Of all wealthy countries, the United States is the most dangerous place to have a baby. Our maternal mortality rate is abysmal, and over the past five years, it’s only gotten worse. And there are huge racial disparities: Black women are three times more likely to die than white women. Despite some claims to the contrary, the problem isn’t race, it’s racism.
In this episode we trace the origins of this harrowing statistic back to the dawn of American gynecology—a field that was built on the bodies of enslaved women. And we’ll meet eight women who have dedicated their lives to understanding and solving this complex problem.
About Innate: How Science Invented the Myth of Race
“The Mothers of Gynecology” is Episode 10 of Innate: How Science Invented the Myth of Race a podcast and magazine project that explores the historical roots and persistent legacies of racism in American science and medicine. Published through Distillations, the Science History Institute’s highly acclaimed digital content platform, the project examines the scientific origins of support for racist theories, practices, and policies. Innate is made possible in part by the National Endowment for the Humanities: Democracy demands wisdom.
Hosts: Alexis Pedrick
Senior Producer: Mariel Carr
Producer: Rigoberto Hernandez
Associate Producer: Padmini Raghunath
Audio Engineer: Jonathan Pfeffer
“Innate Theme” composed by Jonathan Pfeffer. Additional music by Blue Dot Sessions
Medical Bondage, Race, Gender, and the Origins of American Gynecology, by Deirdre Cooper Owens
Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society, by Arline T. Geronimus
Serena Williams on Motherhood, Marriage, and Making Her Comeback, by Rob Haskell
Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites, by Kelly M. Hoffman, Sophie Trawalter, Jordan R. Axt, and M. Norman Oliver
Being Serena, Directed by Noah Lerner for HBO
Lost Mothers: Maternal Mortality In The U.S., Special series by NPR and ProPublica
Pregnant While Black: Advancing Justice for Maternal Health in America, by Monique Rainford
America’s Maternal Nightmare, TEDx Talk by Monique Rainford
The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States, by Saraswathi Vedam, Kathrin Stoll, Tanya Khemet Taiwo, Nicholas Rubashkin, Melissa Cheyney, Nan Strauss, Monica McLemore, Micaela Cadena, Elizabeth Nethery, Eleanor Rushton, Laura Schummers, Eugene Declercq & the GVtM-US Steering Council
Alexis Pedrick: Welcome to Distillations. I’m Alexis Pedrick, and this is Innate, how science invented the myth of race. We’re at episode 10, the Mothers of Gynecology, and before we start, a content warning for our listeners. This episode contains descriptions of violence, as well as upsetting details about complications during childbirth and pregnancy.
Alexis Pedrick: In 2017, Serena Williams gave birth to her daughter, Alexis Olympia Ohanian Jr., via C-section.
Alexis Ohanian: What did you say when someone said that a little girl was gonna win Wimbledon in, like, 15, 20 years?
Serena Williams: Not if I’m still on tour [laughs].
Alexis Pedrick: In this clip from her documentary series, Being Serena, she’s in her hospital bed, holding her brand-new baby, joking around with her husband, and applying concealer under her eyes.
Serena Williams: Everything went great, and I even put a little makeup on, so I could take pictures with the baby. And I just remember getting up, and I couldn’t breathe. And I was like, I can’t breathe. Like, I couldn’t take a deep breath. I told the nurse, “I can’t breathe. I need a, I need a g-, I need a mask.” So I put the ma-, the oxygen mask on, and, um, I started coughing, because I couldn’t breathe. It hurt so bad. It hurt so bad. And then my stitches broke, and I remember I was in the bathroom with my mom, and I was just crying and crying. She was crying. She’s like, “You just gotta breathe,” and I was like, “I can’t. I can’t breathe.” And, um, it was just really hard.
Serena Williams: After that, I remember being wheeled back to the operating room, because they had to reopen my C-section, and restitch it, and then they had to check for, you know, blood clots and everything. So they were doing all these different tests, and everything was negative.
Alexis Pedrick: Serena had a history of blood clots. She’d previously suffered a pulmonary embolism, a blood clot that blocks the blood flow to an artery in the lung. It usually starts in a vein in the leg, and it can be fatal. When she found herself struggling to breathe, she was sure she had another one. So she told a nurse, and that nurse dismissed her, saying she must be confused from all of the pain medication. But Serena knew something was wrong. Doctors did run an ultrasound on her leg, but it showed nothing.
Serena Williams: I’m like, “Listen, I need you to run a CAT scan with dye, because I have a pulmonary embolism in my lungs. I know it. I know I… I’ve had this before. I know my body.”
Alexis Pedrick: They ran the CAT scan, and sure enough, there it was, a pulmonary embolism.
Serena Williams: Every day, I was in the operating room for something different. You know, it was one thing after another, and eventually, I got another blood clot in my leg.
Alexis Ohanian: [inaudible 00:03:38]
Serena Williams: So the decision was going in for a third surgery, where they put a, um, filter in me that blocks blood clots from being able to get up to my heart. I was so healthy. My pregnancy was so easy. Like, I didn’t have any problems, but unfortunately, once I had the C-section, everything from there was pretty much a nightmare.
Alexis Pedrick: Nightmare is actually a good word, because the maternal mortality rate in the United States is abysmal. Not only that, over the past five years, it’s been getting worse. For the purposes of this story, we’re gonna be using the word “women,” but we wanna make sure we state here that we’re really talking about all pregnancy-capable people.
Alexis Pedrick: Between 800 and 900 women die from pregnancy-related complications each year, and there are huge racial disparities. Black women are three times more likely to die than white women, and yes, that experience extends to celebrities. Serena Williams sold her harrowing birth story in Vogue Magazine in 2018. Later that year, Beyonce shared her own traumatic experience giving birth to her twins. Here’s Monica McLemore, a professor of nursing and public health, and self-described anti-racist birth equity scholar. She tells the story of these two superstars often.
