Race Maternal Mortality in the U.S.: A History of Midwifery

Race Maternal Mortality in the U.S.: History of Midwifery

In September 2017 professional tennis star, businesswoman, and philanthropist Serena Williams gave birth to her daughter, Alexis Olympia, in what turned out to be a traumatic, near-death experience. Concluding a relatively normal pregnancy, Williams gave birth via emergency C-section after Olympia’s heart rate dropped during contractions. However, even after her daughter was delivered successfully and in perfect health, Williams knew something was off within her own body. After feeling shortness of breath and knowing that her personal history of blood clots put her at a high risk for further complications such as a pulmonary embolism, Williams alerted her care team. Her personal assessment was initially dismissed. Her care team prescribed pain medication, but Williams persisted. Her doctor then ordered a Doppler ultrasound on her legs. “I was like, a Doppler? I told you I need a CT scan and a heparin drip,” Williams recalled. After nothing resulted from the ultrasound, Williams continued to advocate for herself until her doctor finally ordered a CT scan, where multiple small blood clots were found in her lungs, confirming her initial self-assessment. Williams spent her first six weeks of motherhood bedridden in recovery. Alongside Williams, other Black celebrity women, such as Beyoncé and Allyson Felix, have shared their own harrowing experiences of pregnancy and childbirth. 

Image: Serena Williams with daughter Alexis Olympia. Source: Vogue February 2018. Photographed by Mario Testino. 

While survival is the fortunate outcome of Serena, Beyoncé, and Allyson’s stories, many women in the United States—especially Black and Brown women, immigrant women, and poor women —  frequently do not survive. Although it is one of the richest and most highly developed nations in the world, the U.S. has the highest rate of maternal mortality in relation to all other comparatively developed nations. Given the wealth and development of U.S. medical infrastructure, this suggests another cause is at play: racism and classism has historically, and contemporarily, put marginalized women at a greater risk for pregnancy, childbirth, and postnatal complications.  Studies demonstrate that U.S. women’s self-reporting and pain is taken less seriously in health care settings generally, and that this dismissal is compounded for marginalized women due to institutionalized racism, classism, and other intersecting forms of discrimination. According to data from the CDC, the maternal mortality rate specifically for Black women in the United States in recent years is nearly three to four times higher than for white women.  Institutionalized racism informs this astounding statistic; compared to white women, Black women’s pain, overall wellbeing, and self-reporting are neglected in medical institutions, which is also linked to socially uninformed or lacking medical school curricula.  Turning to the humanities helps to illuminate and contextualize this modern issue. A long history of gender and inequality in health care, legacies of racism and classism, and a historic shift in maternal-fetal health values in the early twentieth century demonstrate how the story of someone like Serena Williams is not anomalous but instead highly typical for modern U.S. women. 

In the early twentieth century, a crucial shift in prenatal, birthing, and postpartum care took place in the United States. Up until the early decades of the twentieth century, most U.S. women, especially women of color, poor women, and/or southern or rural women, maintained their pregnancies, gave birth at home, and healed in the postpartum stage with the help and guidance of a community-based Black midwife, or “Granny Midwife” as they were often referred. Black women relied on Granny midwives because of a lack of health care facilities, limited transportation options to those that did exist, financial inaccessibility, racial restrictions, and cultural preference (preference for a caregiver of one’s own race and community). Aside from all these factors that excluded Black women from the medical facilities and networks utilized by white women, there were a host of factors that made Granny midwives highly sought after and celebrated figures within their communities. 

Image: Collection of the Smithsonian National Museum of African American History and Culture, Gift of Robert Gailbraith.

Granny midwives were elder Black women who were revered in their practice. As scholar Laurie Wilkie describes, “the prestige they held was not arbitrary, for midwives literally held the community’s future in their hands.” Granny midwives learned their craft and internalized it as “an extension of maternal responsibility, passed through generations.” At the core of this traditional maternal knowledge was care and community. Black Granny midwives performed “motherwork,” or what feminist scholar Patricia Hill Collins coined as care for the future, “whether it is on behalf of one’s own biological children, or for the children of one’s own racial ethnic community, or to preserve the earth for those children who are yet born.”  Granny midwives ensured mother and child were nurtured not only as patients in a medical exchange, but also as valued members of a larger extended and enduring community to which Granny midwives also belonged. This well established system of maternal-fetal healthcare based on empathy, respect, and care, the highly revered community status of Granny midwives, and the close kinship bonds that Granny midwives formed within their communities was disrupted with the professionalization of midwifery at the turn of the twentieth century.

Beginning in the late nineteenth century, medical schools were growing and actively seeking new fields for expansion. Obstetrics and pediatrics were viewed as fields for lucrative expansion, and traditional birth workers or midwives, including Granny midwives, were portrayed by the American Medical Association (AMA) as suspicious, uneducated, unprofessional, and antiquated. By the early twentieth century, a systematic campaign to disrupt women’s reliance on midwives resulted in a host of new state legislation, which required traditional midwives to become formally educated, professionally licensed, and supervised by (mostly white) male physicians. The newly controlled profession thus became regulated by the state. All the vast experience and wealth of knowledge possessed by Granny midwives, which was passed down through generations, was in effect deemed worthless and outlawed by professionalized medical institutions which operated in tandem with the state. A generation of Granny midwives were forcibly pushed out of their positions by this deliberate switch, and Black women were left without the eldest members of maternal protection and care of community based motherwork. Still, Black birth workers remained. Some of the younger generations went on to “professionalize” and license their work, while others became doulas or birth workers who provide companionship, and emotional and mental support, without offering formalized medical advice. For the medical aspect of care, however, Black women were forced to rely on predominantly white patriarchal medical institutions for their maternal-fetal health. Thus, racial disparities in maternal-fetal mortality and health in the later twentieth century up to the present day have resulted from the erasure of Black women’s maternal medical knowledge and racist/classist intentional disruption of long established systems of community care. 

