Black Maternal Mortality
Weathering- The Lived Experience of Racism
My baby is over a year old now but I still remember being eight months pregnant, reading a copy of the latest National Geographic while connecting with my bump and being completely floored by the story of Keira who died at the age of 39 from internal bleeding after delivering her second son by planned C-section.
This was my first introduction to the fact that African American mothers are three times more likely to die than their white counterparts. I was intensely angry I’m not sure but some of you probably know that hot, breaking feeling when something is so unfair and you’re so enraged that the only way for the emotion to escape is through your eyeballs. This was how I felt. I remember thinking, well that is in the US, surely it can’t be such an issue here in the UK.
I was so wrong, here in the UK black mothers are five times more likely to die than their white counterparts.
Fast forward a few weeks I come home from yoga and my waters break all over my kitchen floor. Just like in the movies. About 30 hours later I hadn’t delivered my baby and I had started to bleed. This took us into the hospital. I had done my research, talked to several people and was confident that the best place for me at that point was still as home and the risk to myself and baby was still very low.
The midwife was accepting of this and had assessed the bleeding wasn’t anything to worry about. She just needed the doctor to ‘sign us out’ and we could be on our way back home. This is when things started to spiral. The doctor came in and gave no introduction or acknowledgment to myself.
‘We have to put you on antibiotics and induce you immediately’ she said.
Oh goodness.
The standard archetype for a doctor like this in my mind is white, senior and male. But standing before me was a young, female, non Black person of colour. I had to fight with this doctor to exercise autonomy over my own situation and body. I began by telling her what I would like to do and the reasons why I am comfortable with my decision.
She refused to have an open discussion about any research or outcome that fell outside the hospitals guidelines. Things escalated very quickly between the two of us. I remember thinking how is this happening right now. This is the last thing I need.
I was in tears telling her to stop talking. She wouldn’t stop telling me that if I were to go home my baby would die, that I was chasing a particular type of birth and was selfishly putting my baby at risk.
In the end I left the hospital distraught and against medical advice. I had to fight for my voice to be heard. I was made to feel small, uninformed and already a bad mother.
The cost of this encounter to my birth experience is hard to quantify, as there isn’t a way to know how else it would have gone. But the fear this doctor instilled, the adrenaline she inspired, and effort she stole, placed me in a situation whereby I felt unsafe. I doubted my body’s ability to safely birth my baby as well as my own instincts, voice and knowledge.
I always think what happens to women who don’t have the capacity to advocate and champion themselves during their births? Whose vulnerability is exploited? Those who don’t have supportive birth partners or were able to arm themselves with knowledge.
It’s not a case of having been given information contrary to what I wanted to hear. Or that I was narrow sighted due to a particular birth I had envisaged. I know that it is possible to have a birth that deviates far from your birth plan and still be empowered by your birth experience.
If I had been treated with respect, made to feel understood, my information acknowledge as having merit and exercise autonomy over my own body, I am certain that my experience and the way I still feel about my birth would be very different.
A few hours later I was at a point where I needed to return to the hospital.I felt too scared to go back. I remember sitting in my bathroom crying, thinking what else could I do and where else can I go. I didn’t feel safe having to go back.
The risk to baby and myself was created by the carelessness of the doctor. This doctor probably went home and complained about a crazy woman in labour and got on with her life.
If I had on been in a situation whereby I really was in danger and needed to stay in hospital or, as was the case, return to the hospital, this doctor had severed the trust I had in the care I would be provided.
The question I have found myself as a result of this experience is how do you know if what you experienced was due to racism or unconscious bias? I imagine it’s adding up all the little things and feelings but in honesty I still don’t really know. Here’s what I do know.
The conversation around the issue of Black women being five time more likely to die in birth and birth related complications has gotten louder and shifted into more mainstream conversation. Yet when I mentioned the statistics to friends and sent around a link for them to sign the petition to ‘Improve maternal care for black British women’ all were completely unaware of the issue and had questions I didn't have the answers to.
So I did some more research.
The MBRRACE report published in 2018 identified that black women in the UK are at 5x greater risk of dying in pregnancy and pregnancy-related complications than white mothers. This report is the key reference in the recent discourse that has begun here in the UK on the issue of black maternal deaths.
It is important that the numbers are finally out there, but it is also important to highlight that this report fails to even mention the potential impact of unconscious bias or racism.
I had hoped that the revised report in 2019 might look to improve upon this, however, I was left wanting.
This here is an attempt to fill a gap that I have identified in the discussion on black maternal outcomes in the UK and the issue of racism and unconscious bias. To set a precedent for future conversations, debates and action.
In looking to discover more about the issue here in the UK it has become evident that we are far behind our American counterparts in the language, available statistics, information and discourse.