Monica McLemore: But when you think about Serena Williams, and what happened to her and Beyonce, I always like to remind people of a couple of things. Number one, they both lived. They both survived their pregnancies, right?
Alexis Pedrick: Survived and thrived. Serena competed in the French Open just nine months postpartum, and Beyonce headlined Coachella less than a year after her twins were born. They were two of the lucky ones, but they’re also part of another statistic.
Monica McLemore: And they’re what we call near-misses. So again, if the deaths are between 800 and 900 every year because of pregnancy complications, we estimate that there are 50,000 near-misses, and that’s an underestimate. I mean, there are these near-misses, where you don’t die, right [laughs], from pregnancy complications, but you almost do. And those are the pieces that we also need to be talking about as well, because in my opinion, in my research, we’ve seen that those are the areas where we could intervene. Had we intervened soo-, uh, sooner, that we might have, have mitigated some of those traumatic birth experiences.
Monica McLemore: So it’s one thing to say that people die from pregnancy-related complications, but we also have to look at those people who almost die. Because that is far more common, and, and we also believe that those deaths, those deaths, as well as those experiences, are preventable.
Alexis Pedrick: Experts think about half of these fatalities and near-misses are preventable. When we started working on this episode, that statistic about black women being three times more likely to die came up a lot, and then, our senior producer, Mariel Carr, came across a new book by an obstetrician named Monique Rainford. It was called Pregnant While Black, Advancing Justice for Maternal Health in America. And she phrased that statistic a little bit differently. It wasn’t just black women are three times more likely to die. It was, quote, “If she’s described as black, she’s three times more likely to die from her pregnancy than if she is described as white.”
Monique Rainford: That was definitely intentional.
Alexis Pedrick: Monique wanted to be clear. There is nothing innately wrong, or flawed, or different about black women’s bodies.
Monique Rainford: The genetic differences within races are actually greater than between races, and a person who may look black and be described as black may have more genetic similarities to someone who looks white, and described as white, uh, than they do to someone else who also looks black, and is described as black. And that is the root of a lot of the racial disparities in health, particularly for black women in America.
Alexis Pedrick: The problem isn’t race. It’s racism. But what does that mean? Are we talking about individual doctors who are overtly racist, and mistreat their patients? No, though clearly, that does exist. What we’re talking about are the things that fall between systemic racism, the policies and structures throughout society that harm people of color, and implicit bias, a kind of unintentional but still harmful kind of discrimination and judgment.
Alexis Pedrick: So that’s where we’re gonna take you for this last episode, into the causes of this harrowing statistic. And to do that, we’re gonna introduce you to eight women, two of whom you’ve already met, who have been working on this problem for a long time. They’re gonna help us understand how we got here, why it’s so complicated, and what we can do about it for the future.
Alexis Pedrick: Chapter one, the history of gynecology. History’s not just what we do. It’s also a good place to start. The field of gynecology has a pretty well-known history, but we wanted to think about it in terms of this specific issue. So we went to historian of medicine Deirdre Cooper Owens. She’s the author of Medical Bondage, Race, Gender, and the Origins of American Gynecology.
Deirdre Cooper Owens: The development of American gynecology had deep linkages to the institution of American slavery. So much was happening in the slave-holding south, largely because of access to enslaved people’s bodies.
Alexis Pedrick: Her book covers a man named James Marion Sims, who’s often called the father of American gynecology. He also invented the speculum, something half of our adult population is still intimately familiar with today. Now, these accomplishments have improved the health of countless people, no doubt, but they relied on exploiting and abusing the bodies of enslaved women, who did not and could not give their consent. And before you go thinking we’re gonna chalk this whole issue up to a lone bad guy, we’re not. I mean, if you’ve been listening to this whole season, you know that Sims wasn’t uniquely evil.
Deirdre Cooper Owens: He is just representative of a structure that had already been in place. It, it was the nature of 19th-century medicine. They’re robbing the graves of, of paupers, and criminals, and enslaved people. In the south, you had this almost four million, you know, person, um, patient population, or possible patient population.
Alexis Pedrick: In a small hospital on his property near Montgomery, Alabama, Sims spent five years performing experimental surgeries on enslaved women who he leased from their captors. We know the names of at least three of them, Anarcha, Betsy, and Lucy, though there were about nine more unnamed women. Sims performed 30 surgeries on Anarcha alone.
Deirdre Cooper Owens: They have no real autonomy. They don’t have ownership over their bodies, so what the doctors are really doing, they’re asking the owners, “Hey, you know, can I remove Betsy, or whomever, from the farm or the plantation so that I can bring her to my hospital or my office to fix her,” right?
Alexis Pedrick: And that’s one of the things we wanna make clear. The field of gynecology was dependent on slavery, and slavery was dependent on medical science. Doctors in the south were indispensable to the institution of it, especially during the mid-1800s, when the international slave trade had been abolished.
Deirdre Cooper Owens: Black women’s bodies are the vessels that perpetuate U.S.-based slavery. Medicine becomes a part of that when you start to have the professional growth of slavery. So sometimes my students are really shocked when they find that there were slave management journals. Most of the questions that came in, and many of the articles written in these, uh, plantation management journals, were about how to keep enslaved people healthy, but more importantly, how do I ensure that my enslaved woman has a healthy and successful birth? It takes up so much space in those journals.
Alexis Pedrick: So this is the world that Sims is working in, one where the myth that black bodies were innately different from white bodies was pointed to as justification for enslaving human beings, and used as an excuse to experiment on them, because of a belief in what Deirdre Cooper Owens calls “the medical super body.” Here’s how she explains the concept.
