We bawl so we are heard: the stories we must tell about obstetric racism

Keywords:

• Black maternal care
• obstetric racism
• racial disparities in maternal care
• storytelling
• using voice

During a torrential downpour the day after my grandfather’s funeral, my two older cousins and I sat in my grandparents’ house telling stories to pass the time. This was a familiar feeling for us – as children, we spent much time in my grandparents’ living room in a small house in the southern part of Trinidad. As a close-knit extended family network, this was where we often came to share stories with a twist of levity. There was great comfort here. On this day, as we passed the time, my cousins compared notes on their toddlers and proceeded to recount their birthing stories. As the only person in the room without a child, I soaked up their words like a sponge.

“My mother said, if you have to bawl, bawl! Don’t be quiet … you must let them know something is wrong. And I made sure to bawl!” offered my soft-spoken cousin. Leg-slapping laughter filled the room while conjuring up images of this quiet, mild-mannered woman bringing herself to such a raucous act. My other cousin chimed in, “My friend told me that if they tried to send me to a hospital further away, I should pretend like I was in excruciating pain; put on my best performance and scream. So said, so done!” As the more theatrical of the two, it wasn’t very hard to imagine her rendition of a person in unbearable pain, especially with her re-enactment. We all laughed until we cried. We all laughed until we lost our breath.

My cousins were taught to scream so that they didn’t lose breath during obstetric complications. They were taught to cry out so that they wouldn’t hemorrhage after labour. As Black women, they had been coached on how to command an audience when their embodied knowing alerted them to danger. They were coached on how to convince others that their bodies were worth the attention required. As Black women, their mothers and friends with experience passed down generational messages about the cruel possibilities of perinatal care. The stories they told that day demonstrated how they heeded those cautions and highlighted the shared experience of approaching maternal care as a Black person. Obstetric racism is not new. Black women and birthing people had been fighting for their lives for generations. The generational storytelling, outlining tragic experiences and near misses, has and continues to serve as an important function for cautioning and protecting Black women in their maternal care experiences.

The concept of race as biologically situated, and the understanding of intellectual, physical, and dispositional differences as aligned with racial categories, resulted in the political, economic, and social positioning of Black people in previous centuries.^1–4 Rooting race and racial difference in these ways set a foundation for how health and disease were understood, as well as what kind of healthcare should be delivered on the basis of these differences.^1,2,4 Additionally, the classification of Black people as biologically different as a result of racial classification, as well as Black bodies as property during slavery, acted to restrict the agency Black people could exercise over their bodies, especially during the antebellum period.^1,2,4,5 According to Roberts^1,2 and Washington,⁴ physicians formed relationships with plantation owners and determined the appropriate treatment for Black enslaved people based on race-based understanding of clinical symptoms and the plantation owners’ complaints. The absence of agency of Black bodies meant that plantation owners were consenting to treatment, and not the enslaved people themselves.^1,2,4,6

In addition to the role medical practitioners played in supporting the use of Black bodies for labour during slavery, there were also particular interests in Black women’s reproductive capabilities as a means for production and reproduction.^4,5,7,8 Black women’s bodies in the antebellum period were uniquely positioned because of their ability to produce Black bodies for labour following the abolition of the Trans-Atlantic slave trade.^4,5,7–9 Thus, interest in the optimal reproductive functioning of Black women’s bodies introduced new sites of exploration and exploitation. The lack of agency Black people had over their lives and their bodies, as well as the use of Black women’s bodies for labour and reproduction, situated them as objects to be acted upon.

