The Racial Disparities in Pregnancy and Childbirth

Brian: It's The Brian Lehrer Show on WNYC. Good morning, again, everyone. Have you heard about the death of Tori Bowie? Do you know who Tori Bowie was? The death of Tori Bowie has called attention to persistent racial health disparities, particularly in pregnancy and childbirth. Frentorish Bowie, Tori for short, if you don't know, was a three-time medalist at the 2016 Rio Olympics who later earned the title of fastest woman in the world after a big win at the 2017 World Championships.

Now, Bowie was found dead at her home in Florida in early May. She was just 32 years old, and she was eight months pregnant. The autopsy report which was released this week concludes that she died due to complications from childbirth, and lists respiratory distress and eclampsia as possible causes. Context, the maternal death rate among Black Americans is 2.6 times higher than the rate for white Americans. At every income level, this disparity persists.

We'll talk now about how the sometimes insidious, sometimes very blatant health disparities are perpetrated, and the death of Tori Bowie in particular. With me for this is Linda Villarosa, a writer at The New York Times Magazine, a contributor to the best-selling 1619 Project, author of the book Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation. That book catalogs the long history of racial health disparities and lays bare some of the reasons why in the richest country in the world, Black Americans are disproportionately robbed of years of life again, and again, and again. Linda, welcome back to WNYC. Thank you for joining us, even under these terrible circumstances.

Linda: Thank you. Good to be with you, Brian.

Brian: What went through your mind when you'd seen the news that Tori Bowie had died due to complications from childbirth?

Linda: I think I just felt heartbreak. I also thought about respiratory distress. That made me think of I Can't Breathe, which should have been a beautiful pregnancy for her. Childbirth turned into a tragedy for both her and her baby.

Brian: If Tori Bowie was a world-class, world-renown athlete, would it be wrong to assume that she would have gotten all the proper medical care in pregnancy and that her death does not reflect a pattern of racial disparity that might be more income and status-linked, or how would you contextualize her death, at least potentially?

Linda: I don't think we know everything, but someone who is a world-class, college-educated athlete, you'd assume that she'd have access to the best healthcare that she could, that she'd know how to take care of her body when pregnant and in general, and so this turns especially shocking for someone who-- we don't know everything, but who seemed to have access to all that money could buy, at least.

I think the other thing to think about is I think a lot about other athletes who have had trouble in childbirth including Serena Williams, and also including her teammate on that 2016 4x100 meter relay, Allyson Felix. She also had the same thing, preeclampsia, needed an emergency C-section in 2018. Her daughter was born at 3 pounds 7 ounces. That is severely underweight, low birth weight, and puts that baby at risk for early infant mortality.

Brian: Yes, so Tori Bowie, Serena Williams. A study published by the National Bureau of Economic Research found that wealth and income don't really protect Black mothers and babies from this disparity. How come?

Linda: I don't think we know everything, but the thing we do know is much of it happens before you get even into the healthcare system. Something about the lived experience of being a Black person, and especially a Black birthing person in America puts mothers and babies at risk. Then once we do get into the healthcare system, it's without a doubt evidence-based that we have a poorer time, we get poorer service in the healthcare system, and that's what happened with Serena Williams.

Brian: Is it worth trying to separate implicit bias from explicit bias if we understand those to mean that explicit bias is, on purpose, treating Black people as lesser than white people, and an implicit bias might be doing it without meaning to do it?

Linda: I think this is almost entirely implicit bias. People don't go to be healthcare providers; doctors, nurses, midwives to do harm to people. This is about implicit bias, which is part of our country, and it's part of our healthcare system.

Brian: Listeners, we invite you to call in and share your thoughts and maybe experiences of racial health disparities, particularly during and after pregnancy, and especially if you're a Black woman, 212-433-WNYC, 212-433-9692. You're welcome to share a remembrance of Tori Bowie, the track athlete, Olympian, and expectant mother who was found dead last month while eight months pregnant, possibly of respiratory distress and preeclampsia.

212-433-WNYC, 212-433-9692. If you would like to say anything or text anything, you can also tweet @BrianLehrer. What works in addressing these issues? Are there examples of communities taking steps to improve outcomes for Black mothers and babies that have proven effective?

