Leslie Farrington

 

Though they belonged to a healing profession and pledged to ‘First do no harm’, physicians in the Antebellum:

• Worked at slave markets attesting to the health of enslaved peoples to improve the profitability of the slave trade.
• performed experimental surgeries on enslaved women to develop techniques, procedures, and instruments. J. Marion Sims was the most famous because he was self-promoting, but there were several documented early Gynecologists who honed their craft on enslaved women. They also trained the women who were recovering from surgery as surgical assistants according to historian Deidre Cooper Owens.
• used no anesthesia for those surgeries – even when it was available – claiming that Black people did not feel pain like whites, despite the need to hold the bondswomen down so they wouldn’t move while they were operated on.
• contributed racial pseudoscience to the medical literature, disparaging and dehumanizing the enslaved as biologically inferior to whites. Their research and writings were flawed and contradictory. They used the bodies of the enslaved to perfect surgeries and they would then use the same techniques on white women. The proof that all women had the same organs and tissues escaped those early physicians. They would attribute poor healing in Black women to hypersexuality – not on being forced to work after surgery and poor nutrition or being raped by their oppressors. White physicians made up diseases which were unique to Black people.

For example: Drapetomania was a conjectural mental illness that, in 1851, American physician Samuel A. Cartwright hypothesized as the cause of enslaved Africans fleeing captivity.

Physicians did not ‘care’ for enslaved people except insofar as they were able to develop surgical techniques and tools or increase the profit off those in bondage.

Contrast that role with that of the Granny Midwife who assisted birthing mothers and cared for the sick and injured and passed down traditional skills and knowledge. This is a rich history which should be further elaborated.

In the late 1800’s to 1960’s doctors organized professional organizations, continued to use Black people to advance their research, and built hospitals. In so doing they:

• convinced women that midwives were dirty, unskilled, and births were far safer in the hospital.
• instituted public policies to prevent midwives from practicing.
• under Jim Crow laws discriminated against descendants of the enslaved by not accepting them as patients in their hospitals
• segregated Black people into separate (and unequal) wards in the North, if they did admit them to the hospital.
• excluded Black physicians from professional organizations and practicing in white serving hospitals.
• perpetuated stereotypes about African Americans in medical research and education.
• Conducted Syphilis Experiment in the Tuskegee Alabama area
• Forced or coerced sterilization on women of color (recent reports of immigrant ICE detainees having unwanted gyn surgeries)
• Used Henrietta Lacks biopsy tissue for scientific advancement without her consent.

From the 1960’s to Present, despite the Civil Rights era and end of Jim Crow laws, structural and institutional racism, and personal bias and stereotypes continue to affect the health of African Americans.

• The determined agenda of white supremacists to preserve white domination generated a concerted backlash to civil rights era laws which impacted social determinants of health. From restricting Medicare to people over 65 to undermining affirmative action (why the % of physicians who are Black is still 5%) to non-expansion of Medicaid in southern states with the Affordable Care Act – just 3 examples of white backlash from the 1960’s to 2000’s affecting health of Black people.
• 1/3 of Black Americans report discrimination in healthcare settings
• 27% of Black mothers report disrespect or abuse while in the hospital to give birth
• 3 to 12 times as many Black mothers die of pregnancy related complications as whites (depending on city/region) in the US
• Black mothers with college degree are 5 times more likely to die than their white counterparts
• California medical professionals implemented improved obstetrical practices between 2005 and 2013 and cut Maternal Mortality in half in that state, but Black women still died at 3x the rate of whites. They are now focusing on racism as a root cause and mandating anti bias training for medical providers.
• 50% of physicians in training believe stereotypes about Black people’s bodies, which affects 40% of treatment decisions
• white doctors spend less time with their patients of color and communicate poorly
• Stress of racism and discrimination have been shown to contribute to many medical conditions including premature births, hypertension and heart disease.
• The theory of ‘Weathering’ or premature aging of Black women’s bodies due to racism has gained more traction in recent years with biological studies supporting physical damage to telomeres, hormonal alterations, and inflammation in the uterus. *Think about Erica Garner who became an activist after her father was choked to death by police in Staten Island. A few years later during her pregnancy she was found to have an enlarged heart. She died of heart problems exacerbated by asthma 4 months postpartum.
• Medical providers often blame patients for bad outcomes saying they were poor historians or noncompliant.
• Despite public health research going back decades and the landmark report ‘Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare’ from the Institute of Medicine in 2003, doctors are mostly in denial that Black lives are not valued when accessing healthcare. The many stories of women who report symptoms of complications and are not listened to provide a different narrative. Take Serena Williams, for example, who knew she was experiencing a pulmonary embolism the day after giving birth by c-section. She was dismissed when she asked for what she knew was life- saving treatment. Only her white husband was heard.