Deirdre Cooper Owens: These bodies were exceptionally strong physically. They were almost masculinized bodies. Um, you know, these bodies could withstand pain, all of, all of these kinds of things. So it’s, it’s a super body in that sense, but at the same time, it’s a devalued body, right?
Alexis Pedrick: This idea, that black people don’t experience pain, has come up a lot this season. It showed up in episode two, when historian of medicine Rana Hogarth described how founding father Benjamin Rush pushed the theory that black skin pigmentation resulted from leprosy. Yes, this was an article back in 1799.
Rana Hogarth: There’s this sort of arresting passage by Rush, actually, where he talks about, um, black people being sort of, um, ih- insensible to pain, right, that they don’t seem to suffer as much.
Alexis Pedrick: And even Rush didn’t invent this idea. He was just repeating what another doctor in Jamaica had observed. That doctor wrote, quote, “They bear surgical operations much better than white people, and what would be a cause of insupportable pain to a white man, a Negro would almost disregard. I have amputated the legs of many Negroes who have held the upper part of the limb themselves,” unquote. It’s horrifying, and as the scientific literature proves, it was a myth with staying power.
Alexis Pedrick: Fast forward to James Marion Sims performing his experimental surgeries, and it’s not surprising that he writes of patients withstanding abnormal amounts of pain, not seeming bothered, et cetera. But here’s the catch. It was obviously not true. Deirdre Cooper Owens found that fact hiding in Sims’s own records. She uncovered the real experience of the women between the lines.
Deirdre Cooper Owens: So there might be a sentence or two that talks about how this patient resisted, and they had to be further restrained so that the surgery could go on. And I’m saying, “Wait, if there was a medical and scientific belief that people didn’t experience pain, why restrain them?” And so, the words say one thing, but the practice says something entirely different. So they’re restraining black patients, just as they do white patients, right? They are trying the same surgical methods on black patients as they do white patients.
Deirdre Cooper Owens: The only difference might be, they don’t give black people, um, the benefit of the doubt when black people are saying, “This hurts.” Or they don’t give them pain-relieving medicines, um, you know, those kinds of things, because of this, this sense that black people are not truthful, but also, black people don’t experience pain in the same ways, and that they can manage pain, right? And so, what I wanted to do was to show how we could also read against the grain when we center the lives and the perspectives of, of black women.
Alexis Pedrick: Sims’s experiment perpetuated slavery by keeping enslaved women’s reproductive systems functioning, but there was another huge reason for his work.
Deirdre Cooper Owens: When they find these cures, they are treating all women, and that includes white women.
Alexis Pedrick: He was perfecting the surgical procedure for white women, which maybe makes you wonder. If black bodies and white bodies were believed to be so different, how is this logical?
Deirdre Cooper Owens: There is so much racial fiction, but also hypocrisy. You know, when I first started, um, giving talks, a lot of the, the, you know, students and people in the audience, they’re just like, “It doesn’t make sense. They’re using black bodies to cure white bodies ultimately. These folk have to know it’s false.” I’m like, “Of course they do.” Despite all of the scientific and medical beliefs about black people, they ultimately know that if they cut open a black women’s body, right, they’re gonna find not a black cervix, not black Fallopian tubes. They’re gonna find Fallopian tubes, and they’re gonna be human [laughs], you know, human Fallopian tubes, human cervixes, all of those kinds of things.
Deirdre Cooper Owens: So they understand that they are still practicing on humans who are s-, who are the same, who are identical to white women. But they have to write a narrative that bends and fits into a segregationist, anti-black point of view. So this is entirely a space where these folk are governed by anti-blackness every step of the way.
Alexis Pedrick: You met Monique Rainford at the beginning of our story. She spent many years as a full-time practicing obstetrician, but recently turned her energy towards solving this problem.
Monique Rainford: Sometimes, a cause chooses you. You do not necessarily choose the cause. I didn’t know this is what I was gonna do with, uh, with my life, to be quite honest. However, fast forward 2016, 2017, I began to learn more of the causes. And then, knowing all I knew about obstetrics, knowing all I knew about delivering care, knowing all I knew about ho- improving outcome, I felt an internal push to try to learn more about it, and try to do something about it. And I’ve decided to pivot more into doing real work to address the health disparities.
Alexis Pedrick: Monique was in medical school at Harvard in the 1990s when she first learned about the disparities between black and white maternal health.
Monique Rainford: I was told that it was related to economic factors. It didn’t quite make sense to me, because that just didn’t seem like the whole story.
Alexis Pedrick: She remembers being shown a statistic that said things were worse in the U.S. than they were in Jamaica, where she was raised.
Monique Rainford: And I knew instantly that it couldn’t just be about economics, because Jamaica, it’s a developing country. And if it’s about wealth, if it’s about poverty, it could not be that in a developing country, it would be better, if it were only based on poverty alone.
Alexis Pedrick: Monique was right. It’s not just about socioeconomic status. Serena Williams and Beyonce make that point clear, and Monica McLemore, who you also met at the start of the episode, has proven it in a study she conducted called The Giving Voice to Mothers Project. It surveyed more than 3200 people in all 50 states.
Monica McLemore: The things that protect other, you know, racial groups, uh, don’t, are not protective of black women, regardless of socioeconomic status, regardless of education, regardless of income. That risk of dying or being a near-miss during pregnancy and childbirth ih- is equitable, and that really led us to ask some very important questions. And that is, okay, well, if the risk is equitably shared, then what’s the common characteristic, or what is the c-, the common cause? And a lot of people wanted to point to us and say, “Well, there, clearly, there’s something genetically wrong with black people, that this is happening to them.”
