My Master’s thesis was on Black maternal mortality in the United States. Find my introduction below:
The United States is failing Black women.
Approaching American history through the lens of race and sex with a focus on the Black woman reveals a unique lived experience of the country, its beliefs and systems, that demands a more in-depth examination. Enshrined in the American Declaration of Independence is the principle of an inalienable right to, “Life, liberty, and the pursuit of happiness.” For Black women, even the most basic of these – life – is not safe.
Misogynoir, a portmanteau of the words “misogyny” and “noir (the French word for ‘black’)” deals with hate and bigotry toward Black women specifically. Though they can have interactions based on one or the other, Black women experience the world not solely as a Black person or as a woman, but rather an inextricably linked amalgamation of the two. An unfortunately assured element of existing as any of these identities in today’s world, is discrimination. This can happen on an individual level or on a much larger scale at a systemic level. One of the clearest examples of systemic misogynoir in the US, is in health and healthcare. Not limited to the physical, this includes psychological health, as, at the beginning of the millennium, the World Health Organization declared, “There is no health without mental health. (World Health Organization, 2022)” Black women and girls are seeing increased rates of depression and suicide, likely due in part to societal pressure from adultification and the expectation that they embody the Strong Black Woman stereotype (Liao, et al., 2019) (Leath, 2019). Additionally, they go undiagnosed or are diagnosed later in life for neurodiverse conditions like Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) (Mandell, et al., 2009) (Clerkley, 2022).When it comes to matters of physical health, the disparities are also evident. Fibroid tumours are more common and severe in Black women than any other ethnic group (Eltouhki, Modi, Weston, Armstrong, & Stewart, 2013) (Clerkley, 2022). In October 2022, the American Cancer Society (ACS) released a report with findings that despite having a 4% lower incidence rate of breast cancer compared to white women, Black women had a 40% higher death rate from the disease (Giaquinto, et al., 2022). Addressing the issue, Rebecca Siegel – senior scientific director of ACS Cancer Surveillance and co-author of the study upon which the report was based – said, “We have been reporting this same disparity year after year for a decade. The differences in death rates are not explained by Black women having more aggressive cancers. (McDowell, Breast Cancer Death Rates Are Highest for Black Women—Again, 2022)” We see the pattern repeated when it comes to maternal mortality. The data indicate Black women dying at higher-than-average rates, and over 2.5 times more than the group with the lowest occurrence. Learning this, one is prompted to ask, “Why?” The answer is often, “Research cannot pinpoint why Black women are more susceptible,” or simply, “We do not know.”
“Maternal mortality is widely accepted as a key indicator of health and socioeconomic development. It is a reflection of the whole national health system. (Sajedinejad, et al., 2015) (Mizoguchi, et al., 2012)” Placing this in context, between 2000 – 2020, the world maternal mortality rate dropped around 34% (World Health Organization, 2023). In the US, it has risen 78%, surging to its highest levels since 1965 (Toy, 2023). In 2020, almost all of these maternal deaths (≈95%) occurred in low and lower middle-income countries (World Health Organization, 2023). Concerns about maternal mortality are often directed to the Global South, but the reality is that even one maternal death, regardless of where in the world it occurs, is one death too many. Part of the reason the United States draws so much criticism for not only its Black maternal mortality rate, but the overall maternal mortality rate, is because it is the worst of the world’s industrialised nations. In the US, this is most worrying for Black women, who are dying at a rate more than twice the national average of mostly preventable causes (Taylor, et al., 2022). Because the US is also the only one of these countries that does not have universal healthcare, the argument could be made that this plays a role. Notably, though their average maternal mortality is relatively low at 10.5 (when corrected for COVID-19), the only other country to collect this data by race – though not the only other developed country with a significant Black population – the United Kingdom, has a Black maternal mortality rate higher than that of the US, at 3.7 (Knight, et al., Saving Lives, Improving Mothers’ Care Core Report – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20, 2022), which raises additional questions about the true state of Black women’s health and wellbeing in the UK and Global North. Maternal mortality is a key indicator in a country’s overall health, and the United States is in critical condition.
Black Women Must Be Superheroes
Across time, a universal element of culture has been and remains, storytelling. From an anthropological perspective, the interest is “in how narratives help individuals and groups make sense of experience; how narratives contribute to socializations into group practice, norms, or moral values; and how they help transmit ideologies, theories, or imaginaries (Götsch & Palmberger, 2022).” In storytelling, whether traditional literature, filmmaking, or even comic books, there is a character archetype which is “The Superhero.” Those who fit into this archetype possess superpowers – abilities that go beyond human capacity – and are tasked with saving the world.
