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In the February 12, 2023, article “Childbirth Is Deadlier for Black Families Even When They’re Rich, Expansive Study Finds,” the New York Times reported on a new study documenting the disparity between Black and white women for adverse maternal and infant mortality outcomes.
The numerical depth of the study featured in the report, analyzing the outcomes of two million first-time mothers across class and race in California, is unprecedented. Kate Kennedy-Moulton and colleagues demonstrate the various differential registers at which women by race and class live through these adverse outcomes and notably reference the environmental, social, and public health conditions that lead to said outcomes.
While we commend the study authors for providing more evidence on the scope of differences in adverse outcomes by race, these are longstanding, known disparities, which have persisted since at least the 1850s. Historical economist Michael Haines published data in 2008, showing the difference between Black and white infant mortality in 1850 was 1.6 times higher for Black infants than white. By 2000, it was 2.3 times greater for Black infants compared to whites. The California study finds that the disparity not only persists but has increased over the decades.
Serious attention to the class dimensions of racial differences in maternal and infant mortality is not as comprehensive, however. The question posed by the California study was specifically about the health disparities for “wealthy” Black women—which the New York Times article found “newsworthy.” The study found that while wealthier white women were also at risk for poor birth outcomes, they generally were treated for their health concerns, but wealthy Black women were not able to have their vulnerabilities addressed. Although this seemed a novel finding, these differences have been documented by both epidemiologists and anthropologists.
In 1992, Dr. Diane Rowley, then a senior program officer at the Centers for Disease Control (CDC), published a study with her colleagues which revealed that college-educated Black women were twice as likely as white women to have poor outcomes. She and her colleagues concluded that more contextual understanding could be gained by conducting qualitative research to complement the epidemiological approaches.
Subsequently, Rowley and her colleagues funded a series of studies in different cities to gain insight into the social conditions that might be resulting in poor reproductive health. One of these was the Harlem Birth Right study led by anthropologist Leith Mullings, then a distinguished professor at the Graduate School of the City University of New York. Mullings and the lead ethnographer for the study, Alaka Wali, published their findings in 2001 and documented through combined ethnographic and epidemiological research the specific sources of chronic and acute stress (a primary factor in high rates of morbidity and mortality) for both college-educated middle-income and low-income Black women in Central Harlem. These included poor environmental conditions (air quality, rodent infestations, abandoned buildings) due to neglect by the City and State government, economic precarity (even middle-income Black women were vulnerable due to lack of wealth accumulation and less access to more secure occupations), and implicit and explicit bias on the part of medical professionals. The stress was compounded by the fact that women fought to improve their living conditions despite significant obstacles. In this way, the study went beyond the numbers to demonstrate why the lived experience of racism was deeply detrimental to women’s reproductive health and why mere access to higher income does not protect Black women.
Mullings captured the combined impact of gender, class, and race and resistance to racism in the concept of the “Sojourner syndrome.” Subsequent epidemiological and ethnographic studies have upheld the powerful saliency of Mullings’s theory that explains the oppressive dynamics of race, class, and gender that Black women experience but also highlights the way they resist and disrupt those dynamics. Sarita Davis used the framework to understand Black women and HIV risk. Karen A. Scott draws on the Sojourner Syndrome in her approach to transforming perinatal quality improvement.
Serious attention to the experiences of gender, class, and racism during medical encounters has also recently become a robust site of qualitative inquiry. In Reproductive Injustice: Racism, Pregnancy, and Premature Birth, Dána-Ain Davis points out the long durée of adverse birth outcomes and racist treatment of Black women during pregnancy, labor, and birthing among middle-class Black women. She also describes the affective ways that Black women understand their medical experiences during prenatal and postnatal care. They interpret racism in the ways they feel dismissed, neglected, coerced, talked down to, treated as if they are criminals, and more.
The continued devaluation of Black women in the United States speaks volumes to the way they are generally treated by the population at large. Celebrity status and wealth did not protect Serena Williams because the medical staff did not “see” her and dismissed her concerns. With the renewed focus on racialized health disparities during the COVID-19 pandemic, journalists continue to publicize Black women’s medical encounters and the toll of racism on Black maternal mortality. This visibility to the persistence of adverse outcomes is needed and should be expanded.
The central question we need to ask is, Why have medical and public health systems been unable to improve reproductive outcomes for Black women, despite knowing that disparities have persisted for decades?
Public health officials, the medical complex, and society at large deny the cumulative impact of environmental, economic, and racism factors that must be systematically addressed. For example, after the results of the Harlem Birth Right study and other qualitative research studies were presented at a major conference hosted by the CDC, senior officials minimized their implications and recommendations and once again reverted to assumptions about high-risk behaviors as the cause of racial disparities. This is but one example of how by and large, the State and the medical profession have refused to address the root causes and real consequences of racism, deeply embedded in institutional practices and policies and habitual attitudes. Time and again, what dominates public inquiry centers on blaming Black women for their own adverse outcomes. Women’s behaviors continue to be highlighted when it comes to reasons for low birth weight infants as well as their own adverse health outcomes.
As the California study once again showed, rich Black women have terrible outcomes and so-called high-risk behaviors are not sufficiently explanatory for the racial disparities. There have been some laudable attempts to improve Black women’s reproductive care. But those examples are local in scope and do not represent standardized practice. For instance, several states have begun to see the positive outcomes of pregnant people having doula support and have put forward legislation for Medicaid reimbursement. A hospital system in Pennsylvania committed to advancing equity in Black maternal health implemented a strategy that linked executive pay to reductions in maternal morbidity and mortality among Black women. Such efforts aside, we keep persisting in creating a false narrative that Black women’s behaviors explain adverse outcomes.
As Mullings and Wali recommended, and as Davis has done in her work, there must be investments in solutions such as focusing on quality improvement in infrastructure in Black neighborhoods, addressing environmental racism, finding remedies for the persistence of the wealth gap, and uplifting the incorporation of ancestral knowledge and collective self-care practices in prenatal and postnatal care into medical practice. The medical profession must continue to address deeply embedded racial bias in its practices and norms. These interventions will mitigate the causes of chronic and acute stress and save Black women, birthing people, and children by improving reproductive outcomes. We have enough evidence to shift the focus of our interventions. Let’s do that.
Meryleen Mena and Annika Doneghy are contributing editors for the ABA section in Anthropology News.