The recent tragic death of civil rights activist Erica Garner four months after the birth of her second child and the life-threatening experience of tennis great Serena Williams one day after the birth of her first child has catapulted the issue of racial health disparities into the headlines.
Garner died Dec. 30, after a week in the hospital following a heart attack. She was 27. Four months earlier, she had given birth to her second child, a son, whom she named after her father, Eric Garner. He had died on New York City sidewalk in 2014, after being placed in a police chokehold. Erica’s heart attack was triggered by an asthma attack. During her pregnancy, she had been diagnosed with an enlarged heart.
Serena Williams, 36, came close to dying last September, after the birth of her daughter, Alexis Olympia. The baby, Williams’ first, was born by emergency Caesarean section. Williams has a history of blood clots, and had been taking blood-thinning medication to prevent them from forming. After her daughter’s birth, however, she temporarily stopped taking the medication to enable the surgical wounds from the C-section to heal.
The morning after giving birth, Williams woke up feeling short of breath. Here’s what happened next, as described in a profile of Williams that appears in the February issue of Vogue magazine.
Because of her history of blood clots, and because she was off her daily anticoagulant regimen due to the recent surgery, [Williams] immediately assumed she was having another pulmonary embolism. (Serena lives in fear of blood clots.) She walked out of the hospital room so her mother wouldn’t worry and told the nearest nurse, between gasps, that she needed a CT scan with contrast and IV heparin (a blood thinner) right away. The nurse thought her pain medicine might be making her confused. But Serena insisted, and soon enough a doctor was performing an ultrasound of her legs. “I was like, ‘a Doppler? I told you, I need a CT scan and a heparin drip,’” she remembers telling the team. The ultrasound revealed nothing, so they sent her for the CT, and sure enough, several small blood clots had settled in her lungs. Minutes later she was on the drip. “I was like, listen to Dr. Williams!”
The United States has an alarmingly high rate of pregnancy- and childbirth-related deaths — the worst in the developed world. But the death rate is particularly high for black women. As a 2016 New York City study found, black college-educated mothers who gave birth in that city’s hospitals were more likely to experience severe pregnancy- or childbirth-related medical problems than white women who never graduated from high school.
To find out more about this racial divide, MinnPost talked with Rachel Hardeman, an assistant professor of health policy and management at the University of Minnesota School of Public Health. An edited version of that conversation follows.
MinnPost: How unusual are the cases of Erica Garner and Serena Williams?
Rachel Hardeman: I don’t think they’re unusual at all. I think we’re just hearing about them more. People who wouldn’t normally be talking about these issues are starting to talk about them. [Erica Garner’s story] is not something that is unique or abnormal if you look at recent statistics around maternal mortality. Black woman are three to four times more likely to die during childbirth or within the first year postpartum.
Serena Williams’ story is about not being heard and not getting the care that she needed without having to really fight and advocate for herself. That’s a story we’ve been hearing for decades. And certainly the preliminary findings from the research that I’m currently doing are showing the same thing. Women are not feeling heard. They’re not feeling a relationship and a bond and trust with their providers.
MP: It was extraordinary how assertive she had to be.
RH: Exactly, along with the fact that she had dealt with a pulmonary embolism before, and she knew what it felt like and she knew what she needed. I mean most patients aren’t able to say with such certainty and such specificity, “This is what’s happening. This is how it needs to be resolved.” It’s a pretty unique case — that she was able to advocate so clearly and so directly for herself in that way, particularly when you think about the hierarchy of the medical profession. We have been taught that physicians know a lot and they hold a lot of knowledge and power, and we implicitly kind of trust that. To be able to overcome that and speak up is a really hard thing to do.
MP: You mentioned that black women have a much higher rate of death during and after childbirth. What are some of the other racial disparities you and other researchers have found?
RH: African-American infants are more likely to die in the first year of life. And African-American women are more likely to give birth preterm, before 37 weeks [of pregnancy]. We know that preterm birth increases the likeliness of infant mortality, as well as a lot of other complications that can really impact the [baby’s] life course. African-American women are also more likely to have a low-birth-weight baby.
To put [these statistics] into context, African-American women are only 21 percent more likely to die from heart disease, but 243 times more likely to die due to complications of childbirth. That’s a pretty significant indication that we have a lot more work to do to be able to truly say that everyone in our society is healthy.
MP: How is Minnesota faring compared to other states?
RH: I don’t know what our maternal mortality and morbidity rate is in Minnesota, but when it comes to birth outcomes, black and American Indian babies are twice as likely [as white babies] to die in the first year. When you’re looking at the averages and overall statistics for our state, we actually rank as one of the healthiest states in the nation. We’re often in the top five, and even more often in the top three. But when you start to peel back the layers and look at things by race, that’s when our numbers start to drop. And that’s the case not just for birth outcomes, but for a lot of health outcomes and quality-of-health indicators in our state.