The characterisation of Black women by society as “superheroes” can be dangerous. How Black women are perceived impacts how they are treated. The way that the world views and understands Black women, is as self-sacrificial labourers and saviours (Geyton, Johnson, & Ross, 2020). One of the most ubiquitous narratives in the US today, is that of the “Strong Black Woman.” This perception finds its origin in chattel slavery and the belief at the time, of doctors like the controversial figure, J. Marion Sims, held by many as the father of modern gynaecology. His expertise in the field came from experimenting on enslaved Black women without anaesthesia because “Black people feel less pain. (Hohman, How this Black doctor is exposing the racist history of gynecology, 2020).” Almost 200 years later, this myth persists, continuing to be taught and documented as fact in medical textbooks, and informing how doctors and nurses care for their Black patients (Hoffman, et al., 2016). Today, the Black woman is often praised for her impenetrable resilience and ability to make the impossible possible for those around her. Renown author Zora Neale Hurston, in her 1937 novel “Their Eyes Were Watching God,” details the main character’s – a Black woman’s – search for identity. In it, she says “The Black woman is the mule of the world.” Artist Nilé Livingston explains this by saying, “Black women are the mules of the earth because we are conditioned to serve the needs of others and to invest in strength to our own detriment (Livingston, 2018).” Regardless of how deleterious the impact on them, it has seemingly always been incumbent upon Black women to “save the world,” and they have seemingly always acquiesced. When taking into consideration Black women’s resulting allostatic load and health outcomes however, the question that now arises, is “At what cost?”
There are at least two ways to interpret the assertion made in the title, that “Black women must be superheroes.” Black women must be superheroes. One can focus on the superheroism – the idea that Black women are not afforded the privilege of mediocrity. They must be exceptional, and with no thought of self, they must save the world. As we have seen since Africans were first enslaved in what is now the United States of America, there has been an entitlement to the lives and labour of Black women. Equally, it can be understood as, “Black women must be superheroes” – an obligation in order to stay alive. To be successful, or perhaps, when one considers issues like Black maternal mortality, simply even to exist in a world where you are the antithesis of those for whom the world was created, there is no other option for Black women but to possess an incomprehensible – a superhuman – ability to endure. Survival necessitates it.
Looking into Black women’s health outcomes and self-reported experiences, a trend becomes clear. It has been acknowledged that there is discrimination in medicine based on race and sex. Equally, it has been established that Black women are dying of preventable causes at higher rates during pregnancy, childbirth, and postpartum. It stands to reason, that Black women, who exist in the intersection of Blackness and womanhood, are experiencing worse health and healthcare conditions based not just on one or the other, but both concurrently – misogynoir. When examining the data on the state of maternal health and mortality, the contrast between Black women and those from other racial/ethnic backgrounds, is stark and largely unexplained outside of systemic discrimination and inequity. The author hypothesises, “Misogynoir is the main cause of higher Black maternal mortality rates in the United States.” It must be noted that the hypothesis does not posit only medical misogynoir as the cause of higher rates, because acting as comorbidities, are the effects of non-medical misogynoir – like the aforementioned allostatic load – which also contribute to Black women’s poor health outcomes in general and with Black maternal health and mortality specifically. Understanding misogynoir, how it can present, and the impact it has on health outcomes, creates the ideal foundation upon which to build a framework for reducing Black maternal mortality.
Based on the hypothesis, the overarching question driving the research will be, “In which ways does misogynoir contribute to higher Black maternal mortality rates in the United States?” There are myriad ways misogynoir can manifest. In exploring these iterations as well as additional causes of Black maternal mortality, it can be determined whether those which fall under the umbrella of misogynoir outweigh other contributing factors. Additionally, it provides a guide on the most pressing issues to be addressed to reduce Black maternal mortality.
Understanding the intersectional experience of Black women in the United States including the provenance and history of medical misogynoir
It is impossible to fully grasp the extent of the impact misogynoir has had on the Black maternal mortality rate in the US today, without delving into the history of the Black woman in the country, their treatment and exploitation in the field of medicine, and roles in the development of the field of obstetrics and gynaecology specifically. To do this, it is necessary to take into account intersectionality and how the identities of race and sex compound to form an another that has its own idiosyncratic experiences. This also creates the foundation for a broader view of the concept that allows one to understand how factors that may not have initially been considered to be misogynoir do in fact, belong in that category.
Examining the ways in which misogynoir contributes to the Black maternal mortality rate
Though they may be the cause, “Racism,” “sexism,” or “misogynoir” would never be listed as the cause of death on a death certificate. Using only Centers for Disease Control (CDC) data on maternal deaths and causes would not result in an accurate representation of the state of Black maternal mortality today. To realise this aim, while qualitative data from the CDC will be included, work including research, reports, and commentary on the subject from government agencies, independent organisations, and academic institutions must be taken into account. Considering a range of perspectives alongside the facts and figures will assist in determining whether, per the hypothesis, misogynoir is in fact, the “main cause of Black maternal mortality in the United States.”