The pregnancy, birthing, and postpartum experiences of Serena Williams and other Black Americans would likely be vastly improved, safer, and nurturing if an ethos of care, empathy, and motherwork were re-implemented and established in mainstream medical establishments. A way of improving the maternal-fetal care for marginalized women in the U.S. can thus be discovered by studying and understanding the longer history of maternity along with intersecting social factors of race, gender, and class. Thankfully, although there is still much to be done to improve the current statistics and experiences of Black mothers, there has been yet another, more positive shift. Today there is a current tendency for more and more marginalized women, especially Black and Brown women, to rely once again on the care of a Black community-based midwife and/or doula. While further nuanced study is needed on the impact of Black midwives and doulas for Black mothers in the modern era, research thus far is encouraging. A (2013) study on the impact of doulas on birthing outcomes suggests that there is a highly significant positive correlation between reliance on doulas and improved overall maternal-fetal outcomes, birthing experiences, baby birth weight, and breastfeeding success. Many Black birth workers already know this. One such example is Sabia Wade (she/they), who is a Black doula out of San Diego, California. Their work exemplifies the clear benefits of community-based pregnancy and birthing support. It is the rest of the medical community, the formalized medical institutions, and schools who have some major catching up to do. All people, regardless of race, gender, class, or other identity, deserve a safe and healthy pregnancy and birth, one that is based in care. 

Endnotes:

[1] Haskell, R. “Serena Williams on Motherhood, Marriage, and Making Her Comeback.” January 10, 2018. Interview for Vogue Magazine. 

[2]Fitzpatrick, H. “Beyonce Opens Up About Pregnancy Complications with Twins.” Good Morning America. April 18, 2019. Online.; Felix, A. and MacKenzie, M. “Allyson Felix  Risked Everything by Speaking Out. She’s Not Finished.” Glamour. June 16, 2020. Online. 

[3]  World Health Organization. “Trends in Maternal Mortality: 2000-2017.” Online Executive Summary. 

[4] Hoffman, D. E. & A. J. Tarzian. “The Girl Who Cried Pain: A Bias against Women in the Treatment of Pain.” Journal of Law, Medicine, and Ethics. 2001. 28(4). 

[5] Hoyert., D. L. “Maternal Mortality Rates in the United States, 2020.” National Center for Health Statistics: CDC. 

[6] Wilkie, L. A. The Archaeology of Mothering: An African-American Midwife’s Tale. 2003. Routledge: New York. 

[7] Ladd-Taylor, Molly. “Grannies’ and ‘Spinsters’: Midwife Education Under the Sheppard-Towner Act.” Journal of Social History. 1988. 22(2)

[8] Collins, P. H. “Shifting the Center: Race, Class, and Feminist Theorizing about Motherhood.” In E.N. Glenn, G. Chong, K. Foray (eds), Mothering: Ideology, Experience, and Agency. 1994. Routledge: New York. 

[9]  Wilkie, L. A. The Archaeology of Mothering: An African-American Midwife’s Tale. 2003. Routledge: New York.

[10] Gruber, K.J., Cupito, S.H., & Dobson, C.F. “Impact of Doulas on Healthy Birth Outcomes.” The Journal of Perinatal Education. Winter 2013. 22(1): 49-58. 

References: 

1. Collins, P. H. “Shifting the Center: Race, Class, and Feminist Theorizing about Motherhood.” In E.N. Glenn, G. Chong, K. Foray (eds), Mothering: Ideology, Experience, and Agency. 1994. Routledge: New York. 
2. Felix, A. and MacKenzie, M. “Allyson Felix  Risked Everything by Speaking Out. She’s Not Finished.” Glamour. June 16, 2020. Online: https://www.glamour.com/story/game-changer-allyson-felix 
3. Fitzpatrick, H. “Beyonce Opens Up About Pregnancy Complications with Twins.” Good Morning America. April 18, 2019. Online: https://www.goodmorningamerica.com/culture/story/beyonce-opens-pregnancy-complications-twins-62480855  
4. Gruber, K.J., Cupito, S.H., & Dobson, C.F. “Impact of Doulas on Healthy Birth Outcomes.” The Journal of Perinatal Education. Winter 2013. 22(1): 49-58. 
5. Haskell, R. “Serena Williams on Motherhood, Marriage, and Making Her Comeback.” January 10, 2018. Interview for Vogue Magazine. Accessed Online: https://www.vogue.com/article/serena-williams-vogue-cover-interview-february-2018 
6. Hoffman, D. E. & A. J. Tarzian. “The Girl Who Cried Pain: A Bias against Women in the Treatment of Pain.” Journal of Law, Medicine, and Ethics. 2001. 28(4).
7. Hoyert., D. L. “Maternal Mortality Rates in the United States, 2020.” National Center for Health Statistics: CDC.
8. Ladd-Taylor, Molly. “Grannies’ and ‘Spinsters’: Midwife Education Under the Sheppard-Towner Act.” Journal of Social History. 1988. 22(2).
9. Smithsonian National Museum of African American History & Culture. “The Historical Significance of Doulas and Midwives.” Image. https://nmaahc.si.edu/explore/stories/historical-significance-doulas-and-midwives 
10. Wade, Sabia. https://www.sabiawade.com 
11. Wilkie, L. A. The Archaeology of Mothering: An African-American Midwife’s Tale. 2003. Routledge: New York.
12. World Health Organization. “Trends in Maternal Mortality: 2000-2017.” Online Executive Summary.