Linda: I think the first step is to really listen to the experiences that mothers and birthing people have had in the system. I think that will really help. In some places, when you listen to women, when you listen to people whose experience it's been, and you think, "Oh, what are the things that they complained about? What are the things we can change?" One of the things is to have some kind of anti-racism or implicit bias training among healthcare providers who work with birthing people at all levels of pregnancy and after the birth. That certainly is one way to dial down the implicit bias.

The harder things to think about are what happens to you before you get into the healthcare system itself. I think of Tori Bowie who was from Mississippi. She died in Florida, but she lived most of her life in Mississippi, which has the highest rate of infant mortality. It's the poorest state. It's the place where it has problems with reproductive justice. It's the place where abortion was totally banned. It has the second-highest rate of maternal mortality. When you grow up in a state and in an environment where things are so disadvantaged, as they say, the body keeps the score. That can build up, and it can become a tragedy during pregnancy and childbirth.

Brian: I guess we should say these issues don't just come out when Black women get pregnant. Maybe you want to talk about how inequality and just the daily stress of racism put a strain on Black people's lives and bodies generally.

Linda: From birth to death, Black people in America have worse health outcomes. We have the lowest life expectancy compared to other groups. We live six years fewer. We also have the highest rates of infant and maternal mortality, but it's not just Black people. Our country in general has terrible health outcomes compared to other wealthy countries. You could look at our country which lacks universal healthcare compared to Sweden where midwives deliver most babies. They have long paid leaves when you have a baby and subsidized childcare. I think that we have problems on two levels, first as a country, but then as a demographic for Black people from birth to death, our health outcomes are simply worse.

Brian: Let's take a phone call. Here's Janet in Brooklyn. You're on WNYC. Hi, Janet.

Janet: Is that me? I don't know.

Brian: That is you. Sorry. Did I get your name right? Is it Janet?

Janet: Janet, that's right.

Brian: Hi.

Janet: I called in just to say that in case it's of some interest in the discussion, 50 years ago when I was traveling around, there was a South African woman staying in the same place. I don't know what we were talking about exactly, but she did contribute. A South African nurse, did I say, that Black African women or some part of them have a hip structure or some anatomical skeletal, I guess, shape that made their births more difficult. I don't know if that's pertinent at this date. I hear it being discussed in terms of racism, and I thought that this might be a factor of interest in the discussion.

Brian: Thank you. Have you ever heard that before or something you would want to put in context?

Linda: I think I wouldn't argue with what you heard, but there is no real genetic difference. There's no pre-term gene or low birth weight gene that Black women, Black people as a demographic have that contributes to this that has been studied in the United States, especially. It's not necessarily a problem with the structures of our bodies or our genetics. This is a problem that happens in our communities, in the healthcare system, and that happens to us in society.

Brian: By the way, I wonder if you can clarify a term for us because I think I said it two different ways so far in this conversation and I want to make sure we get it right for the listeners. The condition that may have contributed to Tori Bowie's death, eclampsia, or preclampsia, or preeclampsia. Are they the same thing or are they two different things?

Linda: They are different but related. Preeclampsia is a form of hypertension related to pregnancy. That means you have high blood pressure, which is never good when you're pregnant. When it gets worse, it can progress into eclampsia, which can cause seizures. Often, if you don't get treated for preeclampsia, it can turn into eclampsia and turn deadly. Preeclampsia is a leading cause of death related to pregnancy, and Black women are 60% more likely to suffer from preeclampsia during pregnancy than white women, and also more likely to develop severe preeclampsia, which then can progress into eclampsia, which is deadly.

Brian: I'm not sure if there's an easy way to connect Tori Bowie's tragic death to this but you spend a lot of time in your book with the Relf sisters. To give people a little bit of background, in the 1970s as really young girls, Mary Alice and Minnie Lee Relf were sterilized against their will and without the informed consent of their parents. Do you want to say more about Mary Alice and Minnie Lee Relf and how their experience highlights the reality of medical racism?

