DURING A ROUTINE prenatal visit in 2009, Lisa Keyser’s obstetrician lectured her about her weight gain. She told Keyser, a former NCAA Division III swimmer in her 20s, that she needed to walk faster when she went to the mall, that she should cut back on soda. Keyser, who is Caribbean-American, didn’t visit malls or drink soda. She was a D.C. professional, and had become pregnant at a healthy weight, having even shed the 20 pounds she’d gained after college.
“It was not a warm bedside manner, but more coming in like I’m doing everything wrong,” Keyser recalls. It was not the treatment she expected.
Keyser’s delivery was rough. After 28 hours of labor, 45 minutes of pushing, and a suite of interventions she had not planned for, she was brought into the operating room for a caesarean section that was lengthy and traumatizing. Keyser also did not know the baby’s sex, and she recalls that the delivery team took awhile to tell her she’d had a boy. Back in her room, Keyser’s pain was too intense to sit up and pick up her son when he cried. “It was a very helpless feeling,” she says.
While labor and delivery can be long, difficult, and painful for anyone, Keyer’s experience — from pregnancy to postpartum — appears to have been shaped by disrespect and stereotypes, particularly about black women’s tolerance for pain.
Postpartum, her care was chaotic; she returned to the hospital three times for help breastfeeding. When she made an emergency appointment with her OB for more narcotics, because she was in so much pain, she was dismissed. Instead, the stitches in her incision were removed two days early. When her incision became infected, the physician reopened it without introducing himself or even offering anesthetic.
As a result of her treatment, that year — the first year of her first child’s life — Keyser developed postpartum PTSD. She would shake, cry, have flashbacks, and break into sweats when anyone, even her husband, tried to touch her. Once, she ran out of a pediatrician’s office because of a sudden, inexplicable fear that the doctor would take away her son.
She says lawyers from her health insurer sent letters inquiring whether she might have a claim for malpractice. But Keyser was so emotionally drained that she threw the letters in the garbage, something she now regrets.
I ask if, during that year, she’d experienced flashbacks whenever she went to her own doctor or the dentist. I don’t know, she says. I didn’t go.
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THERE ARE MANY reasons pregnant, laboring, and postpartum women experience mistreatment, which can encompass behaviors that range from disrespectful to dangerous. Some healthcare providers have not learned respectful communication. Others are steeped in a medical culture that providers “know best.” Then there are systemic causes: prenatal visits that last only five or 10 minutes; strained providers who lack the time or incentive to listen deeply to women’s concerns; hospital staffing conditions that constrain nurses to remote monitoring of laboring mothers, rather than checking on women in person, in their rooms.
The culture of obstetrics as it has traditionally been practiced doesn’t help: women on their backs, legs spread, while physicians use tools on their bodies.
Given these conditions, it may come as no surprise that a new survey of 2,700 US women published in June found that nearly 1 in 6 pregnant, laboring, and postpartum women experienced mistreatment by medical providers. For women who delivered in a hospital, as opposed to a freestanding birth center or at home, that figure climbed to nearly 1 in 3.
But the study, conducted by the University of British Columbia’s Birth Place Lab and published in the journal Reproductive Health, also showed what advocacy groups such as Black Mamas Matter Alliance and Black Women Birthing Justice have long been working to address: that pregnant, laboring, postpartum, and breastfeeding women of color face disparate rates of mistreatment, which for Black women, persist even when accounting for education and income.
According to the UBC study, 32.8 percent of Native American, 25 percent of Hispanic, 22.5 percent of Black, 19 percent of Asian, and 14.1 percent of white women had been mistreated.
To determine what constitutes mistreatment, researchers worked with women from five communities of color, gathering survey questions that had been used to measure respectful maternity care in previous research. They then asked the women to choose the most relevant and important questions. When women could not find questions that described their experiences, they collaborated with the researchers to design questions that did. This means that the survey measures what it purports to measure: mistreatment, as women understand and experience it.
The two most common types of mistreatment that the study identified are being yelled at or scolded (8.5 percent) and ignored or refused assistance when asking for help (7.8 percent).