Antebellum physicians such as François Marie Prevost, Nathan Bozeman, and J. Marion Sims advanced developments in gynecology by addressing issues experienced by Black enslaved women during labour, delivery, and thereafter.^4,5,7 Physicians’ approaches to care for Black women’s bodies at that time were different from the standard of care received by White women.¹⁰ Their access to Black women’s bodies, the positioning of Black bodies as property^4,6,11 and the interest in preserving Black women’s reproductive health as a means for reproduction,⁷ set the foundations for a particular gaze on and approach to the care of Black women’s bodies.¹¹ The legacies of these physicians, and others like them, are cemented in history in medical journals, through observations and case notes obtained from the treatment of enslaved Black women.^8,11

The differential treatment of Black women in maternal care continues today. Cooper Owens and Fett indicate that, “although Black women live longer lives now, the effects of racism have reverberated in their lives and those of their children in damaging and fatal ways” (p. 1343).¹¹ African American woman are 243% more likely to die from issues in pregnancy and childbirth than White women in America.¹² Additionally, complications resulting in maternal death and injury are more likely to occur in Black women than White women, despite similar rates of the presenting conditions.¹² Analyses of maternal morbidity and mortality often focus on language barriers, access to health services, challenges with health literacy, as well as values and cultural conflicts.^12,13 While social determinants of health account for some aspects of maternal outcomes, there are other aspects of maternal care that arise that require further exploration and attention. Black women have often described being disregarded by healthcare practitioners about their wisdom with respect to their own bodies.¹² Moreover, feelings of anger, stress, and distress with healthcare providers continue to plague Black women, reinforcing suspicions of not feeling heard.¹²

The context in which women interpret those experiences is the result of being knowledgeable subjects who have lived their lives in a country where the legacies of racism, evidenced by the racial capitalism of enslavement, segregation, and medical experimentation, influence their understanding of the treatment they receive.⁶ (p. 569)

The legacy of the differential treatment of Black women in maternal care became entrenched in practice and policy and acted to reproduce harmful stereotypes. Today, this is known as obstetric racism. Defined by Davis, obstetric racism is “[…] the mechanisms of subordination [in reproduction to which] Black women are subjected that track along the histories of anti-Black racism” (p. 57–58).¹⁴ It encompasses forms of violence and abuse from healthcare staff and by institutions on Black women, from attempts to conceive and throughout the perinatal period.¹⁴ Obstetric racism includes critical lapses in judgment, being subjected to neglectful, dismissive or disrespectful treatment, and medical abuse.¹⁴ Racial reconnaissance – the burdensome task of avoiding or managing anticipated racist encounters – is also encompassed in obstetric racism.¹⁴ From choosing healthcare providers and care environments that may mitigate mistrust and judgment, to highlighting social status in order to manoeuvre around race-class stereotypes, racial reconnaissance is the emotional and practical labour borne by Black women in reproductive care.¹⁴ Silencing oneself and one’s needs as a means of avoiding racialisation and averting racism also occurs in this context.¹⁴

Where prevailing and pervasive negative beliefs have the potential for interfering in the patient-provider encounter, Black women find ways to mitigate harms and resist stereotypes in their maternal care journey.¹⁵ Learning and using medical vocabulary, as well as managing fears and concerns by communicating that which is deemed as efficient and rational to the provider, are ways in which Black women develop and build social privilege in these encounters.¹⁵ These actions create a system of cultural health capital,¹⁵ which ultimately serves as mechanisms for demonstrating why they are owed dignity and their lives should be seen as valuable. As I saw from my cousins that day, not only have Black women found ways to manage these burdensome interactions, but they have also passed down techniques and strategies for navigating these onerous encounters from generation to generation. Through my cousins’ stories, I saw that when efforts towards racial reconnaissance have been exhausted, and cultural health capital can no longer liberate us, we teach each other to bawl.

I also saw that bawling should not to be mistaken for anger, aggression, or lack of self-control. These associations are borne from constraining stereotypes.¹⁶ Moreover, these kinds of harmful tropes at the intersection of race, gender, sexuality, and class have long histories of distorting and controlling images of Black women.¹⁶ From the tales of Mammy and Matriarch to Jezebel and Hoochie Mama, the social constructions and contortions of Black women over time have been deployed for our subjugation.^1,16 Further, these poisoned discourses have been entrenched in laws, policies, and practices to justify our continued oppression: in the workforce, our families, and our communities, centering our reproduction.¹⁶ Thus, the sounds of Black women’s cries have been disconnected from their humanity. However, the act bawling aims to change that. It uses the strength of the voice to command attention, to reclaim agency, and to demand justice as people and parents worthy of fair and compassionate treatment. Black women will move beyond bawling. Until then, the sounds that are made to ensure survival are necessary to begin to thrive.

