PUBLIC HEALTH CRISIS: Maternal Mortality in the US

Today is Maternal Health Awareness Day and I’m giving you a run down on why we even need this day in the first place! It was difficult to find its origin story, but it seems that its first appearance was in 2018. However, it’s true origins go very far back in our country’s history.

That’s right, back to slavery once again!

Thomas Jefferson is quoted saying, “I consider a (slave) woman who brings a child every two years more profitable than the best man on the farm”. Prior to the industrial era, agriculture was the dominating way of life. For poor whites and especially African slaves in rural states, pregnant women were extremely profitable because more children meant more bodies to put to work on the plantations.

In 1807, Congress abolished the importation of slaves into the United States (US). However, slavery was still very legal and plantation owners had no intentions of letting up on the demand for more slave labor. As the only source for new slaves, African women became cash cows. Slave owners needed to ensure a steady stream of workers and forced enslaved women to have more children to breed more free labor.

Throughout that time, the business of maternity care was largely in the hands of traditional midwives, also known as granny midwives. They were valued members of society as slave owners wanted to ensure that live, healthy babies were being produced to stock their plantations full of more free labor. Both black and white mothers traditionally gave birth in their home with the assistance of these granny midwives.

That was pretty much the standard until slavery was abolished in 1865. Slave owners had to release all of their free labor and that meant that thousands of free blacks were wandering around the country with seemingly equal access to white resources. The overabundance of freed black families posed a major problem to southern whites, who happened to be some of the most powerful people in the country.

Speaking of wealthy white men, medical doctors were among some of wealthiest and most well-connected men in the country. They also often owned slaves. As medicine began to modernize, doctors began doing experiments on slave women to advance gynecological medicine. I’ll try not to go into too much detail for the sake of time (and because there were so many medical atrocities committed during this time frame), but it’s important to focus on at least two men. Ephraim Mcdowell provided the first recorded evidence of experimentation on black women’s bodies. Dr. McDowell’s claim to fame is his “brave” surgery (ovariectomy) on a white woman who reportedly gave her consent and “sang hymns” during her unmedicated surgery. However, he should also be known for his experimentation on at least 10 enslaved women, performing unmedicated abdominal surgeries without their consent.

Between 1845-1849, another doctor named James Marion Sims performed 30 experimental surgeries on one 17-year-old enslaved woman and did surgeries on at least 11 other enslaved women. Sims was especially cruel, forcing other slaves to hold down his patients during his excruciating procedures. Even though anesthesia was introduced in 1846, he chose not to use it on slaves under the notion that black people did not feel pain the way that white people did.

I must mention these two men because these are the founding faces of Obstetrics and Gynecology in our country. Not women who spent years understanding the processes of physiological birth. They are two surgeons who used nonconsenting black women as guinea pigs to advance their surgical techniques. In the late 1800s and early 1900s, as obstetrics “advanced”, doctors needed to make money and get women to come to the hospital to give birth. But, women, both black and white, were accustomed to home births attended by midwives. As a caveat, part of the push to move births to hospital was well-intentioned. Medical advances had led to the invention of pain medication and better life-saving techniques for infants. At this time, the infant mortality rate was very high. Doctors were working to decrease the infant mortality rate and over the course of the last 100 years, they have been incredibly successful!

Doctors were historically very close with slave owners; being dependent on them for financial stability and they were often slave owners themselves. When slavery ended, there was no longer a need for black mothers to continue to produce children at the rate that they were going before. In the eyes of southern whites, there were now “too many black people”. Since midwives were also predominantly black, they were an easy target to start to decrease the rate of healthy, live black births. Some states outlawed home birth midwives completely while doctors like Dr. Joseph B Delee, named the “Father of Modern Obstetrics”, went on a rampage convincing the public that midwives were “a relic of barbarism”. This was highly effective as black mothers often could not afford hospital care and often were not allowed in anyway because of segregation.

While the above-mentioned doctors were on their own mission to profit off birth and abolish the midwives, people like Margaret Sanger, founder of Planned Parenthood, were on their own little mission of targeted population control. In the 1910s-30s there was a migrant boom (which included eastern and southern European descendants) to the US, and this caused white people in power to lose their minds. Sanger was a proud eugenicist and pushed for the creation of birth control specifically to limit "undesirable" groups, like immigrants and blacks, from reproducing. She infamously founded the Negro project which functioned to push birth control on black women in the south.