In dire cases, brushing off a woman’s concerns when she asks for help can lead to “precious moments lost,” says Saraswathi Vedam, professor of midwifery at the University of British Columbia, the paper’s lead author, and a practicing midwife. (Serena Williams, who had a pulmonary embolism after her caesarean section, is one frequently cited example; health care workers initially dismissed her when she said she was having an embolism, despite her history of blood clots. Had she not been treated, she would have died.)
More than 5 percent of women in the study reported having their physical privacy violated and 4.5 percent said they had been coerced into an intervention, such as an induction, epidural, or a caesarean section, or had been threatened with having a treatment withheld. Less common were other threats; physical abuse, including refusing anesthesia for an episiotomy (a cut to the perineum to aid with delivery); or sharing private information without women’s consent.
The study also found that the factors that elevate risks of mistreatment — such as being younger than 25 and of a lower socioeconomic background — aren’t borne equally. Some 26.9 percent of women of color of a low socioeconomic status reported mistreatment, compared with 17.7 percent of white women. Likewise, some 30.9 percent of women of color aged 17-25 experienced mistreatment, compared with 18 percent of white women in that age group.
Experts interviewed for this story assert that most providers are not outright racists and do not think of themselves as such. Vedam notes that many join the “caring professions” because they “want to help people.”
Rather, implicit bias contributes significantly to disproportionate rates of mistreatment — which Sayida Peprah, a licensed clinical psychologist, doula, and consultant explains as the “cultural lens that impact[s] the way you see people, [and] the way people see you.”
And it happens at well-ranked and poorly ranked hospitals alike, says Regina Conceição, a doula with the NYC Department of Health and Mental Hygiene’s By My Side Program, who also sees private clients in her own doula practice. (Doulas are advocates who help patients articulate needs and wishes to providers, particularly during labor and delivery. They are not health providers.) Conceição, who has 19 years of experience, says that even when her clients express a desire to deliver at “good” hospitals, where “white women go,” they are not treated by the same standards.
In the worst case, mistreatment can result in preventable death or serious harm. The United States, according to the World Health Organization, is the most dangerous country for pregnant women in the developed world. It is especially dangerous for Black women, who are 3-4 times more likely to die from a “pregnancy-related cause” than white women, according to the CDC, even when accounting for women’s income and education. The numbers are even worse for Alaska Native and Native American women, who are 4.5 times more likely than white women to die from childbirth, according to a study that looked at outcomes for urban-dwelling members of those groups. The outcomes for these women’s babies are also disproportionately poor: Black and Native American babies are more likely than white babies to die by their first birthdays.
But measuring a woman’s pregnancy outcome by whether she or her baby dies focuses attention on the worst-case scenarios and away from more quotidian experiences that can exert lasting physical and psychological harm.
Death “is the very tail end of a whole dysfunctional system that mistreats people in all kinds of ways,” says Cristen Pascucci, the founder of Birth Monopoly, a non-profit that advocates for mothers’ rights to make choices about where and with whom they will give birth, and who has worked to raise awareness about disrespect and abuse against people giving birth.
“The vast majority of those bad outcomes are not going to end in death. They’ll end in PTSD, complications, injuries, people deciding, ‘I’m not going to have any more kids,’ people suffering from preventable complications, sexual assault survivors being completely re-traumatized,” she says. “We’re finally paying attention to the worst of the worst. And that is a very good thing. But poor maternity care also affects people across their entire lifespan in so many ways.”
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IN THE DECADES before the Civil War, a strain of the American scientific and anthropological communities promoted a “polygenetic” theory of racial difference: that God created different races as different species. These same figures sought “evidence” for the theory through fieldwork, analyses of skulls (some taken from Native American burial grounds), and photographs of enslaved people. They drew on phrenology and physiognomy — studies of skull size, shape, and facial features that then held scientific legitimacy — to categorize races as more or less primitive, worthy, intelligent, and moral. Some of the resulting works, including Philadelphia physician Samuel Morton’s 1839 book Crania Americana, would shape American thought about race for decades, Brian Wallis wrote in his article “Black Bodies, White Science.”