Monica McLemore: And in the qualitative work that we conducted, and in the, the survey work that we did in The Giving Voice to Mothers Project, what we really found… Y- black skin does nothing, except overexpose people to racism.
Alexis Pedrick: We said it once, but it bears repeating. It’s not the race. It’s the racism. But let’s break that down, shall we? Cause number one, the pain myth. Confession, we didn’t just start with Sims and the history of gynecology to give you context. We also wanted to establish a timeline, so that when we give you this next date, you can count backwards, past Sims, past Benjamin Rush, and the decades and decades of medical literature before Rush, to see how long this myth has endured. Are you ready? 2016. That’s right. Racial myths, baked into the system hundreds of years ago still impact healthcare today, and that year isn’t arbitrary. It’s the date of an actual study. Here’s Kelly Hoffman, the behavioral scientist who led it.
Kelly Hoffmarn: Racial disparities in health and healthcare have been pervasive for a very long time, um, and in the area of pain management, they’re particularly stark. So black patients are systematically under-treated for pain relative to white patients.
Alexis Pedrick: Kelly Hoffman and her co-authors wanted to drill down and figure out why this was. Like the racial disparities in maternal deaths, access to healthcare has been pointed to as one explanation. But this study focused on something else.
Kelly Hoffmarn: This idea that people don’t recognize the pain of black patients, and therefore, they don’t treat it.
Alexis Pedrick: They surveyed medical students and residents at the University of Virginia, separated out by race, as well as lay people.
Kelly Hoffmarn: We wanted to examine whether people with and without medical training hold these kinds of false beliefs about the black versus the white body. So beliefs that the black body, uh, the black body… I’m sorry, black people’s skin is thicker than white people’s skin, or that their blood coagulates more quickly.
Alexis Pedrick: There was also this one, that the nerve endings of black people are less sensitive than the nerve endings of white people.
Kelly Hoffmarn: And then we showed them case studies about a black patient and about a white patient, and we asked them, “How much pain is this, uh, patient experiencing on a scale from zero to 10?” And then we also asked them to, uh, write in what would they recommend for treatment for this pain. And so, we had a few surprising, um, findings. So one was just the, the sheer amount of endorsement of these false biological beliefs.
Alexis Pedrick: More than half of the white medical students and residents held at least one false belief about biological differences.
Kelly Hoffmarn: So that black bodies are just different than white bodies. And moreover, that predicted racial bias in pain perception and treatment. So people who more strongly endorsed these false beliefs thought that a black patient would feel less pain than a white patient, and they were less accurate in their treatment recommendations for the pain, right? And so, this was evidence that not only do people with medical training have these false beliefs about biological differences, but that it may be contributing, not just to perceiving the pain of a black patient differently, but to also treating them differently.
Alexis Pedrick: And this plays a part in black women’s birthing experiences. Monica McLemore has found in her research that black women were more likely to experience failure in their pain medication, and have providers ignore their pain and anxiety. And Kelly Hoffman’s study didn’t only come up when we talked with Monica. It actually came up in most of our interviews. Here’s Rana Hogarth.
Rana Hogarth: Yeah, when that came out, um, some people were shocked, and then there were the historians of medicine who study race who were not shocked. I will say, though, that I don’t know that the residents or the, the folks that were actually surveyed, if they are familiar, like what medical literature they’re familiar with, or if this is just sort of hearsay. Like, I, I tend to think it might be just things they’ve heard in the he- ether. Like, I don’t know that they have actually read a, a text or a dermatology book, or something that literally is still perpetuating these kinds of ideas.
Rana Hogarth: That actually makes it more terrifying to me, that it’s, it’s sort of lore, right, that I can’t pinpoint an origin. It just, it sounded like something that people would believe. This is my whole thing about the, um, uncritical, like, acceptance, where if somebody says, “Oh, yeah, I heard that their skin is thicker,” or, “I’ve heard that they don’t suffer as much,” at that moment, it’s not the moment to shrug. It’s the moment to say, “Wait, what? Where are you getting that from?”
Alexis Pedrick: Monique Rainford told us that she, too, was familiar with the study.
Monique Rainford: And it’s disappointing, I should say, not shocking to me anymore, but disappointing. But the studies have shown that healthcare professionals have the same level of implicit bias as anybody else, and that’s why it’s dangerous.
Alexis Pedrick: Cause number two, medical mistreatment. The WHO has called maternal deaths in the U.S. a violation of human rights, and they point to mistreatment in maternity care as being part of the problem. When Monica McLemore did her survey back in 2019, the study defined mistreatment as “being shouted at or scolded by a healthcare provider, healthcare providers ignoring and/or refusing requests for help, or failing to respond to requests for help in a reasonable amount of time, violations of physical privacy, healthcare providers threatening to withhold treatment, or forcing people to accept treatment that they didn’t want.” Keep those definitions in mind. Now, how many people reported mistreatment in her survey? One in six.
Monica McLemore: However, when we drilled down to race and ethnicity, the, the statistics got even worse, right? So when we looked at it for black and native indigenous individuals, they were four to five times more likely to experience mistreatment. People, uh, you know, uh, reported not feeling heard or not being listened to, and they had to ask repeatedly, over and over, for things like, “There’s something wrong in my body. I need, you know, pain medication. There’s something not right in my legs.” You know, so that was the not being listened to, not being heard.
Monique Rainford: If a black woman says, “No, I don’t feel comfortable with that person. That person, you know, is not treating me well.” Oh, they didn’t mean that. Oh, don’t worry about that. No, that’s not really happening. Oh, what you feel, oh, you didn’t really feel. And the people who say that, they don’t mean to be harmful, but they, they don’t recognize it, and they can’t recognize it sometimes. And that’s the, some of the nuances, I’d like to say, of implicit bias.