Future

The Pandemic and the masses of people reacting to the deaths of George Floyd and Breonna Taylor, and racial injustice in general, are currently drawing attention to what Public Health experts, Reproductive Justice Activists, and others have been saying for decades – Racism is killing us.

There are movements, some led by Black Women, addressing racial disparities in multiple areas of medicine. These are gaining momentum because of the recent upheavals:

• Movement is Life Caucus – addressing disparities in joint diseases

• Respectful Maternity Care – decreasing disrespect and abuse of birthing people

• Decolonizing Birth – women taking back their roles as life givers – birth workers, Doulas, Midwives caring for birthing people in their communities.

• Black Mamas Matter Alliance – Black women-led cross-sectoral alliance which centers Black Mamas to advocate, drive research, build power, and shift culture for Black maternal health, rights, and justice.

• Health Care Transformation Task Force which runs the Maternal Health Hub

Topics at Upcoming Decolonizing Birth Conference -RJ & BJ stand for Reproductive Birth Justice:

In addition to activists there are progressive politicians pushing for those sociopolitical policies and legislation which are needed to influence environmental injustice, access to healthcare, universal coverage, criminal injustice, discrimination in housing, living wage, etc.

Some examples:

H.R.6142 – Black Maternal Health Momnibus Act of 2020

Green New Deal

Attorney General of Philadelphia Larry Krasner is an innovative Criminal Justice reformer

NYC Standards of Respectful Care at Birth (from Dept of Health in collaboration with community members)

There are many more legal and policy innovations which can have some impact, but often they are band-aids on the abscess of white supremacy in the US. To achieve wealth and health equity will take decades of concerted effort and political will to effect substantive change. What is needed is the dismantling and restructuring of systems which were designed to neglect or oppress Black people.

Researchers are beginning to look at how whiteness influences design of studies, and the language used. Some are centering marginalized groups. Community led or guided research is more common now. There is the idea of studying medical professionals to figure out how to change their behavior with patients.

What the Black Community can do Now to improve Health and Well-being:

• Increase numbers and use of Black midwives, nurses, doulas, physicians
• Healthcare Advocacy – Amplifying Black voices in medical settings for example the ACTT Curriculum of Black Coalition for Safe Motherhood
• Ubuntu – Caring Community

Neighborhood Gardens

Healthy food collectives and food banks

Drive through Baby Showers

Chocolate Milk Caf© (lactation support groups)

Doula Support

Community Health Workers

Community Based health services

Age Friendly Community Initiatives

Holistic Community support for Birthing people

Support Black Owned Businesses (wealth is key to health)

 

 

Thank you for this opportunity to shed light on why racism is a public health crisis AND how racism impacts health and well-being of birthing families in NYC. Some community-based solutions will be discussed in a panel later today.

First, I will explain that I am the daughter of an interracial couple who experienced frequent episodes of bigotry and discrimination so I was not surprised that some of my white colleagues were prejudiced. I have overheard disdainful comments about patients of color made by white medical professionals because they did not know I am Black.

What I did not realize for most of my career was how bias and paternalism led directly to mistreatment and neglect, resulting in harm and traumatic birth experiences. I did not learn until about 5 years ago that higher rates of complications among Black mothers are often related to the biological impacts of the chronic stress of growing up Black in America. The prevailing medical opinions in the 80’s and 90’s were that life style and infections were the cause. This is called “Mother Blaming”. There are several stereotypical narratives which are passed down since slavery blaming Black people for poor health outcomes and these are part of medical education. Even today 50% of doctors in training believe that Black people have higher tolerance for pain. Despite data proving otherwise, many medical professionals cling to their biases and don’t realize they are mistreating, disrespecting, and not listening to their Black patients. Tennis Greatest of all time Serena Williams pointed this out after her birth complications.

Maternal health crisis statistics in the US and NYC:

754 women died and 50,000 almost died of pregnancy related complications in 2019. 658 died in in 2018. According to the CDC, 2/3rds of these deaths and complications are preventable. The US maternal death rate has doubled since the 90’s, while the rest of the world has been reducing maternal mortality. We rank 55th behind Russia and just ahead of Ukraine. And despite the fact that the US spends at least twice as much as all other wealthy nations, our maternal death rates were at least 3 times higher. I think its worth noting that births everywhere else are attended by midwives and here 90% of babies are ‘delivered’ by doctors. Black women with college degrees die 5 times more than their White counterparts. These disparities exist even when allowing for preexisting risk factors like age and obesity.