Linda: I also want to add that I talked to them day before yesterday, and in their 60s. They're doing much better now that their story has been brought to life, the tragedy of them being sterilized so that they could never have children throughout their lives, but they survived it. That's part of it. They live in Montgomery, Alabama. All of this is part of a term called reproductive justice.

Reproductive justice simply means that you as people have the right to have a child. It shouldn't be like the Relf Sisters where you get sterilized against your will or without consent. You have the right not to have a child, so that means that you should have access to birth control, you have access to abortion care. Then the third leg of it is if you do have a child, then you have the right to raise that child in a safe and healthy community.

I think about Mississippi where Tori Bowie was from, and I think that child death is very high in that state. That state where she spent most of her life has the worst reproductive justice, perhaps in the country. That's how they're all related. If you die during childbirth, that is part of the reproductive justice package.

Brian: Shayla in Montclair, you're on WNYC. Hi, Shayla.

Shayla: Hello. I'm a little bit worried that we are putting the emphasis on giving birth because, as a Black woman, I've had so many bad experiences in my life that I thought there was something wrong with me. I believe that the problem is with the medical system, which is a reflection of the society that we live in.

Brian: Linda, you want to talk about that?

Linda: Yes. I want to say to you, I'm really sorry about that, and you're not wrong. There has been plenty of evidence enough to fill the Library of Congress, that when we as Black people and sometimes other people of color enter the healthcare system, our experience is not good. It might mean our legitimate concerns are ignored. It might mean we just don't get equal treatment even when we have equal access to health care.

I'm sorry for that. I also am sorry, and part of the reason I wrote my book is because I heard so many people blaming themselves when it wasn't them. It wasn't them. It's not your fault. It is true, and without a doubt that we just receive poor health care in the system here in this country.

Brian: It's interesting, and I'm not going to put these calls on the air, but there are a number of people calling in with "what about" questions. Somebody said, "What about the fact that she was really thin?" She had read in Tori Bowie's case that she was just 95 pounds when she was eight months pregnant. I don't even know if that's true, but that's what the caller is saying. Somebody else called and said, "Where was this family's support system? It can't be just the medical system." I'm just curious if you hear those kinds of things a lot when you raise the issues that you raised in your book.

Linda: I think the knee-jerk response is to blame the woman, is to blame someone. We don't know about her life circumstance. What we do know is that she wasn't well. It sounds like she did not receive medical care for what seems to be preeclampsia. I don't know why, but what I do know is, in general, this is what happens to Black women. I think our conversation here isn't to focus on this individual person came into the news and it brought up this conversation that's long-standing about what happens to Black women, even across class and education lines when we give birth, but also what happens to us in the healthcare system, and our health outcomes, even when other things are equal.

Brian: Amani in White Plains, you're on WNYC. Hi, Amani.

Amani: Hi. Thank you for having me. I just wanted to say for this conversation, I myself, also, I'm a Black woman. I have a child. She's just a year old. After I had my child, I had what is known as postpartum preeclampsia. I only discovered it because I myself was taking my blood pressure every day at home after I had the baby because I was aware of this conversation around Black maternal health and around some of the complications that can happen postpartum.

When I went into the doctor because my blood pressure was so high, she actually asked me, "What made you do this? Why were you checking? Were there any symptoms?" There weren't any symptoms, and nobody had discovered anything, although, on the way, because I had normal blood pressure throughout my pregnancy, except towards the end it started getting a little high, but no one seemed to be worried about it. Even though I myself thought, "You know what, I'm Black, I'm over 40." These complications, no one seemed to think that it was a problem. Again, after I had the baby, it was a problem and I had to go to the hospital and get treated. Otherwise, maybe I would have died.

Brian: Linda, go ahead.

Linda: Taking care of yourself and advocating for yourself, but that shouldn't be the case. In our country, we should have postpartum follow-ups. You should have that kind of care. You shouldn't have to be worried about your own blood pressure every single day. You should have some kind of postpartum follow-up care. In fact, most of the tragedies do happen after the baby is born in the months after. I'm really, really happy for you that yours didn't turn into a tragedy.