Providing recommendations for the reduction of Black Maternal Mortality Rates in the United States
In stark contrast to the principles upon which the nation was founded, equitable systems, and in particular equitable healthcare – with consideration for Black women specifically – needs to be one of the country’s core values, demonstrated through tangible, informed action and replicable results.
It is important that once a problem and its causes have been determined, steps are taken to rectify and eliminate, or mitigate the issue. This third aim seeks to answer two questions: 1. What needs to be done? 2. How does that come to fruition?
The answers to these questions and resulting recommendations should be informed by historical context; the most up-to-date data, research, and current discourse on the subject; and the ongoing efforts of activists, those in the medical field, institutions working toward this goal, and most importantly, by listening to Black women.
Clerkley, K. (2022, May). The Under Diagnosis of ADHD in Black Females. 1441. Retrieved from https://scholarworks.lib.csusb.edu/etd/1441?utm_source=scholarworks.lib.csusb.edu%2Fetd%2F1441&utm_medium=PDF&utm_campaign=PDFCoverPages
Eltouhki, H. M., Modi, M. N., Weston, M., Armstrong, A. Y., & Stewart, E. A. (2013, August 11). The Health Disparities of Uterine Fibroids for African American Women: A Public Health Issue. American Journal of Obstetrics and Gynecology, 10(3), 194 – 199 https://doi.org/10.1016/j.ajog.2013.08.008.
Götsch, B., & Palmberger, M. (2022). The Nexus of Anthropology and Narrative: Ethnographic Encounters with Storytelling Practices. Narrative Culture, 9(1), 1-22.
Geyton, T., Johnson, N., & Ross, K. (2020, December 14). ‘I’m good’: Examining the internalization of the strong Black woman archetype. Journal of Human Behavior in the Social Environment, 32(1), 1 – 16 https://doi.org/10.1080/10911359.2020.1844838.
Giaquinto, A., Sung, H., Miller, K. D., Kramer, J. L., Newman, L. A., Minihan, A., . . . Siegel, R. L. (2022, November/December). Breast Cancer Statistics, 2022. CA: A Cancer Journal for Clinicians, 72(6), 524-541.
Hohman, M. (2020, June 29). How this Black doctor is exposing the racist history of gynecology. Retrieved from TODAY: https://www.today.com/health/racism-gynecology-dr-james-marion-sims-t185269
Knight, M., Bunch, K., Patel, R., Shakespeare, J., Kotnis, R., Kenyon, S., & Kurinczuk, J. J. (2022). Saving Lives, Improving Mothers’ Care Core Report – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. University of Oxford, National Perinatal Epidemiology Unit. Oxford: University of Oxford.
Leath, S. (2019, August 15). HOW THE EXPECTATION OF STRENGTH HARMS BLACK GIRLS AND WOMEN. Retrieved from Scholars Strategy Network: https://scholars.org/contribution/how-expectation-strength-harms-black-girls-and
Livingston, N. (2018, March 2). Black Women Are The Mules Of The Earth – Zora Neale Hurston. Retrieved from Nile Livingston: https://nilelivingston.com/black-women-are-the-mules-of-the-earth/
Mandell, D. S., Wiggins, L. D., Arnstein Carpenter, L., Daniels, J., DiGuiseppi, C., Durkin, M. S., . . . Yeargin-A. (2009, March). Racial/Ethnic Disparities in the Identification of Children With Austim Spectrum Disorders. American Journal of Public Health, 99(3), 493-498.
McDowell, S. (2022, October 3). Breast Cancer Death Rates Are Highest for Black Women—Again. Retrieved from American Cancer Society: https://www.cancer.org/latest-news/breast-cancer-death-rates-are-highest-for-black-women-again.html
Mizoguchi, N., Oestergaard, M. Z., Wilmoth, J. R., Say, L., Mathers, C. D., Zureick-Brown, S., . . . Chou, D. (2012, July 13). A New Method for Deriving Global Estimates of Maternal Mortality. Statistics, Politics, and Policy, 3(2), https://doi.org/10.1515/2151-7509.1038.
Toy, S. (2023, March 16). The Wall Street Journal. Retrieved from U.S. Maternal Mortality Hits Highest Level Since 1965: https://www.wsj.com/articles/u-s-maternal-mortality-hits-highest-level-since-1965-f9829776
World Health Organization. (2022). Health and Well-Being. Retrieved from World Health Organization: https://www.who.int/data/gho/data/major-themes/health-and-well-being#:~:text=Mental%20health%20is%20an%20integral,socioeconomic%2C%20biological%20and%20environmental%20factors.
World Health Organization. (2023, February 22). Maternal mortality. Retrieved from World Health Organization: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality
NB: Submitted: Friday 31st March, 2023; Published here: Tuesday 4th April, 2023