by Keisha Ray, Ph.D.
In a previous blog I wrote about racial disparities in health and health care in which black patients fare much worse than white patients, including worse health outcomes. For instance, black patients are more likely to experience inadequate pain management from their practitioners than white patients. Black people are also more likely to experience lower quality of sleep than white people, which can contribute to other health problems such as hypertension. Recently bioethicists have been somewhat more attention to another racial disparity, the disparity between black and white women who die during or after childbirth.
By some estimates black women are 3 times more likely to die from pregnancy or pregnancy related ailments than white women. The World Health Organization (WHO) estimates that black women’s survival rate during pregnancy is similar to women in developing countries. In my home state of Texas, according to the Task Force on Maternal Mortality and Morbidity, black women accounted for 29% of maternal deaths even though they only accounted for 11% of births in 2012. White women accounted for 38% of maternal deaths in Texas but accounted for 35% of all births in the state. These numbers are concerning given the technology and the supposed sophistication of our health care system and the health care resources at our disposal compared to that of developing countries.
In my research on racial disparities in health care I have found a troubling trend among bioethicists and that is a reliance on a connection between poverty and lack of education that black people experience to explain their poor health and racial disparities in health care. As the typical argument goes, black people tend to be poorer and have less education than white people and since wealth and level of education are some of the social determinants of health, it is expected that they would experience adverse health issues such as high death rates during pregnancy and child birth.
This attempt to explain poor black health by focusing on social factors is problematic for many reasons, including it misleadingly contributes to the narrative that all black people are poor and it ignores an increase in black wealth. But more importantly this argument relies on assumptions that are not backed by data. For instance, according to a 2016 study that analyzed 5 years worth of data on pregnant women in New York, “college-educated black mothers who gave birth in local hospitals were more likely to suffer complications of pregnancy or childbirth than their white counterparts who never graduated from high school.” This study disproves the traditional narrative in bioethics that education can be equated to better health and better health care. This may be true from some people, but as a general rule it is not true for black people, specifically black women giving birth. Just as more education does not always equal better health and better health care from practitioners for black women giving birth, neither does income. Recently tennis star Serena Williams has perhaps unwittingly become an exemplary of this idea.
Serena Williams, one of the greatest, if not the greatest professional tennis star of our time given her many accomplishments in the sport recently detailed the circumstances of her daughter’s birth that could have ended with her death. After delivering her daughter, Alexis via an emergency Cesarean section Williams felt short of breath while recovering in her hospital room. Williams, who has a history of blood clots left her hospital room and told the nearest nurse that she needed a “CT scan with contrast and IV heparin right away.” After being told by the nurse that her pain meds were probably making her confused, Williams remained adamant that something was wrong. A doctor then performed an ultrasound on her legs. After the ultrasound revealed no blood clots Williams again remained adamant that an ultrasound is not what she needed but that she needed a CT scan and a heparin drip. The doctor then allowed a CT scan to be performed and it indeed did reveal several blood clots in her lung and she was put on a heparin drip. Perhaps somewhat jokingly and seriously Williams recounted “I was like, listen to Dr. Williams!”
Although patients are not always in the best position to determine their necessary health care needs, Williams story makes me think of all the black women who have died during or after giving birth who did not have the money or celebrity status to help them convince their nurses and doctors that something wasn’t right and that they needed medical attention. If it weren’t for Williams status as a popular elite athlete, model, spokeswoman, now wife to wealthy Reddit co-founder Alexis Ohanian (who is also the father of her daughter) Williams story could have turned out much differently. If Williams had a hard time convincing her doctors that she knew her body and knew something was wrong, we can image just how hard it would be for another black woman who does not have the accolades or wealth of Williams to convince a suspicious nurse or doctor. After Williams went public with her story, other black women have also come forward with their similar stories, including nurses who have witnessed similar incidences.
Just as Williams has emerged as an example of how money and celebrity status does not safeguard black women from possible death after birth, Shalon Irving has emerged as an example of how education does not safeguard black women from dying after birth. Shalon Irving, was a young black woman and an epidemiologist at the Center for Disease Control and Prevention (CDC). She had a B.A., two master’s degrees, and a Ph.D. Irving died weeks after giving birth. So if it is not a lack of income, as Williams shows, and it is not a lack of education as Irving shows then why do black women have a higher maternal-mortality rate then white women? I’m sure the answer is complex. It could be a combination of structural inequalities that create life long unequal access to resources needed for health such as safe spaces for recreation and exercise and access to health care. The answer could also be “grit” attitudes in the black community that discourage black women from seeking health care when ill. But as Williams, Irving, and other black women’s narratives show, health care as an institution and individual practitioners must take responsibility for at least one reason for black women’s high maternal mortality rates—black women’s narratives carry little weight in health care; practitioners simply don’t trust black women’s words. Marsha Jones, director of a group based in Dallas who is working to get the Texas legislature to give more attention to reproductive health access for black women expressed this sentiment when she asked “Who is going to listen to us talk about black women?”
Detailing the intricate ways in which medical racism and racial biases have remained in health care is beyond the space allotted here but we do see how they are reflected in patient-practitioner interactions and patient care. Black women’s maternal deaths are at least one manifestation of racial biases that linger in the field. It explains why their pain and other concerns about their physical and mental health are ignored and it explains why their dismissal as knowledgeable stewards of their bodies are ignored and sometimes result in their death. Black women are sharing their stories and telling us that their doctors and nurses don’t believe them when they say something is wrong with them before they’ve given birth or after they’ve given birth. Black women are telling us that it is taking multiple interactions with their doctors and nurses before diagnostic tests are performed. So while we are looking at factors like income and education, (which may deserve some investigation as a part of overall structural inequalities) practitioners’ biases also deserve more attention because based on the experiences like those of Williams, practitioners simply don’t trust black women as stewards of their own bodies.
If we want to eliminate racial disparities in health care we can start by listening to black women’s stories and recognizing our own biases. Black women are dying at disproportionate rates during and after child birth and unduly focusing on their lack of education and low income is scientifically, medically, and ethically irresponsible. Black women shouldn’t have to be one of the greatest and most well-paid tennis players of our time to avoid death after giving birth to their children.