In 2017 in NYC out of 21 deaths from pregnancy related causes 11 were Black mothers, 6 Latinas. 3,000 birthing people almost died, 947 of whom were Black mothers. In NYC 8 times as many Black women die of pregnancy complications as White women. And I want to repeat the point that most of pregnancy related deaths are preventable. Too often Black women report warning signs and their concerns are dismissed. In a recent survey of birthing people mistreatment was reported by 1 in 6 mothers, and was twice as common for people of color than whites.

In a 2017 survey by Harvard School of Public Health and NPR, 32% of African Americans report discrimination in healthcare settings. Racism in the healthcare system is one root cause of this public health crisis. Another is racial oppression influencing every aspect of Black life since slavery and continuing in the present with discrimination in hiring and housing, segregation and underfunding of schools and hospitals, racial profiling and mass incarceration, I could go on. African features have been stigmatized as part of white supremacist ideology to justify slavery and oppression. It remains embedded in society.

Experts in public health today will tell you that it’s racism that’s killing Black mothers. And racism also is the reason Black infant mortality is two to three times that of white babies. I will give you just two studies to show how we know it’s racism and not race or socioeconomic status that is deadly. Recently in a study in Florida of 1.8 million births, the death rate of Black newborn babies under the care of Black doctors was half the death rate under the care of white doctors. A study in Detroit comparing birth weight of babies born to African American mothers, white mothers, and African immigrant mothers showed that African babies and White babies had the same birth weight but African Americans babies were significantly smaller. African ancestry does not increase risk of death. Race is a social construct, not a biological difference. Pregnancies of mothers who experienced racism through their life course are at increased risk due to the biological impacts of stress. Cardiovascular health is also impacted by racism and discrimination. This is why African Americans need and deserve better medical care not worse. Racism is a public health crisis and has been for centuries.

The Ongoing Tragedy – An Iceberg of Harm

The main message to take away is that the premature deaths of Black people, either in the care of doctors, or at the hands of the police, is the tip of an iceberg. When it comes to maternal health, the disproportionate numbers of Black women dying of pregnancy related complications is the tip of an iceberg of harm experienced by Black families, in this city and throughout the African Diaspora.

Interviews conducted by NYC DOHMH of 15 mothers who almost died in NYC hospitals revealed that most experienced microaggressions and disrespectful communication with their providers.

During pregnancy, and especially during the birthing process, treatment decisions, which go against patients’ wishes, are frequently made without their input. Labor & Delivery routines are often not based on medical evidence, and go against the natural process of human labor and birth. Informed consent to undergo obstetrical interventions is often based on opinions of providers and not sound evidence, and birthing persons’ preferences are not respected. Worst of all birthing people experience coercion without regard for their human rights. For example, a birth companion in Brooklyn told me that a Haitian Creole speaker was forced to have an emergency C-section without an interpreter. Doulas I speak to tell me laboring women are pressured into vaginal examinations and procedures as if they had no bodily autonomy, which is basically rape culture. It’s called Active Management of Labor and its part of the training of doctors in New York City hospitals, it was the same when I trained.

A Brief History of Maternity Care

We must study the history of racism and patriarchy in maternity care to understand why deaths of both white and Black women have been rising in the United States since the 90’s.

For centuries women with skills supported other women giving birth. The traditional midwifery model of care supports a spontaneous birth under a birthing person’s own power, usually without intervention.

In the 1800’s US doctors experimented on poor and enslaved women to develop the medical specialty of Obstetrics and Gynecology. They introduced instrumental delivery with forceps and surgical interventions like C-sections and episiotomies. They pathologized and medicalized the natural process of birth. Â In the early 1900’s hospitals and doctors began to capitalize on birthing. They put traditional indigenous and Black midwives out of business by spreading the narrative that midwives were dirty and uneducated and that birth was a dangerous condition requiring a doctor’s services. Midwifery was essentially outlawed in the 1920’s and 30’s. C-sections and other medical Interventions have increased in the 100 years since, leading to increasing complications. The medicalization of birth and development of technological innovations have increased revenue for hospitals. Since the late 1980’s Doctors have been under increasing production pressure to see more patients at a faster pace due to declining reimbursement from health insurance and increasing costs. Nurses are expected to do more in less time. Hospitals serving Black communities and rural communities have closed for lack of funding.

