The Unsaid: Black Women and the Childbirth Experience in Oregon
by Kathryn Bereman-Skelly
January 17, 2011
When I had my first baby, I was just scared. The nurses at the hospital whispered around me, and treated me like I was ignorant. It’s what the nurses and doctors didn’t say—the looks they gave each other, the tone of their voices--it was the unsaid things that made me feel afraid.
Nia carefully pulled herself out of the taxi on a drizzling night, carrying only a small plastic bag with a newborn outfit folded neatly inside. She slowly, cautiously stepped her way through the hospital doors, and down the seemingly endless hallway to the elevator--stopping every few feet to hold onto the wall through each contraction. Finally, she arrived at the labor and delivery ward where a nurse quickly ushered her into a cold, bright exam room. Nia changed into a hospital gown and climbed onto the papered exam table. She closed her eyes through each wave of contraction, waiting, wanting the experience to be over.
Nia had never felt so alone, and wished out loud for her mother and sisters to be there. Soon a nurse, too cheerful for Nia’s ears, entered the room. Nia pretended to be brave, but felt vulnerable and scrutinized under the bright fluorescent lights. The nurse checked her dilation, took her weight and blood pressure, then asked a series of questions which Nia remembers as strange and insulting, including whether or not her children all had the same father (this was her first birth), and which street drugs she had used during pregnancy (she hadn’t). Nia squeezed her eyes shut, one contraction after another. She quietly complied when the nurse asked for a urine sample for a drug screening test.
Much later, in another room, her labor failed to progress. Nia was told she would be receiving Pitocin in her IV. She asked for an explanation about the workings of the drug, and the doctor told her simply, “this will help your baby.”
Her baby boy quietly entered the world in the middle of the night, with only hospital staff nearby.
Nia held the baby in her arms throughout the night and tried to breastfeed. In the morning, when the door to her room opened, she thought with relief that a lactation specialist had finally arrived to help her. But the woman who sat down at her bedside was a social worker who asked dozens of questions about Nia’s personal life, sexual history and family living arrangements. Nia panicked, thinking could they really be considering taking away my child?
Most mothers who deliver babies in hospitals are not given routine drug screenings, nor are they asked invasive questions during an important window of mother and infant bonding time. Generally, only mothers who admit to drug use or have histories of substance issues undergo this type of scrutiny. Perhaps Nia was asked these questions because of her status as a young mother, alone, using public insurance. More likely, she received this treatment because she is a black woman giving birth in America today.
A disturbing reality in the United States is that black women have a four-times greater risk of childbirth-related deaths than white women. Statistically, black women die at a rate of 36.1 per 100,000 live births, compared with 9.6 for whites and 8.5 for Hispanics, according to a 2008 report by the Centers for Disease Control and Prevention (CDC). This death rate is not remaining constant, though, it is in fact rising. Even when socioeconomic factors are the same as whites or Hispanics, it appears that just being a black woman in America puts one at risk for childbirth complications.1
Various reasons for this problem have been hypothesized, from lack of prenatal care, to higher rates of health issues like obesity, diabetes, and heart disease. However, no one really understands why the discrepancy between black women and other races is so high and continuing to climb in the US. It seems the problem cannot be limited to physical health issues alone. Another hypothesis is a syndrome identified by Dr. Arline Geronimus, a professor at the University of Michigan School of Public Health, called ‘weathering’, which is the lifelong exposure to social, economic, and environmental stressors--including the stress to be a ‘model minority’ --that causes health to deteriorate prematurely.
While many studies have looked at the physical and socioeconomic stressors of childbearing black women, few have analyzed mental health stressors in relation to this trend. It is well known that excessive life stress during pregnancy can lead to pre term births2, and extreme anxiety during childbirth can make the progression of labor more difficult. When labor becomes complicated in a hospital setting, medical interventions often beget more medical interventions, which contribute to surgical risk and play a role in worse mortality outcomes overall.