Alexis Pedrick: Sound familiar? Serena Williams had to demand that CT scan. The nurse was dismissive at first. Still, she survived. A woman named Shalon Irving wasn’t so lucky. This is Monique Rainford giving a TED talk in 2018.
Monique Rainford: Shalon is who I would call a superstar. She was a lieutenant commander for the U.S. Public Health Service Commission Corps, and an epidemiologist for the Center for Disease Control and Prevention, the CDC. She earned two master’s degrees and a double PhD, but Shalon also had a dream of becoming a mother, a dream that, despite many odds, came true. And after a risky pregnancy, she had a safe Cesarean delivery of a beautiful baby girl, Soleil.
Alexis Pedrick: A week after she went home, Shalon developed a wound complication. It was missed by the first doctor she saw, but another one caught it and treated it. Still, she kept feeling sick, and was seen by doctors four times.
Monique Rainford: On two of those occasions, her blood pressures were so high that, according to the American College of Obstetricians and Gynecologists, they should’ve been treated with urgent hypertensive therapy. They weren’t. On her last attempt to get help, a nurse practitioner sent her home with a prescription for blood pressure medicine and said, “There’s nothing we can do. You just have to wait. Give it more time.” The only time she got was five more hours that evening, and four days on life support. She was only 36 years old, and autopsy revealed complications of hypertension.
Alexis Pedrick: The autopsy revealed complications of hypertension, a big cause of postpartum deaths. This is her mother, Wanda Irving, in a clip from NPR
Wanda Irving: She thought they were not paying attention. She did indicate that, yeah, mom, they never listen to us.
Alexis Pedrick: If doctors and nurses had listened to Shalon and admitted her to the hospital, she would still be here today. And it makes us think about Serena Williams. I mean, what if she wasn’t a famous superstar? What if she wasn’t known throughout the world for her physical abilities, and her knowledge of her own body? Would her medical team have listened to her? Would she have made it?
Monica McLemore: Now, imagine how arrogant you have to be if you are a, you know, multi-million dollar, world-class athlete who makes your living from your own physical conditioning. Imagine how arrogant you have to be as a clinical healthcare prac- provider not to listen to that person [laughs].
Alexis Pedrick: Both Serena Williams and Shalon Irving were successful and educated. They got the care at the best hospitals. People couldn’t point to their stories and make up socioeconomic excuses anymore.
Arline Geronimus: I think it, it sort of was a wake-up call to a lot of people when their, their cases got publicized.
Alexis Pedrick: This is Arline Geronimus, a public health researcher we’re gonna hear from more in a bit.
Arline Geronimus: I think that catches the public’s attention, and really does sort of say, “Wait a minute. We’ve been thinking about this too stereotypically and too simply.”
Alexis Pedrick: The flip side of being denied care is getting unwanted care, being coerced into something that wasn’t part of your birth plan. And a glaring example of this is also a contributing factor to pregnancy complications and death. Cause number three, C-sections.
Monique Rainford: While generally speaking, as obstetricians, we think we can deliver you safely with a Cesarean section, we are exposing a mother to more risk, and those risks can be fatal.
Alexis Pedrick: Risks include excessive bleeding at delivery, which potentially requires a hysterectomy. There’s also uterine rupture, wound complications, and infection, and complications of anesthesia and surgery. And like all other maternal health risks, African-American women are worse off. They get more C-sections than white women, even when they have no identifiable risk factors.
Deirdre Cooper Owens: When we look at the black belt south, places like Louisiana, Alabama, Georgia, black women’s bodies are still disproportionately being used by physicians for C-section surgeries. So literally from the 1830s until 2021, these states that have huge black populations… I’m talking about 30%, 40% plus. Their bodies are being used in the same ways that their foremothers were being used in the 19th century. And so, that means the 19th century, the 20th century, and we’re now in the 21st century, and the stats have not changed very much.
Deirdre Cooper Owens: I think the l-, the longer legacy, if we, you know, put the past and the present together, is when we think about the ways that black women’s bodies have been used, and I might say boldly abused, um, in, in obstetrics and gynecology, is based on some of these older ideas.
Alexis Pedrick: Something called a VBAC calculator has contributed to some of these excess C-sections. VBAC stands for vaginal birth after Cesarean section, and the calculator isn’t a physical tool. It’s basically a questionnaire. If you’ve already had a C-section and wanna try and have a vaginal birth, you answer questions about your age, height, weight, delivery history, and then whether you’re African-American or Hispanic. It tallies up your answers into a score, and checking African-American or Hispanic can result in a significantly lower score, which meant the likelihood of a successful vaginal delivery was lower.
Monique Rainford: And so, if you think, going in as an obstetrician that, oh, her chances aren’t that good, you may give up quicker. If you think the chances are really great, maybe you try a little harder. And so, you can see how that could have been part of the reason why black women, or why black women have a higher Cesarean section rate, just one part of it, because it’s complex. Everything is complex. Everything has multiple factors, but why black women have higher Cesarean section rates than white women in America, for example.
Alexis Pedrick: There’s good news, though. In 2021, race was removed from the calculator, in part because of a study by an obstetrician named Shakeela Faulkner. She found that almost half the black women in the study had unfavorable scores when they listed their race, but only 12% of them did when they didn’t include it. Why was race there to begin with? It’s not clear.
Monique Rainford: Maybe I can say this. Garbage in, garbage out. So if the, the stuff is biased, then the tools will be biased. If the input is based, the tools will be biased.
