I opened my phone a couple of days ago to a headline reading, “A Black doctor died in childbirth, highlighting a tragic trend that affects pregnant women of color in the US.” Chaniece Wallace, a Black physician, died while giving birth from complications due to pre-eclampsia (a pregnancy-related high blood pressure condition).
For context, I am an American psychologist living and working in London, and so the majority of news I consume concerns what is happening in the States. 2020 has been a year of ongoing hardship, and in particular what my brain has become hyper-fixated on is the enduring systemic inequality sewn into the fabric of the nation in which I was raised. And, specifically, the disparity in the quality of maternal health care — including mental health care — that Black women receive.
One reason this particular news saddened me to my core is because I work in the field of perinatal psychiatry, which means my everyday work revolves around pregnancy, the postpartum period, and the complications (specifically mental health) that women and their babies can experience throughout. So each time I see yet another headline, whether in the US or the UK, about a maternal or infant death that could have been prevented, it really hits home. For example, see our previously-written blog about unjust infant deaths among incarcerated women.
What do we know about maternal health care in the US?
In 2019, a comprehensive policy report estimated that the US has the highest rate of maternal and infant mortality among any developed nation in the world. What’s worse, is that when compared with white women and their babies, Black women are over three times more likely to die due to complications from pregnancy and childbirth, compared with white women, and their infants twice as likely. And so, while the overall mortality rate is 17.2 maternal deaths per 100,000 pregnancies — for context, the rate in Sweden is 4 per 100,000 and in South Africa, 119 per 100,000— when maternal ethnicity is parsed out, women of the Black, Indigenous, and people of color (BIPOC) community are at an especially heightened risk and the rates actually look more like this:
Black women: 42.8 deaths for every 100,000 pregnancies
American Indian/Alaskan native women: 32.5 deaths for every 100,000 pregnancies
Asian/Pacific islander women: 13.5 deaths for every 100,000 pregnancies
White women: 12.7 deaths for every 100,000 pregnancies
Hispanic women: 11.4 deaths for every 100,000 pregnancies
Even more problematic is that in New York City, where I lived before moving to London, the mortality rate for Black women is an astounding 12 times that of white women.
In a country that is already struggling to reduce maternal mortality among all women for conditions identified as preventable — 60% of maternal deaths are classified as ‘preventable’ — it is even more inexcusable that giving birth while Black is considered to be especially dangerous.
Of note, Black women are at significantly higher risk of cardiovascular (heart), circulatory (blood vessels), and pulmonological (lungs) emergencies during and after childbirth.
In fact, a study in the US showed Black women are three times as likely to experience severe or life-threatening pregnancy-related complications, including pre-eclampsia, renal (kidney) failure, and need for a blood transfusion. Of note, the authors of the study found that this risk to Black women still persists over and above any possible external factors, including socio-demographic and economic difficulty, and other medical conditions, suggesting that something else is going on.
Moreover, another study conducted in 2019 specifically looked at the intersection between maternal race and socioeconomic status in pre-eclampsia, a blood pressure condition that has a significantly higher risk for mortality among lower socioeconomic groups and Black women. Findings show that not only are white women less likely to experience pre-eclampsia, but where risk does exist, it appears to be mitigated by higher socioeconomic status. Meanwhile, Black women remain at greater risk for pre-eclampsia and, contrary to expectation, high socioeconomic status does not serve as this same protective factor.
This unjust occurrence has been referred to as a ‘diminishing return,’ meaning that the addition of a positive variable (like high socioeconomic status) may not necessarily lead to a more desirable outcome — and in this case, essentially widens the gap in maternal healthcare equality between Black and white women. Again: something else is going on.
In fact, two notable female figures in America, Beyoncé and Serena Williams, have spoken out in the last few years about their experiences of life-threatening preeclampsia to call attention to the experience of birthing while Black in America.
This must be an America problem, right?
While the US has received a lot of attention over this past year with regard to its ongoing struggles with systemic racism and inequality, what I have come to learn throughout my time in London is that this endemic is not just an American problem — in fact, the UK is just as guilty.