Brian: Yes. Can you talk about that fact? I just read that recently myself, and I was startled by it. I did not know that most of what we consider deaths from childbirth, maternal mortality don't happen in pregnancy or during labor, but sometime in the first year after childbirth.

Linda: Yes. I think that's newish research because I think how we picture it is the deaths happening during labor and delivery. What happens after is like what our caller said, she sat home, she isn't given adequate follow-up care, and then something happens. It's still her body. It's still that same body that may have been privy to the negative effects of what happens to you in America as a Black birthing person, including discrimination and toxic stress.

Brian: Listener tweets, "Do you have data on other ethnic or racial groups in the US? I'm a six-month-pregnant Latina." What do you say to that listener?

Linda: I say to you, I'm really happy for your pregnancy, Black women. There's not been enough evidence, enough research on indigenous women, but Black women are the worst. I don't think we should categorize everything by race. I think you're an individual person, and I wish you the best with your pregnancy.

Brian: Deborah in the [unintelligible 00:20:18] section of the Bronx, you're on WNYC. Hi, Deborah.

Deborah: Yes. I wanted to bring up the point of the role, the type of insurance you have may play. When I was pregnant with my daughter, I had a PPO insurance, so I was able to look in the member's guide and pick out the best of doctors. We did genetic testing. We did everything. At some point, I went in, the doctor just said, "You are going to have to have the baby." I had preeclampsia. My birth pressure was so high.

I think had I not had good insurance, compared to like say now I don't have that particular job, I have Medicaid, it's three months to get an appointment at Bellevue for anything. It's so hard. I'm wondering, does the type of insurance you have matter? Do you guys consider that as a factor in us getting better care? I am African American, or I should say Black anyway as well.

Brian: Thank you. Linda.

Linda: This is how I'm going to answer that. If you are poor or if you have not great insurance, that's never good. It's always better when you have the best or adequate or you have good health insurance. However, in this bigger discussion, the research that has been done is on highly educated women and also wealthy women. The assumption is that they did have the best insurance, but still, our birth outcomes are equal to white women with an eighth-grade education or the poorest of white women. That is the thing I think about.

Certainly, I hope for you that you latch back onto that good health insurance you had before. That's never good, but I think in this discussion, we're talking about how even education, access to health insurance, access to healthcare do not protect Black women, even educated and wealthy.

Brian: One more. O'Brien in East Orange, you're on WNYC with Linda Villarosa. I'll say again that she is the author of the book which was a finalist for the Pulitzer Prize called Under the Skin: The Hidden Toll of Racism on American Lives and the Health of Our Nation. Hi, O'Brien.

O'Brien: Hello. Question. Since it's known that women have such poor outcomes for maternity, shouldn't it be the default in the medical system that if you have a Black pregnant woman in front of you, that everyone in the system should have a heightened level of care as a default for that person? If we know that the outcome is so dire, why not just have a heightened level of care for all Black women who are experiencing pregnancy?

Brian: It's a great question. If you know that an individual is statistically at higher risk, for whatever reason, it would make logical sense to give that person an extra amount of attention to make sure that those statistics don't become individual in their case. Linda, what do you think of that idea?

Linda: I think, for individual healthcare providers, everyone should have a heightened level of care. I think, in this discussion, what we've been talking about is, Black women including Serena Williams have not gotten adequate care. Everyone should have the best treatment and care, especially when you're birthing. I'm not sure if Black women need a heightened care, but certainly in my own life and when I talk to individual friends and family members, whoever they are, I say it's wonderful if you can get a doula to go with you during your birth and even before and after.

If you can bring a family member, have someone with you because when you're in birth, you're not at your best. It hurts, it's dramatic, and so have someone with you to be your eyes and ears, to be your support system. That's how I think of it.

Brian: Linda Villaros. Besides being author of that finalist for the Pulitzer Prize book Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation, she also is a professor at the Craig Newmark School of Journalism at CUNY and a contributor to the New York Times Magazine. Thank you so much for talking about this important topic with us, and unfortunately using the death of the runner Tori Bowie to help bring it to light. Thank you.

Linda: Thank you. Thank you for having me.

 

 

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