In the 1950s, black women were routinely sterilized without permission when going to the hospital for other medical procedures. A woman might go into surgery to remove a gall bladder and come out having a full hysterectomy. The targeted sterilization continued even into the 90s when birth control, like Norplant, was being heavily pushed on teenaged black girls. Former leader of the KKK, David Duke, famously supported a bill to incentivize “welfare mothers” to use birth control by promising them a monthly cash payout. The bill, thankfully, was never moved any further.

I recognize that birth control is a far cry from forced, unmedicated surgeries. However, I want to highlight that the same racial biases that started with the first slave woman have travelled through time in various forms. There has never been a time when black women have been able to have complete autonomy over their bodies. With each decade, came a new wave of obstetric and societal abuse.

At present, despite over 200 years of medical advances and the rise of racial equality, black women routinely have limited access to quality prenatal care. As recent as 2016, a nursing textbook still contained racially biased information about pain perception in black people. Black mothers are still 3-4 times more likely to die due to pregnancy and childbirth related complications than white women. While prominent organizations like the Center for Disease Control (CDC) have come out in acknowledgment of this striking statistic, they continue to appear “confused” about what’s driving these statistics.

The cause is deeply rooted in our country’s history. Race aside, modern medical maternity care was founded by male surgeons who historically were not involved in the majority of “normal”, natural births. Many of the practices of traditional midwifery, practices that have been passed down since ancient times, have been lost in this new form of maternity care.

Today, less than 10% of all births in this country are attended by midwives and 5% of all midwives are women of color. This is in stark contrast to the rest of the world. In the United Kingdom, 50% of births are attended by midwives. In Sweden, Denmark and France, 75% of births are attended by midwives. All of these countries have a maternal mortality rate less than 10% while the US mortality rate is almost triple that at 26.4%.

At present, despite continuous advancements in technology and medical treatments, the mortality rate continues to climb. If hospitals are the safest option, then how could a country with 90% of births happening in hospitals have a growing mortality rate?

Again, the answer lies in our history. Childbirth is as old as time. Birth was happening long before the first man decided to become a doctor. Ancestral midwives use a family-centered approach which emphasizes undisturbed, unmedicated, vaginal birth. Reports have shown that mothers who birth autonomously have better birth outcomes and babies born to those mothers have higher chance of survival immediately after birth. To improve maternal health outcomes, we must reset the system to a mother-centered approach that involves the least amount of medical intervention possible.

I don’t want to diminish the amazing skill that comes with being an OB/GYN! These doctors, without a doubt, save lives every single day! There are circumstances where mothers and babies would have been lost if not for the skilled work of their doctors. I believe there is room for both OB/GYNs and midwives in maternity care. Midwives are experts in low-risk, vaginal births while OB/GYNs manage high-risk pregnancies routinely. The US system is unevenly yoked at present. While some states are becoming more midwife-friendly, most states still have laws that make it extremely difficult for midwives to practice, especially in the home setting. Most insurance companies will flat out refuse to cover any practitioner outside of a hospital even though states where midwives are more prevalent tend to have lower rates of premature births, neonatal mortality and c-sections.

Birth workers and mothers around the world are lobbying for improvements in maternal healthcare and decreasing the black mortality rate. Since 90% of births occur in hospitals, the focus has been on improving the way mothers are cared for in the hospital setting. Retraining doctors and hospital staff on best practices in during childbirth is a great first step! However, there is still a lot of work to be done. The best way to move the needle forward is to educate yourself! Get in tune with your own body and educate yourself about pregnancy and birth as soon as you can. The more educated a woman is going into it, the more likely she is to have a more positive outcome. Bringing the autonomy back to mothers is our best chance in making lasting changes to the current system!

By the way, you can check out the video I made for this topic here!

References:

“Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present” by Harriet Washington

“Autonomy Revoked: The Forced Sterilization of Women of Color in 20th Century America” by Paula Alonso

“The US Medical System is Still Haunted by Slavery” by VOX

“This American Doctor Pioneered Abdominal Surgery by Operating on Enslaved Women” by Kat Eschner

“DUKE PRESSES LOUISIANA BIRTH CONTROL” by Maralee Schwartz

“Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modeling study”

DOI: https://doi.org/10.1016/S2214-109X(20)30397-1

Is modern genetics the new eugenics?

https://www.nature.com/articles/gim2003376

High maternal death rate shames America among developed nations