MP: What are the key reasons for racial disparities in pregnancy and childbirth outcomes?
RH: I think the jury’s still out. There are a lot of people, myself included, working to examine these issues. What we do know is that it’s not an access issue. Even when women have access to prenatal care, that’s not enough. We also know that when we control for what we would consider risky behavior, like tobacco use or substance use during pregnancy, that’s also not the underlying cause. So, a lot of the research is now [focused on] understanding the social determinants of health. My work looks at the impact of structural racism and other forms of racism on birth outcomes. Racism has a significant association with a lot of these outcomes. The weathering hypothesis suggests that years and years of being treated differently, being treated poorly, anticipating poor treatment because of your race — all of those things get under the skin and impact health, in ways that we don’t even quite understand yet.
Nancy Krieger, who’s at Harvard, looked at the [black] infant mortality rate both before and after Jim Crow — before and after legalized discrimination and legalized racism. The infant mortality rates dropped after Jim Crow was abolished. So we have examples of how structural racism [leads to health disparities]. Our existing systems and structures perpetuate inequity in a lot of ways. I think the Serena Williams case is a really clear example of that.
MP: What are you finding in your research?
RH: A lot of my work focuses on maternal stress. We’re working on a study right now where the hypothesis is that being pregnant and being exposed in the media to racialized police violence — seeing all of the incidences of black men being killed by police officers, particularly when you live in a community where that’s happened — [has a harmful impact] on pregnancy and birth. Our early findings show that African-American women who are carrying a male baby are more stressed out during their pregnancy. We’re also hearing stories of women who don’t want to find out the gender of their baby because they don’t want the anticipated stress of knowing that they’re bringing a black male into a society where, frankly, he’s not going to be valued.
MP: That’s extremely troubling. What needs to be done to change this situation?
RH: This is something that has to be attacked from a lot of different angles and different levels. There’s work to be done at the health-care delivery system level — how health-care organizations and hospitals offer care to postpartum women. The focus is on the infant, on the baby. The baby has constant checkups. But the moms have one six-week postpartum checkup and that’s it. We need to be thinking about how to better support and monitor mothers both during the prenatal period and during the postpartum period, too. That’s particularly true for black women. Also, at the clinic and provider level, we need to be doing more about implicit racial bias. It’s become a kind of buzzword over the past few years. You even hear about some clinics or hospitals or even medical schools doing a lecture or quick training on implicit racial bias. But it has to be bigger than that. If we’re not connecting implicit racial bias to bigger issues around systemic or structural racism, I think we’re missing the point.
MP: Can you expand on what you mean?
RH: Yes. We’re all kind of programmed to automatically have ideas, attitudes, thoughts about people or certain groups. There’s a huge body of literature that shows that clinicians, particularly when they are on a time crunch, rely on automatic biases or unconscious biases to make decisions about a patient. So a white physician walks into a room and sees a black patient and automatically has, without even trying, stereotypical thoughts of what it means to be black. That’s harmful for how health care is delivered. So we need to be doing a better job of working on that, but we also need to be thinking how that piece of individual interaction links to these broader systems. I think a lot of our hospitals and our health-care systems were not made to offer the type of care that black women in particular need.
A lot of my research is working with a African-American-run birth center [the Roots Community Birth Center] here in the Twin Cities. That’s not to say that every woman should birth in a birth center. But what I would say is that our findings so far are supporting the birth center’s model of care, which is very culturally focused. It honors the person and their cultural context — where they come from and what that reality is. The provider has conversations with the patients about the role that racism plays in their lives. They’re more understanding of the lived experience of being a black woman in our society.
MP: Until those broader structural changes are made, what can individual African-American women do when they’re pregnant to help ensure better outcomes for themselves and their baby?
RH: That’s a hard question. I don’t want it to be a blame-the-victim thing. Because it’s not about behavior. It’s not about lifestyle. There are these structural determinants that are dictating a certain lifestyle or certain decisions about behavior. So I’m very careful when I talk about that. But women — black women in particular — can take the power that they have and choose whom they receive care from. In some of the focus groups I’m doing right now for a research project, I’m hearing from women who had a bad experience in a certain hospital setting. They felt like they were being judged, or they were not being consented properly for certain testing, or their doctors weren’t taking the time to explain why a gestational diabetes test might be important and relevant. And, as a result, they changed providers. They sought out care from someone else. Someone they felt more comfortable with. Someone they trusted. It’s sad that they have to do that, but I think that not enough women realize that they hold that power and can do that and make those changes and demand better.
FMI: ProPublica and NPR co-published a compelling article last December on the role that racism plays in the high rate of maternal mortality among black women in the United States. You can read it on ProPublica’s website.