Alexis Pedrick: Beyond VBACs, Monique Rainford has some theories about why black women get more C-sections, and they’re informed by her experience as an obstetrician. She says that waiting for a laboring woman to give birth takes time and patience, and since obstetricians likely have the same level of implicit bias as other health professionals, which is the same as everybody else, maybe those biases lead to them not giving patients their, well, patience. Maybe they encourage them to have surgery too quickly, or maybe, she says, a lack of connection or trust leads to the patient herself to choose a C-section, because she just wants the baby to arrive safely. Which leads us to our next cause, cause number four, lack of trust. As an experienced black obstetrician, Monique Rainford has a lot of patients seeking her help.
Monique Rainford: I get emails. I get requests. Do you know any black obstetricians? You know, thankfully, I know a few I can refer to, but it’s disheartening when black patients say, “You know, I, I’m scared. I don’t know who to go to. Um, I’m getting care at a certain location, and I don’t feel heard. I don’t feel they’re addressing my needs.” And it erodes trust, because if the person who’s taking care of you doesn’t believe you, then how can you believe them? The best situations are when the patient and I have a relationship where we’re working together to ensure that the care that’s delivered to them is great quality care, and they value my opinion. And I listen to them, and value what they have to say, and we try to get the best outcome. When that trust is violated or not even built, that compromise-
Alexis Pedrick: Studies have shown that both mothers and babies fare better when they have a black doctor or midwife, which is kind of good news. Only, there’s a problem.
Monique Rainford: There are not enough black obstetricians in everywhere that black women need them for black women to have a black obstetrician or a black midwife. There’s just not enough at this point. So on the one hand, we want to train more black obstetricians. We need to train, we want to and need to train more black obstetricians. We want to and need to train more black midwives, on the one hand. But on the other hand, we also need to ensure that, regardless of race, that our obstetrician or midwives are culturally sensitive, because I know for sure that there are many non-black physicians who can give the, deliver the kind of care that black women need.
Alexis Pedrick: There’s a rich history of black midwifery in the United States, but it was systematically shrunken to the point of barely existing when obstetrics became professionalized and dominated by men.
Wangui Muigai: You know, for over 300 years, midwives were the main source and providers of care, and many of these early midwives were black. They were, you know, they survived the horrors of the Middle Passage. My name is Wangui Muigai, and I’m a historian of race, medicine and gender. And so, as obstetrics is putting in place this sort of modern understanding of how to manage births, midwifery is characterized as backward, even as studies at that time are showing that births attended by midwives resulted in fewer deaths.
Alexis Pedrick: The reasons why are complex, but hearing how the care midwives delivered was different from obstetricians seems to offer some lessons we can still learn from.
Wangui Muigai: Midwives listen. They are there to help you through your misery and pain. They remain, you know, in, in the days afterwards, not only tending to, to the mother and the newborn, but also providing, you know, household support. And midwives also describe that there were continued until, you know, two weeks out. You know, that investment, that time spent with mother and newborn, a family unit, is a completely different level of commitment and attention than, than a physician, who’s probably measuring the time in minutes and hours, and not in days and weeks.
Alexis Pedrick: Today, there’s a growing movement of black midwives, and they do incredible work. And they’re certainly part of the solution, but there aren’t nearly enough of them. And they alone can’t solve the problem. One reason is something risking out.
Monique Rainford: Midwives are basically trained to address low-risk pregnancy. I say basically, because midwives, under guidance and with increased training, can handle higher-risk pregnancies. But basically, they handle low-risk. So what happens is, and, uh, it, this happens. I’ve read examples, and know of examples. A black woman enters the care of a midwife, but she risks out of it, meaning she becomes high risk, and she has to leave the midwife and go to an obstetrician because of her risk factors. So midwives are very important, but they can’t do everything.
Alexis Pedrick: Risking out has to do with our next cause, cause number five, weathering. We’ve spent this whole season telling you that race is not a biological thing. There’s no black hypertension gene, no diseases that black people are innately immune to, no innate differences in pain tolerance. Race is not real, but racism, racism is very real. And it turns out, it can take a biological toll on the body. Monica McLemore’s research has attached hard data to prove the mistreatment black women experience during pregnancy and childbirth. Meanwhile, public health researcher Arline Geronimus has shown how exactly that racism impacts health. She’s just published a book called Weathering, the Extraordinary Stress of Ordinary Life in an Unjust Society.
Arline Geronimus: Stress is a very broad word [laughs], and, you know, what one person calls stressful is very different from, you know, the stresses that a soldier feels on a battlefield, not feeling the very same thing as a member of a deeply marginalized group feels on a daily basis for, for many different reasons.
Alexis Pedrick: She coined the term “weathering” decades ago to describe how certain kinds of chronic stressors, things like poverty, hunger, abuse, and, yes, everyday racism one experiences being black in America, how all of these wear the body down, accelerate aging, and lead to chronic diseases. Now, weathering doesn’t only happen because of racism. It’s also caused by other kinds of chronic stressors. In fact, studies have shown similar effects on parents of children with developmental disabilities. But the stress of racism is a big one. The physiology behind it is something that’s actually a protective mechanism. It’s called fight-or-flight.
Arline Geronimus: The kind of archetypal story is, you’re on the savanna, and, you know, some wild animal comes lunging at you. And, and automatically, so it’s not conscious. I mean, you’re scared, so I’m not saying you don’t perceive that animal [laughs]. But you don’t consciously set off these physiological reactions, which are aimed to make it more likely for you to be able to survive that attack, either because you flee, or you fight successfully, or even if you’re mauled to some extent, your immune system has been mobilized. So y-, so you may survive even the attack.