Women who perceive any type of stress during or shortly after birth are also at a much higher risk of developing mental health problems after the birth. Postpartum depression and anxiety are more prevalent among those who have undergone difficult births than those who experience empowered births. Stressful events such as emergency surgery, or even the fear that the state child welfare department will remove a baby, can negatively impact a mother’s bonding with, feeding and parenting her child.
A recent Black Birth Survey, conducted by the International Center for Traditional Childbearing (ICTC) in Portland, Oregon, revealed that black women frequently experience fear, anxiety, and cultural misunderstandings when giving birth in hospital settings. The study was undertaken to analyze the birth experiences of black women in Oregon, and to see if stress and anxiety--emotions that run concurrent with poverty, racism and other psychosocial issues--play a larger role in black births than we realize.
In the Oregon study, 245 black women, ages 16 to 45, answered questions regarding their hospital childbirth experiences. Shafia Monroe, president of ICTC, stated, “ … the survey in many ways verifies what we see and hear from black women in Oregon’s communities. Many are in the public health care system, give birth alone … and expressed fear during their time in the hospital based on their treatment.”
The study also revealed other troubling, but well-documented, facts. Many of the women lacked support of any kind during pregnancy and childbirth. Nearly two thirds of the women did not attend childbirth education classes at all. Half of the women reported fear, racism or disrespect while in the hospital.
Of course, improvements in physical health, early access to care, and community support and outreach programs are all strategies to reverse these trends. Medical professionals should also be made aware not only of the cultural differences of black--and other—ethnic communities, but also of their own racial biases. The ICTC study, though, suggests another important idea: that providing black women with black doulas and midwives allows mothers a culturally appropriate guide during childbirth.
In other counties, doulas and midwives attend most births.
However, such support is not a well-known option in American births today. A professional doula helps to educate, guide and reassure a woman through her pregnancy and birth experience. A doula is not only a conduit of care, but an intermediary and translator between the mother and other medical staff. There is evidence that the presence of a doula results in fewer Cesarean-section births, and healthier birth experiences overall for women.3
It seems obvious that providing culturally congruent prenatal and childbirth care would greatly help mitigate the fear and anxiety that many black women experience. The ICTC, an entity which trains doulas and midwives, sees the pattern first hand. “We have seen birth outcomes for both mother and baby improve when black women have access to affordable doula services,” says Monroe. Unfortunately, public health insurance does not pay for doula services, which makes it difficult for many low-income mothers to afford this type of support. The state of Oregon is taking steps to make doula services an accessible option for mothers, however. A recent bill was passed to allow funds to further explore how doula care could help pregnant and birthing women.
Addressing the cultural and mental health needs of black women during pregnancy and childbirth is a start, at the very least, in curtailing this alarming trend. Providing culturally congruent doula and midwifery services to all black women during pregnancy and childbirth will likely help to decrease the fear and anxiety associated with the birth process. All women deserve to feel respected and treated equitably during the births of their children. Making this a priority for black women will impact not only the mothers who give birth – by improving their childbirth experiences and health outcomes -- but will help foster better lives for the children they bear.
The ICTC is a nonprofit educational and advocacy organization based in Portland Oregon. See more atwww.ictcmidwives.org
Names have been changed for confidentiality
Kathryn Bereman-Skelly is a mother, psychotherapist, and facilitator of community support groups for pregnant and postpartum women in Portland, Oregon.
1. Goffman D, Madden RC, Harrison EA, Merkatz IR, Chazotte C. Predictors of maternal mortality and near-miss maternal morbidity. J Perinatol. 2007;27:597-601. Abstract
2. Tegethoff M, Green N, Olsen J, Meyer A, Meinlschmidt G. Maternal psychosocial adversity during pregnancy is associated with length of gestation and offspring size at birth: evidence from a population-based cohort study. http://www.psychosomaticmedicine.org/content/72/4/419.abstract
3. Sosa R, Kennell J, Klaus M, Robertson S, Urrutia J. The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. http://www.nejm.org/doi/pdf/10.1056/NEJM198009113031101