Many doctors don’t realize how medicalization of birth and lack of respect for mothers’ autonomy and dignity interferes with the natural power of human birthing. About 80% of birthing people are low risk for complications and don’t need the obstetrical model of care controlled by hospitals and physicians. There should at least be the option to receive culturally congruent community care. The research evidence supports making person centered care with a midwife, and the support of a birth companion also known as doulas, available to improve maternal health outcomes. There is excellent work happening in the community by the NYC DOHMH, but their efforts are underfunded. From the White House and Congress to the state house to the Mayor’s office there are efforts to improve care, including access to out of hospital birth, but the needed transformation of maternity services requires bolder action within hospitals and among doctors. I want to emphasize that the steps currently being taken to address the Black Maternal Health Crisis are just baby steps compared to the centuries of racial oppression and trauma which continues today. We are a long way from the culture of respect in medicine.

I believe most clinicians care about their patients, but they are affected by our society and the culture of medicine. My nonprofit, the Black Coalition for Safe Motherhood, is offering a toolkit for communicating with and hopefully partnering with providers. Knowing what I do about the biases they have and the pressures that medical professionals are under I have cocreated the ACTT Curriculum with other birth justice activists. ACTT stands for:

Ask questions until you understand the answers

Claim Your Space – both physical and mental

Trust Your Body

Tell Your Story

I cofounded the Black Coalition for Safe Motherhood to spread these self-affirming and potentially lifesaving steps in Black Communities nationwide and beyond. Using the ACTT steps, my hope is that Black birthing people and their families and supporters will be better equipped to navigate healthcare until it is transformed into compassionate person-centered care that everyone deserves.

 

 

Trauma Porn vs Seeking Justice, The Media and Black Maternal Health

On Facebook I recently learned about the death of Denise Williams, one month postpartum, at the same New York City (NYC) hospital where my grandmother died from a pregnancy complication almost 100 years ago. Racial disparities in health are not new, but in the age of media algorithms, repeatedly featuring these tragic stories causes stressful alarm and fear among Black birthing people. This intentional sharing and broadcasting of harmful news is called trauma porn. But the Facebook video I viewed was posted by Ms. Williams’ grieving family, so there is another side to the social media and news media coverage of the failings of the health system.

Movement to Birth Liberation, a NYC based network of Birth Justice activists, is supporting the Williams family’s search for answers and justice, and calling for more media attention to press for transparency and accountability, in the hopes of addressing why health care in NYC hospitals is failing to save Black birthing mothers. In the case of Denise Williams, there are protests because over six weeks afterwards no answers are forthcoming as to what led to her death two days after she was admitted for treatment of postpartum depression.

In the several years since the rising rates of pregnancy related deaths and complications in the United States were exposed, there have been many news reports about how Black mothers are 3 times more likely to die than their white counterparts. In NYC the disparity is 8 times more likely. Now doctors and midwives are hearing Black women say, ‘I am afraid I’m going to die’. Many Birth Justice activists want to stop the media capitalizing on trauma porn. But even without mainstream media coverage, each tragedy ripples through the deceased mother’s community, and families and activists want more coverage. At the same time a balanced perspective that conveys to pregnant people the high likelihood of healthy birth outcomes can allay fears and reduce stress – which is known to increase the risk of premature birth.

In April 2021, a group of Black birth workforce leaders – nurses, obstetricians, and midwives – pushed back against the stressful narratives Black birthing people hear – with factual information in their Love Letter to Black Birthing People:

Our actual risk of dying from a pregnancy-related cause, as a Black woman, is 0.0417% (41.7 Black maternal deaths per 100,000 live births) — to put that in perspective, our risk of dying is higher walking down the street or driving a car. Based on past and present injustices, we have every right to be scared, but make no mistake: that fear comes at a cost and Black birthing people are the ones paying the bill!

Indeed, the risk of death or near-death complications for Black birthing people is very low. However, the actual numbers – 700 maternal deaths and 50,000 severe complications per year – represent a problem which continues to worsen in the US. At the same time the Black Maternal Health Crisis is the tip of the iceberg of harm and disrespect Black people too often deal with in all areas of the medical system. Major legislation to address the issue, the Momnibus, has been sitting in Congress for over a year. Given the lack of political will to make necessary changes in maternity services, and denial of systemic racism in medicine and society, how do we convince Black birthing people that their birth experience can be a joyful, powerful, and even spiritually uplifting experience? How do we access health care without fear of mistreatment? The Black birth workforce has the answers as noted in the Love Letter. Black community-based organizations can uplift those solutions and support their implementation as we work to hold the existing medical system accountable.