male, pregnancy specialist disagreed. He indirectly classified her as a hypochondriac, questioning why she wanted to be categorized as a high-risk pregnancy. Essentially left to monitor herself, Santana continued to research the possible complications of her pregnancy, set on doing what was best for her children. At 26 weeks, she had a trip planned to visit her husband in another state, though she was unsure if it was the safest decision. Her doctor assured her there was no issue, so she continued with her trip. Upon the plane’s landing, though, she did not feel well and went to the emergency room. Within several hours, she had given birth to her twins, each less than two pounds and severely at risk of short-term health problems. They were sent to the neonatal intensive care unit to be closely monitored. Several nurses and other workers commented on the “strength” of her children, but one of her twins passed away from a hospital-based infection within a month. Santana believes they received lower quality care because the medical professionals viewed them as being strong-willed, a stereotype often associated with African Americans. Had they been White, they may have been seen as fragile or vulnerable and cared for more closely (Davis, 2018). Santana’s experience reflects poorly on the quality of prenatal medical care that Black women and children receive in addition to offering a glimpse of implicit racial bias in the medical field.

Pre- and postnatal care are incredibly important, especially for high-risk pregnancies like Santana’s, in order to monitor maternal and infant health. Studies have shown that mothers should attend four prenatal care visits at a minimum and fewer visits correlated to an increased risk of stillbirth. A majority of maternal deaths occur within two months of delivery, so four postnatal check-ups are paramount for their health as well (Goldenberg & Mcclure, 2017). Women of color, however, experience several barriers in reaching these thresholds. First of all, the mother must be aware of the recommended care, so education level and access to information contributes to the mortality rates. Roughly thirty percent of White Americans have earned a bachelor’s degree, whereas only twenty percent of black Americans have. Of course, a bachelor’s degree is not the sole indication of a well-prepared mother, but the disparity between the races demonstrates a decreased likelihood of learning proper prenatal practices.

Understanding what appointments to attend, however, is not the whole battle, which leads to the second inhibitor. Stereotypes and distrust between the doctor and patient create a sense of discomfort, thus dissuading some mothers from returning. Black mothers are often viewed negatively because they are stereotyped to depend on welfare or have no health insurance. Going even further, some are denied care based on this assumption. In the cases that care is provided, constant microaggressions make them feel disrespected. In one case, an African-American woman asked for a healthy snack to lower her blood sugar in the evenings, and the nutritionist recommended “something left over from dinner such as fried chicken” (Ramaswamay, 2020). The utter disregard for the mother’s cultural background and desire to eat healthily encompasses how challenging and stressful it is for Black women to receive proper medical care.

Implicit Racial Bias

Jessica Carter, a black mother in Atlanta, Georgia, intended to have a birth with as little medical intervention as possible. She decided to use a local midwifery practice to mediate on her behalf if necessary, but one of the midwives named “Linda” continually made her feel disrespected. Linda would express surprise at the level of Carter’s job, almost shocked that a Black woman could be well-educated. Carter believed her to be a racist and hoped that Linda would not be on call when she went into labor. Against all hopes, Linda answered the phone when Carter’s contractions began. Linda seemed inattentive and disinterested, and Carter labored alone for ten hours before Linda arrived at the hospital. Without an advocate, the birthing process did not go the way Carter planned, attached to a fetal monitor and on a labor-inducing hormone. After the vaginal delivery, Carter experienced a tear, which Linda then stitched without any numbing medication. Childbirth should leave every mother with joy, but instead Carter’s experience was characterized by both physical and emotional pain (Davis, 2018).

Implicit racial bias acts as the most direct effect on maternal and infant mortality rates, as it often results in inadequate patient care. It can affect how the medical professionals view and treat the patients, and it also impacts how the patients respond to medical advice. A lack of trust between the two results in more tense communication, increasing the likelihood of an adverse birth outcome (Petersen et al., 2019). A doctor or nurse’s perception of a patient can have a significant impact on the choice of treatment. In Carter’s case, Linda’s continual disrespect led to a painful ending, indicative of abusive practices used in the nineteenth century in the name of “‘advancing’ gynecological procedure (Davis, 2018). Such experiments established a racial stereotype of strength that persists today. Because of this perception, Davis notes that medical professionals are less likely to provide Black patients with pain medication when requested (2018). Through neglect and disrespect, implicit racial bias in the medical field contributes to the racial disparity in maternal and infant mortality in the United States.

Other Considerations and Data Limitations

Other scholars have proposed an alternate theory for the difference in Black and White infant and maternal mortality rates. Because the disparities exist in essentially every socioeconomic class, education level, and age, these scholars suggest that there may be a genetic component (Davis, 2018), but this approach views the issue with too wide of a lens. Non and Gravlee highlight how this perspective “reduces biology to genetics and reinforces the folk view that racial groups are distinct genetic categories” (2019), as any researcher looking for a connection between genetics and biological conditions will find one. While the argument for a Black genetic predisposition to adverse birth outcomes holds some merit, viewing it as the sole cause for the inequality in mortality ignores the possibility of all other influential factors. A more substantial causal relationship between racism and maternal mortality arises when the data is examined more closely. State-wide differences in Black to White mortality ratios indicate that societal conditions have a much greater effect on adverse birth outcomes for Black mothers and infants (Wallace et al., 2017). When considering all available data, racism in society outweighs genetics as the cause for the racial disparity in maternal and infant mortality rates in the United States.

In addition to considering other perspectives on the topic, the limitations of the available data must also be addressed. While Wallace et al. found statistically significant connections between structural racism and infant mortality rates, the conclusions drawn could be improved by several changes in research methods (2017). First, instead of analyzing the current relationships, they claim that the delayed relationships may be more indicative of the effect structural racism has, as many societal inequalities exert their effects over time. Also, some evidence suggests that specific regions within the states, such as counties or neighborhoods, may hold some power over obstetric mortality. These areas could be influenced by racial segregation or differences in public education. Finally, some states’ Black populations were very small, thus making it difficult to find data on more specific aspects of structural racism, such as black level of employment (Wallace et al., 2017). The Center for Disease Control identifies misidentified race or cause of death on the death certificate as potential causes for error, though noting that these account for a very small fraction of maternal and infant deaths (Petersen et al., 2019). Despite these limitations, the significance of the racial disparity in obstetric mortality in the United States indicates that more accurate data would only confirm the aforementioned conclusions.

In conclusion, structural racism, societal and community factors, difficulty in accessing quality pre-and post-natal care, and implicit racial bias all contribute to the racial disparity in obstetric mortality in the United States. Both personal narratives and experimental data support these claims, indicating that neither genetic factors nor a need for medical advancements are the source of the racial disparity. Each of the factors contributing to racism in the United States add to maternal stress, thus increasing the likelihood of adverse birth outcomes for the mother and child (Grimm & Cornish, 2018). Because this is a multigenerational issue, the inequality in obstetric mortality works to perpetuate racial disadvantages in society. Without significant changes to racist institutions and the medical industry, obstetric racism will continue to burden Black mothers with stress and pain in what should be one of life’s most joyous experiences.