At the same time, racial hierarchies shaped federal, state, and local policies regarding Black and Native American women’s reproductive lives. Black and Native American mothers in particular were treated as suspicious, inadequate, and in need of correction. As Dorothy Roberts writes in “Killing the Black Body: Race, Reproduction and the Meaning of Liberty,” Black women were long thought of as inherently lascivious, which is why rape effectively did not exist as a crime that could be perpetuated against an enslaved woman — by either whites or other enslaved people. Importantly, this prevailing myth conflicted with early constructions of the ideal mother, who was characterized as pure, chaste, and white.
Similarly, beginning in the mid-19th century, Native American families were coerced into sending their children to militaristic boarding schools that promoted vocational training in farming and forbade traditional practices, languages, and dress. “Kill the Indian, Save the Man” was the slogan of one of the movement’s leading figures.
Long after the different species theory collapsed, eugenicists in the late 19th and early 20th centuries continued to link racial characteristics to “undesirable” traits. Policymakers and physicians used such “evidence” as rationale to sterilize Black, Puerto Rican, and Native American women without their consent. As recently as the 1970s, Roberts writes, poor black women were “coerced into being sterilized.” And in one of the most shameful chapters of modern gynecology, enslaved black women were operated on without anesthesia, as physician James Marion Sims developed the procedure to treat fistulas.
Yet medical students, Conceição points out, are rarely taught this history. Instead, she says, they’re often inculcated with harmful biases, such as “Black women are stronger; they can take the pain.” Such biases may shape medical care: according to a recent survey that appeared in the Proceedings of the National Academy of Sciences of 222 white medical students and residents, 1 in 2 believed that there are physiological differences between blacks and whites, including that Blacks’ nerve endings are “less sensitive than whites,” and that Blacks have thicker skin and stronger immune systems than whites. In an experiment that followed, researchers found that these biases shaped the pain relief the students would offer patients suffering from an ankle fracture and a kidney stone.
The effects of implicit bias radiate through American society: among many other examples, and all things being equal, research has shown it’s harder to rent on AirBnB or obtain a callback on a job application with a resume that has a “distinctively” African-American-sounding name. Health care providers hold a similar degree of implicit bias as the rest of the population. But the difference between medical and other settings, says Peprah, is that in a hospital, the stakes are life and death.
While interviewing doulas and mothers for this story, stories of mistreatment piled up. There was the young white mother whom a nurse coerced to push, though her physician had told her that her pelvic bones wouldn’t permit a vaginal birth; her son, later born by caesarean section, had a bruise on his head for a month. The Native American woman whose doctor, attempting to deliver her placenta, pulled so hard on her umbilical cord his body began to shake.
Words hurt, too. When Peprah, who is African-American, arrived at the hospital in active labor with her first child, the triage nurse separated her from her husband, and forced her to complete a domestic violence survey. Peprah was a full-time graduate student and, without health insurance, received MediCal, California’s Medicaid program.
“It was so insulting I couldn’t even breathe,” she said. “For one, I’m in labor — I didn’t have the energy to fight that. But I also felt the extreme disrespect. Is it because I’m black, or do you do this to all women?”
Peprah does not know if she was singled out, or if hospital policy was to screen all laboring mothers. But, she points out, either way, it was conducted with a blindness to the assessment’s painful and alienating impact on laboring mothers.
For some Native American people, being coerced into an induction or unnecessary caesarean exerts an additional spiritual blow.
“We have this belief that babies are on a spiritual journey, that they’re picking up teachings from our ancestors,” says Rebekah Dunlap, a doula and Ojibwe member in Fond du Lac, Minn. “I think about that and I think . . . these poor little spirits aren’t getting everything they need.”
“Birth trauma is real,” says Conceição, and can affect breastfeeding and bonding with a baby. It can also contribute to postpartum depression, which is associated with outcomes that hurt families in so many ways, from mothers’ lowered quality of life, to babies’ diminished cognitive and language development.
Longer term, birth trauma and mistreatment can shake a person’s faith in medicine, which might inhibit a person from seeking help when something is wrong, or even obtaining basic preventive care, further harming her health. Once people are angry, Dunlap notes, implicit bias comes in again, in a vicious cycle: “Then they’re the angry Native person, or person of color, or the stoic one that won’t talk to [providers] or won’t listen to their instructions. But they’re hurt, from what happened or what somebody said.”