Black women in the UK are five times more likely to die from pregnancy and childbirth-related complications, according to a recently released report by the Maternal, Newborn and Infant Clinical Outcome Review Programme, and overall, women from the Black, Asian, and minority ethnic (BAME) community are at greater risk than are white women. As such, for every 100,000 pregnancies in the UK, 40 Black women, 15 Asian women, and 23 Mixed women will die, compared with 8 white women, which of course is still 8 too many.
A recent study conducted by the University of Oxford that examined the maternal mortality rates from 2009–2017 again shows that women of both Black and Asian ethnic groups are more at risk. Of significance is that as time went on across the eight-year period of this study, the rates of maternal mortality among Black women have steadily increased and the gap has widened, indicating that care is in fact worsening for Black women and their babies.
In 2019, the BBC wrote about Candice Brathwaite, a Black woman who had just given birth in the UK. She felt her health wasn’t taken seriously by her healthcare professionals and that she was subjected to poorer care due to “racial bias within the NHS.” She writes that she was treated as if her pain was all in her head. Soon thereafter, she suffered from acute sepsis.
Candice’s story is unfortunately not unique in the UK: just this past month The Guardian featured two mothers named Tinuke Awe and Clotilde Rebecca Abe, founders of a group called Fivexmore, which was formed as a response to the growing need for equality in maternal healthcare. Essentially, Fivexmore aims to improve care in the UK for Black women and amplify their voices given how universal a problem it has become and how little attention it has received.
How can we explain this inequality?
Candice Brathwaite recently wrote:
“I think we are long past putting this wholly deplorable outcome on pre-pregnancy health risks and social economic circumstances. It’s time to say it like it is: this is happening due to racial bias.”
— CANDICE BRATHWAITE While many factors have been named, including propensity for pre-existing health conditions, sociodemographic and economic influences, and difficulties in access to healthcare, it is now thought that a major explanation for this disparity is the quality of both prenatal (during pregnancy) and postnatal (after childbirth) care that Black women receive, compared with that of white women.
In fact, Dr Ana Langer, director of the Women and Health Initiative at Harvard, has said that Black women are “undervalued” and “not monitored as carefully as white women are,” and, furthermore, that when Black women “present with symptoms, they are often dismissed.” This all-too-common phenomenon can be attributed to implicit bias and racism present not just in our society — that is, in both the UK and the US — but also within our healthcare systems.
An article published just last month in the Journal of Law, Medicine, & Ethics discusses systemic racism present in maternal healthcare that Black women receive. The author writes:
“I assert that structural racism is a powerful social determinant of maternal health that has roots in a historical system of oppression and devaluing of women of color, and persists today in more subtle health care policies and practices.”
This hypothesis is based upon the notion that Black women have historically been subjected to reproductive oppression which has become ingrained in society and healthcare practices today.
Furthermore, a survey conducted in California among new mothers finds that Black mothers are more likely to report discrimination in the care they received during their birthing experience. As a result of implicit bias, Black women have become primed for prejudice.
In my opinion, until our systems de-centre whiteness and incorporate anti-racism training at all levels, including in education and in healthcare, this injustice will continue at the cost of both maternal and infant lives.
On top of being endangered by systemic racism, women are also subject to ongoing sexism within our healthcare system, and thus the intersectionality — a term created by Kimberlé Crenshaw 30 years ago — of race and sex puts expectant mothers from BIPOC or BAME communities at further risk. A recent review of research in implicit bias in American medicine identified that healthcare professionals are just as likely to exhibit bias in patient-interactions as is the wider community, and that this can affect clinician decisions on diagnoses, treatment, and level of care.
So: when thinking about maternal health care, we have to remember that women are already at a disadvantage for the quality of care they will receive and that this disadvantage is further compounded by race.
What does this disparity mean for Black women’s mental health?
I recently completed my PhD in perinatal psychiatry, and throughout it I worked with women (and their children) who were depressed during pregnancy and their postpartum. One finding that consistently came up was that within the group of women I worked with, mothers who were depressed during their perinatal period (and beyond) were more likely to be Black than white.