I am not assuming that influencing factors in the US and the UK are the same. However, when you listen to the narratives of those affected, similar threads are evident. And they all pull together to support a strong theory for the impact and experience of unconscious bias and racism.
In the US there is a clear correlation between the concept of Weathering, poor maternal outcomes and the overrepresentation of African American mothers within this group.
Yet, in no report or article could I this concept mentioned within the UK.
Weathering is a term coined by Dr. Arline Geronimus and speaks of the compounded effects of the body’s sustained reaction to the fight or flight response over a prolonged period.
‘How the toxic stress that racial and ethnic minorities, including African Americans, Latinos, and Native Americans, experience—regardless of economic or social success—can erode their physical health. It's known as "weathering," a concept developed by the University of Michigan professor of public health Arline Geronimus that suggests the health of African Americans deteriorates earlier than that of whites because of the cumulative effects of racism and bias. It may help explain why even black mothers with the highest levels of education are dying at higher rates than white women with the least education.’
It is not race itself that is a risk factor but rather the lived experience of racism in our societies and systems. This means that in today's context, where the experience and impact of racism and unconscious bias is embedded in so many corners of society, being black or of an ethnic minority is costly to your health.
Over time the build-up and effects of Weathering are evident when we look at numbers. Geronimus states "As a group, black mothers in their mid- to late 30s have five times the maternal mortality rate of black teen mothers, although the older mothers generally have greater educational or economic resources and access to health care." In America, there are numerous cases whereby education and income fail to provide fortification for black women; the loudest of these is perhaps the story Serena Williams shared about the birth of her daughter. The danger of Weathering in the lives of black women is furthered due to the "double jeopardy of gender and racial discrimination." And yet as Dr Fleda Mask Jackson has identified in the US "much of the discourse from care providers and public health professionals has neglected to explicitly name the role of racial discrimination and systemic oppression in black maternal outcomes." This seems especially true and reflective of the situation here in the UK, where the link between racism and the over-representation of black women in maternal mortality statistics has yet to be accepted, let alone remedied.
The 2018 MBRRACE introduction states ‘there still remains a large disparity between the maternal mortality rate of women of white ethnicity compared to women from black and Asian ethnic groups. The almost fivefold higher mortality rate amongst black women compared with white women requires urgent explanation and action. Previous research has suggested that this inequality of outcome may be partly explained by gestational diabetes during their current pregnancy, medical morbidities, previous pregnancy problems and inadequate use of antenatal care, all of which could provide an initial focus for action to reduce this inequality’.
This is a perfect example of the neglect Dr Fleda Mask Jackson speaks of and it also illustrates how the onus is placed on the women themselves rather than the systems that are failing them. Elizabeth Dawes Gay, co-director of Black Mamas Matter and a public health professional gives it to us straight, in her article, Serena Williams Could Insist That Doctors Listen to Her. Most Black Women Can't. "As a public-health professional, I have attended dozens of conferences, meetings, and briefings on maternal health. I have often been disheartened to hear public-health leaders and researchers neglect to explicitly call out the role of racism on maternal health, even when asked about it directly. Providers, researchers, and public-health professionals are more inclined to point to the high prevalence of chronic diseases such as high blood pressure and diabetes, and to the epidemic of obesity in the black community. This places the onus for large-scale change on individuals rather than the systems that we know cause harm.”
Language in this conversation holds such importance and power; this is true for both what is and what is not said. The use of language that fails to call out the systemic racism inherent within the existing medical system, its culture and society at large, is sustenance for continued racism and in consequence the lives of black women and their babies.
Failing to correctly identify and articulate the reasons for the growing rate of black mothers dying in the UK, such as the existence of Weathering, racism and unconscious bias and instead placing blame on the shoulders of these women perpetuates an environment in which these issues can fester and thrive. It also enables stereotypes such as the angry black woman or even the strong black woman to be normalised.
Dismantling the current culture, holding the system to account and addressing the needs of these women cannot take place if black women themselves are absent from the decision making process. If the voices of black women remain unheard we will continue to be misrepresented, have our needs addressed and perpetuate a culture and environment that, by the very nature of its exclusions, allows for racism and bias.
I don’t know the stories of the women who have died here in the UK but I can imagine that they were women who weren’t actively listened to and were disempowered by the system.
Weathering isn’t the sole explanation for why Black women are five times more likely to die and have poorer maternal outcomes. It is a veiled issue of discussion that needs to be included in the conversation and in the discourse of Black health in this country generally.
Racism is insidious. It doesn’t present itself in a tidy package or leave a calling card. Which brings me back to my question of was my birth experience one of the many comprised by unconscious bias and racism? Was my birth altered by the colour of my skin? Was it a lived experience of racism? Given the failings of a medical system stubbornly entrenched in whiteness I would say it is possible.