Steps to redress obstetric racism require a more comprehensive understanding of how this issue presents and is managed in Canada. Disparities in maternal mortality among Black and White women and birthing people have been studied widely in the United States,^12,17 however, there is still a paucity of data in Canada about racial disparities in maternal mortality and morbidity.¹⁸ Efforts to address anti-Black racism in healthcare, more broadly, started to take shape in recent years through medical education,^19,20 and interprofessional symposiums that facilitate discussions about the many issues facing Black people in healthcare.²¹ The importance of race-based data collection to better attend to the community’s needs remains at the centre of discussions (Dryden and Nnorom, 2021).²¹ Despite these important foundational discussions, there is still limited attention given to Black maternal care on a similar scale. Organisations whose primary focus is the physical and mental health of Black pregnant, birthing, and parenting people have and continue to do the work of critical consciousness raising in the community and the provision of material supports to the populations they serve. While these organisations amplify the voices behind the stories of obstetric racism and violence, the absence of documented efforts to formally address these issues in healthcare settings, systems, and structures demonstrates the ongoing need for change.²²

Beyond race-based data collection, anti-racist and decolonised approaches to all aspects of maternal care are essential to redressing obstetric racism.²³ In this way, racism – not race – is more appropriately centred. Moreover, healthcare’s commitment to respect for autonomy, promoting safety, and advancing human dignity should be more intentionally applied within a decolonised approach to obstetric and gynecological care. A commitment of this kind in healthcare requires the appropriate foundation and support in social care, such that autonomy in the healthcare context is not punished or criminalised in social care and other legal contexts.²³ Changes of this kind not only begin to attend to discriminatory factors and systems that currently drive maternal care, but they also challenge us to engage in a more comprehensive exploration of the unique experiences of Black pregnant and birthing people in order to improve care pathways.²³ In addition to systemic and structural conditions, accuracy of diagnoses with attention to conditions that disproportionately affect Black women, as well as timely and appropriate treatments, must be prioritised. These approaches should be at the core of medical education and reinforced through policies, position statements, and research advanced by professional associations and societies (e.g. Society of Obstetrics and Gynecology). Additionally, healthcare settings supporting maternal care should examine their policies and practices using an intersectional analytical framework to advance anti-racist care and improve patient safety. Reproductive justice provides key guidance in these ways, as it centres the lived experiences of Black birthing bodies, as well as supports injustices in reproduction through a human rights lens.^3,24 These approaches set the stage for one of the most important opportunities for improvement in maternal care for Black birthing bodies – the development of trusting relationships between providers and their patients. A foundational way to build and sustain trust should be attending to the concerns described by Black pregnant and birthing people before compensatory and protective strategies are deployed. By expanding on the values of autonomy, safety, and human dignity, trust in this context creates a pathway for redressing the history of harms in gynecological and maternal care practice.

When the rain subsided that day at my grandparents’ house, we gathered ourselves and continued our errands. Memories of the downpour were quickly forgotten when the heat and humidity returned that afternoon. However, the stories told that day lingered longer than the memory of the rain and were far more powerful than simply passing time. Years later, my soft-spoken cousin gave birth again. She recalled being cautioned by medical professionals and friends alike about the risks of giving birth as a Black woman. What she did not expect was the severe postpartum hemorrhage she experienced following her delivery. She was hospitalised for days after her daughter was born. She bawled when she knew something was wrong, and she cried for weeks after returning home over the fears of what could have been.

The act of storytelling has and continues to serve an important function. It convenes Black birthing people to cultivate the sharing of their lived experiences and the ways in which they contribute to protecting themselves and their communities. Storytelling in these ways acts as sources of knowledge, sites of knowledge production, and important modes of cultural transmission as a function of what Clark Hines²⁵ identifies as cultural dissemblance. The stories we must tell are part of the legacies of Black women from generations past. They are means for ensuring the continued survival of Black people.

Disclosure statement

No potential conflict of interest was reported by the author(s).