Alexis Pedrick: This is what’s happening inside your body. Stress hormones, adrenaline and cortisol, start flooding your bloodstream, and as a result, fats and sugars are catapulted into your bloodstream to give you energy to fight or run. Extra oxygenated blood is pumped faster to your large muscles, to your heart, all to help you beat the animal. But at the same time, your other organs and tissues aren’t getting the same kinds of nutrients, and if you’re pregnant, neither is your fetus.
Arline Geronimus: That’s meant to be turned on once in a great while, in an emergency, and then it lasts for three minutes, ish. Um, and then, you may dead, or you may have successfully fled, or scared the raging beast away. So it’s very protective in a, a true life-or-death situation.
Alexis Pedrick: The problem is that this same mechanism is triggered over and over and over again by so many situations that do not involve a cheetah on the savanna. Maybe you’re just going for a prenatal appointment, but you’ve dealt with all the negative treatment from a nurse in the past. Our bodies can react even when there isn’t an immediate threat. There’s just the threat of a threat.
Arline Geronimus: If you have reason from your past experience, like if you’re, let’s say you are in the savanna, and you’ve been mauled before. You’re kind of making an unconscious, calculated, though, decision that this may be, may be a false alarm, or it may be a true alarm. But better to be safe than sorry.
Alexis Pedrick: This anticipation of a threat, walking into a space where you don’t know how you’ll be treated, and you have to be vigilant in case you’re under threat, it provokes this same response.
Arline Geronimus: It’s not even something we’re necessarily conscious of, and even if we’re conscious of the original stressor that provoked the physiological stress reaction, that reaction can continue, um, well beyond the event, and in our sleep. W- for instance, if our heart rate is elevated, it can stay elevated while you’re sleeping. Um, so it’s sort of a chronic activation of this physiological stress response that’s specific to being, uh, in a deplored, or exploited and marginalized group.
Alexis Pedrick: Over time, your organs start to feel the effects. Take your heart, which has been in overdrive from all of these responses.
Arline Geronimus: Your heart can get enlarged, like any exercising muscle would get enlarged. The more it’s exercised, um, by pushing the blood flow so, so strongly through your arteries, uh, you, you eventually will get high blood pressure or hypertension.
Alexis Pedrick: You can also start to corrode those arteries. Plaque will build up from the white blood cells that are constantly rushing.
Arline Geronimus: That plaque can become embolisms, or heart disease, or strokes. Uh, you, um, your immune system gets dysregulated from all the [laughs] false alarms.
Alexis Pedrick: So maybe your immune system gets weakened, or maybe it goes on overdrive, and you get an autoimmune disease.
Arline Geronimus: So you can see the ways that people in, who are in those marginalized groups will, are, are kind of made more vulnerable across their bodies, um, either because some of their systems and organs have gotten too much attention, or others have not gotten enough. So you’re kind of worn and torn everywhere for one of those reasons, and, and so, what, as I see it, weathering explains a lot about why certain populations have so much worse health, and across so many different diseases and conditions.
Alexis Pedrick: But Arline Geronimus says there’s another reason to be optimistic.
Arline Geronimus: So, um, I, I believe that one of the big, one of the reasons to be optimistic is, this is the first time that weathering will be out in the broader public conversation. I’ve obviously published a lot of scientific articles on weathering over the years, but it hasn’t really been part of the public conversation, or the broader policy conversation.
Alexis Pedrick: Chapter four, how do we solve it? Like we said earlier, there’s no one easy solution. For this story alone, we talked to three historians, two public health researchers, one behavioral scientist, an obstetrician, and a midwife, and we need all of their work. We need everyone to help solve this problem. And it might seem like a tall order, but we’re feeling hopeful. Here’s the midwife we spoke to.
Annie Johnson: My name is Annie Johnson, and I’m a nurse midwife. And I live in Portland, Oregon. The midwifery clinic that I work for started, it started [laughs] in a trailer in the parking lot, um, of the hospital. So there were a bunch of nurse midwives that showed up, and were like, we wanna take care of patients here. What patients can we have, basically? And the doctors were like, there are all these poor, mostly black women who live in this neighborhood, and they don’t, they don’t pay anything, basically. Like, we don’t wanna take care of these patients, because their insurance isn’t worth anything. And the midwives were like, “Great. We wanna take care of them.”
Alexis Pedrick: Her clinic, Legacy Medical Center, since moved inside the hospital, but they’re still taking care of the same kinds of patients. Annie is African-American, and she’s experienced all these biases, implicit and not, in her own healthcare. She’s only one person, but she believes midwives are a solution to this long legacy of racism.
Annie Johnson: The answer is midwives, I feel like, and that’s the cool thing, is that I see every day that it, it, we f-, like, it’s getting fixed.
Alexis Pedrick: One thing the clinic does is take communication very seriously.
Annie Johnson: We have a practice where you can call and talk to a midwife 24 hours a day, every single day of the year. Like, that’s what, when you’re caring for people who are busy, who have jobs, who don’t have a lot of money, who don’t have transportation, what they need is for you to pick up the phone when they call. And I think that that makes a huge difference to patients, right? If you call at 3:00 AM, you’ll get a midwife. When somebody calls, I’m like, “What do they need? What is the problem that they’re noticing? What’s the information that they have that I don’t, that’s gonna allow me to take care of them?” And I think, in a lot of other health systems, it’s just way more complicated to get to a person that’s gonna help you.
Alexis Pedrick: And they are accessible, literally.
Annie Johnson: We have transportation for people. We have cabs. We have medical transport. We have food bags in our clinic now that we’re giving out to people, because people don’t have food. Like, people come to us because we have the things that they actually need.