Of course there are numerous explanations for this, and it is often difficult to disentangle all of the contributing factors to perinatal depression, but a few questions repeatedly came up in my mind: firstly, was the quality of healthcare that Black women in our study received any different — and, if so, could this have, at least in part, driven their mental health difficulties? And, furthermore, if this was the case, why haven’t we addressed this profound problem?
It is thought that the mental health of Black expectant mothers may unfortunately already be vulnerable because of intergenerational or vicarious trauma — essentially secondhand trauma. That is, Black women inherit trauma from centuries of oppression and violence towards the Black community.
It becomes complicated because this is then compounded by the possibility for birthing trauma. A Vox article recently highlighted the complex nature of Black motherhood in the year 2020, given the “emotional and physical burden of trauma on Black mothers’ bodies”, between enduring systemic racism, anticipating COVID-19 complications, and fearing pregnancy and childbirth complications.
Kelly Glass, a journalist who often writes about parenting and race, recently discussed birthing trauma and how “it’s not enough, however, to simply and just barely survive childbirth.” If Black women, who are already primed for prejudice, do not feel listened to or treated well during childbirth, they are at risk for re-traumatization.
“there’s no single change that can reverse traumatic birth experiences for Black women in a system built on racism.”
On top of this, once Black women give birth and return home as new mothers, studies have found that those experiencing mental health difficulties have greater difficulty in accessing mental health care and may even present with different types of symptoms — more somatic and less psychological — leading to greater difficulties in identification to begin with.
At the end of September, an organization called The Motherhood Group launched the UK’s first ever Black Maternal Mental Health Week. The impetus for this awareness week came from research that Black women are less likely to receive mental health treatment during their perinatal periods than white women, a disparity that needs addressing given that 1 in 4 maternal deaths in the postpartum are attributable to mental health causes including suicide. This is especially troubling because, according to The Motherhood Group, “healthcare professionals in the UK lacked the training and the confidence for identifying the specific needs of Black women — causing Black mothers to ‘fall through the net’”.
Similarly, the US observed its own Black Maternal Mental Health Week given that Black mothers in America are also at greater risk of mental health difficulties and are less likely to receive adequate mental health care. The American College of Obstetrics and Gynecology recently stressed the urgency of adequately identifying and monitoring mental health difficulties in Black mothers, especially due to the inequality in healthcare likely received.
What must happen going forward?
A Black woman named Kira Johnson tragically and unnecessarily died after internal bleeding following a C-section; she was left bleeding for over 10 hours before her medical team took action and thus her death, like so many others’, could have been prevented. Since then her husband has become an activist fighting for better healthcare for mothers.
Senator Kamala Harris recently tweeted in response to her death that going forward we must “listen to Black women when they say something doesn’t feel right” to “ensure women are listened to in our health care system.”
2020 has been a year of political unrest; yet, it feels like for the first time, real conversations have started to take place with regard to systemic inequality and what must change going forward.
At this point, it’s unacceptable to continue to uphold a system built upon white, patriarchal ideals. It’s no longer enough to discuss how tragic these statistics are. It’s no longer enough to engage in performative activism. And it’s no longer enough to simply raise awareness. We are at a critical turning point where large groups of people are politically and socially mobilised and motivated and we cannot squander this opportunity.
I am hopeful and anxious for a future where women, especially women of colour, need not fear for their own lives in the process of creating new life.
But to get there, we must acknowledge and take responsibility for the oppression and trauma that Black mothers have been subjected to for centuries; we must dismantle the systemic racism and inequality still ingrained within ourselves and our society; we must undergo extensive anti-racist training and de-centre whiteness from our learning; we must train and hire more Black birth workers; we must step up and listen to and validate Black women; and, finally, we must not lose momentum.
NOTE FROM THE EDITORS: This blog has been part of a special week covering #perinatalmentalhealth to celebrate the Royal College of Psychiatrists Annual Perinatal Psychiatry conference 2020 which has been taking place this week. On Wednesday we covered this theme with a personal account on postnatal depression by Hattie Gladwell.