When I read about Serena Williams’ experience giving birth to her daughter in this month’s Vogue, a sense of familiarity washed over me. As an ob-gyn, I’ve cared for many women who have had complex pregnancies and deliveries. I’ve performed emergency C-sections and treated postpartum complications, like the blood clots she experienced. As a mother, it also brought back memories of my own pregnancy and delivery, which was complicated by high blood pressure and preeclampsia. Thankfully, my postpartum course was much less complicated than Williams’ was, but, like many women, I had a pregnancy that wasn’t straightforward. And while reading her story, I couldn’t help but think of how often our own stories—specifically, black women’s stories—don’t end well.
In the United States between 700 and 1,200 women die from complications associated with pregnancy or childbirth every year, and another 60,000 almost die. We have one of the worst maternal mortality rates in the developed world. And it’s getting worse: Between 1990 and 2013 our maternal mortality rate has more than doubled. The reasons aren’t completely clear. Some researchers say the increase is simply because we now have a more accurate and standard way to tally deaths associated with pregnancy and childbirth. Others attribute the increase to the fact that more women are delaying pregnancy until later in life, and later-in-life pregnancies can carry greater risks to the mother. Still, it’s worth noting that whatever the cause of the spike, overall the risk of death because of pregnancy is still fairly low. Most women go on to have uncomplicated pregnancies and deliveries.
But black women are the exception. According to the Centers for Disease Control (CDC), we are three times more likely to die due to pregnancy-related complications than women of other races, something Williams even drew attention to in a recent Facebook post.
This is not new information. Health care providers, researchers, and others in the medical community have known about these disparities for years. In the past they were most often ascribed to the generalized “poorer health” of black women. It is true that black women are more likely to have medical problems—like heart disease, diabetes, and high blood pressure—than women of other races. But do these differences exist solely because of the “poorer health” of black women?
Many researchers now believe that it is racism—not race— that is the problem. For example, even when we take medical history into account, black women are two to three times more like to die from pregnancy-related complications than white women with the same condition. And while maternal mortality rates are certainly greater for poor women than wealthier women, poverty alone can’t explain these disparities either. An analysis of maternal deaths in New York City found that black women who had at least a college degree still had greater mortality rates than white women who had not graduated high school.
In a country where we spend $111 billion per year on maternity care, how is it possible that the color of your skin can determine whether having a baby is a death sentence?
One theory looks at the way stress impacts black women’s health. Experiences of oppression are not unique to black women, of course, but the intersection of certain oppression—like racism, gender discrimination, and economic inequity—is unique to the experience of black women in the United States, and it can have a profound impact on health. This phenomenon is called “weathering,” a term coined by Arline Geronimus, a research professor at the University of Michigan’s Population Studies Center, and it describes the increased wear and tear that poverty, racial discrimination, and political marginalization have on the biology of black women. According to Geronimous, black women experience “accelerated aging,” which accounts for some disparities in health outcomes—including maternal mortality. In other words, the emotional engagement it takes just to function in the world begins to take a toll on physical health.
This phenomenon is exacerbated by the inherent bias—implicit or explicit—in our health care system. Historically, black women have not had the same access to health care services as white women. We are more likely to lack insurance and deliver our babies at underresourced and underperforming hospitals. As Williams described in her birth story, black women’s complaints are also more likely to be ignored or dismissed by medical providers. Studies have found that a patient’s race and ethnicity does have an impact on a physician’s decision making, and that doctors tend to perceive black patients more negatively than white patients. This has a direct impact on the quality of care. One study found that, even when access to care and insurance coverage are the same, people of color still receive a lower quality of health care..
The bottom line is, black women are dying wholly preventable deaths. Part of my job as a health care provider is to understand how these factors intersect to impact my patients and their health. And something like maternal mortality can’t be understood outside of a historical, social, and political context. Considering the intersection of oppressions allows us to seek solutions that challenge the status quo. Advocates, policy groups, and research organizations like the Black Mamas Matter Alliance and the National Birth Equity Collaborative are working to ensure that these solutions don’t further perpetuate inequities.
Delivering your baby should not be a death sentence. Serena Williams lived to tell her story. Many women don’t.
Jamila Perritt, M.D., M.P.H., F.A.C.O.G., is a fellowship-trained, board-certified obstetrician and gynecologist with a background in family planning and reproductive health. She provides community-based care focusing on the intersection of sexual health, reproductive rights, and social justice. Dr. Perritt works as a clinical provider in Washington, D.C., and the surrounding areas and as a reproductive health care consultant collaborating with organizations to provide ongoing support and subject matter expertise on sexual and reproductive health, family planning, and reproductive justice. You can follow her on Twitter @ReproRightsDoc.