Annie Johnson: The medical system do-, is, like, trying to check off all these boxes that are not important to patients, right? I’m like, if y-, if I have all your prenatal labs, right, like, I care, because that’s part of my job of taking care of you, but, like, that doesn’t mean anything to patients. What they care about is if they’re hungry and you have food, and you’re gonna give them a grocery bag to feed their kids every single week. Like, that’s what’s making them come back to their prenatal appointment, not the fact that you check to see if they could be susceptible to rubella.
Alexis Pedrick: Annie Johnson made one more point that often gets lost when we talk about how to save lives.
Annie Johnson: The thing that we tell women all the time is, “The most important thing is healthy mom and healthy baby.” And it’s telling people that if we saved you and your baby, you should be grateful no matter what your experience was. And I’m like, that’s not it. We had a patient who had a demise with our p- practice, who came back, and I did her early ultrasound. And I was like, “Oh, you must be… Like, are you feeling nervous today?” I was kind of assuming that she would be feeling nervous, because her last experience coming to us was having a baby die, and then having that baby delivered by our practice.
Annie Johnson: And she was just like, “I’m not nervous at all. Our family was, like, so held and taken care of by this practice of people while we were going through this tragedy and grief.” Like, she didn’t have any trauma, and I was like, “That’s amazing that, like, the, the outcome is not necessarily the most important thing.” Like, I feel like the ex-, the experience of the woman and the family, uh, of giving birth is pro-, is, in my mind, the most important thing.
Monica McLemore: Human beings, we are so complex, and I hate that science doesn’t really capture this notion that, yes, people can have hardship. People can have traumatic birth experiences and still come out of it, uh, knowing that they will develop the skills that they need in order to be a good parent. People need the supports that will allow them to take those roles on with dignity.
Alexis Pedrick: In addition to midwives, doulas are also a crucial part of the solution. A doula is not a medical professional. They’re someone who attends births to give social support, and research has shown that they lead to better outcomes for everyone.
Monica McLemore: Patients don’t necessarily use the same language that we use to describe things, but I know for me as a nurse, when my spidey senses are very attuned to when someone tells me that something just doesn’t feel right. And to dismiss their concerns, or to dismiss their claims because they’re not using the same language that we would use, I think is a real mistake and a rear, uh, real error. That’s why a lot of people talk about doulas and other birth workers as a potential part of the solution. It’s not that doulas are gonna solve maternal morbidity and mortality, but one thing doulas do very, very well is, they can serve as that, that interpreter. They can help with that lost in translation, of really helping to, uh, like, help healthcare providers really know when they need to l-, uh, escalate levels of care. It’s another set of eyes on pregnant and postpartum.
Alexis Pedrick: Deirdre Cooper Owens goes on medical rounds at various schools, including, ironically, Jefferson University Hospital, James Marion Sims’s alma mater.
Deirdre Cooper Owens: I’m grateful in the ways that physicians and nurses in particular are really being mindful, I think, of medical racism, and the ways that they can dismantle it. Many of them are really doing the work, because I think ultimately, who wants to see pregnant people and their children die? We want them to live. We want them to have a good quality of life. And so, um, I am really hopeful that, um, this will continue, and there will not be the kind of fatigue around talks of race but that we, that we will really stay committed, um, to eradicating th- these disparities.
Monique Rainford: I’m an optimist in many ways. I wouldn’t take on something if I didn’t think I could do something to make it better, if I thought it was futile. Because to put a lot of energy and work into something that you think is futile, you, you just can’t. You have to believe, so I firmly believe, and I am committed to continuing to do work, to do what I can to make a difference, and try to eliminate these health disparities.
Alexis Pedrick: We called this episode Mothers of Gynecology. That name was inspired by Deirdre Cooper Owens. One day during the writing process, she was reviewing the book with a friend at her home. When Deirdre mentioned that James Marion Sims is called the father of gynecology, her friend’s daughter’s ears perked up.
Deirdre Cooper Owens: And so, I guess, uh, her daughter kept hearing me say, “Father, father,” and she’s like, “Well, where are the mothers?” And I thought, yeah, where are the mothers [laughs]? And so, immediately, you know, it, it made sense, that these were truly the mothers of gynecology, and it wasn’t a reach in the Sims case, uh, in particular, because when his two white male surgical assistants quit, because he was failing so much at trying to repair, uh, these women’s, uh, issues, he then taught the women how to serve as his surgical assistants.
Deirdre Cooper Owens: And so, in a very real sense, these enslaved women that Sims operated on, and also made to, you know, they, they were made to, to labor as nurses and surgical assistants, they helped him develop this medical branch. They helped him develop the surgical repair, uh, for what today we call obstetrical fistula surgeries. And so, I think they very much need to be recognized in their roles as the mothers of American gynecology. It kind of balances the scales.
Alexis Pedrick: So, who’s coming to save the day? Well, turn and look at all the women we’ve introduced you to in this episode. They’re the daughters of gynecology. They’re solving the problem. How much more future-facing can you get? In fact, that’s what we want to leave you with for the season. Yes, science invented the myth of race, but science is done by people. And when we make something, we can certainly unmake it. And hopefully, this will be a whole different world for another generation of children, of scientists, historians, researchers, podcasters. This episode was reported and produced by Mariel Carr, and it was mixed by Jonathan Pfeffer, who also composed the Innate theme music. Distillations is more than a podcast. It’s also a multimedia magazine. You can find our videos, stories, and podcasts at distillations.org, and you’ll also find podcast transcripts and resource lists.
Alexis Pedrick: You can follow the Science History Institute on Facebook, Twitter, and Instagram for news and updates about the podcast, and everything else going on in our museum, library, and research center. The Science History Institute remains committed to revealing the role of science in our world. Please support our efforts at sciencehistory.org/givenow. I’m Alexis Pedrick. Thanks for listening.