Mistreatment also hurts doulas, too, who may burn out from what they witness. And it can harm providers, points out Pascucci, who may be expected to dissociate not only from their patients’ emotional needs, but their own. Providers, who suffer from high rates of PTSD, may be ill-equipped to recognize how they contribute to patient trauma when they are being continuously traumatized themselves.
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IN A 2017 statement, the American College of Obstetricians and Gynecologists (ACOG) asserted that “addressing racial bias, both implicit and explicit” is essential to reducing racial disparities in maternal death. To that end, hospitals have begun to adopt anti-racist and implicit bias training of physicians, nurses, midwives, and administrators.
Peprah, who has been doing such trainings with maternity departments since 2016, says that at the start they can be tense. She begins by explaining that we all “have mental structures that put people, things, into compartments — that is how we make sense of the world.” Establishing that common ground helps dismantle some defensiveness. She then asks about people’s “cultural scripts,” and how they shape people’s self-perception and how others see them. After that, she segues into implicit bias, and asks for examples.
The responses are often revelatory for participants.
In addition to addressing providers’ individual biases, systemic shifts that automate interventions are also being implemented. Issued by ACOG and known as AIM (Alliance for Innovation on Maternal Health), these systemic approaches ensure that no matter the patient, the same symptoms will trigger the same “bundle,” or “menu,” of evidence-based interventions, explains Dr. Aviva Lee-Parritz, chief and chair of obstetrics and gynecology at the Boston Medical Center and Boston University School of Medicine, and director of the Boston University Medical Group’s Office of Equity, Vitality and Inclusion.
For instance, healthcare workers have long estimated patients’ blood loss during delivery, rather than measuring it. Requiring nurses to collect, measure, and chart blood loss every time a person delivers — and setting a threshold for the amount of blood loss that automatically triggers interventions — removes the opportunity for individual bias about whether blood loss is excessive. The AIM approach also wraps in group accountability: participating institutions share data and discuss how they’re implementing these care “bundles” so that institutions learn from each other. BMC was one of the firsts hospital in Boston to implement these “bundles” and Dr. Ronald Iverson, vice chair of obstetrics and director of labor and delivery, helped to lead the state to adopt them.
“Health equity rounds” is another innovation. While reviewing complex cases or adverse outcomes is a traditional part of hospital governance, health equity rounds are an opportunity for medical personnel to look at how the patient’s race, social determinants of health, and socioeconomic status potentially influenced decision-making around the patient’s care. Lee-Parritz notes that these review are an important way to raise awareness among physicians, midwives, and nurses when they see a similar case and provide a “great opportunity to teach better habits to the next generation.”
Then there is the importance of framing mistreatment as a significant outcome unto itself. The long-term effects of disrespect, discrimination, and violating patient autonomy, says Vedam, “are health outcomes too.”
Because the type of provider a woman sees influences whether she will be mistreated, another solution is increasing the number of midwives, says Vedam. In the United States, as The Lancet asserted in a series of articles in 2016, maternity care is often overly medicalized, which is evident from the country’s caesarean section rate of nearly 32 percent — even higher, in some states, and especially for Black women, which in some states is as high as 42 percent. (Although there is no firm consensus, some research has put a caesarean section rate of 20 percent of births at “optimal;” the WHO recommends 10-15 percent.)
“Maternity care that is too much, too soon” — including unnecessary caesarean sections, induced labor, and routine episiotomies — “may cause harm, raise health costs, and contribute to a culture of disrespect and abuse,” the journal declared. Midwifery practices can help to cut down on some of these unnecessary interventions, and also improve mothers’ and babies’ outcomes. Yet many women, and in particular women of color, lack access to midwives.
Recently, Representatives Jaime Herrera Beutler, Republican of Washington, and Lucille Roybal-Allard, Democrat of California, introduced the “Midwives for MOMS Act,” which would fund programs to train midwives from racially and ethnically diverse backgrounds, from disadvantaged communities, and those who want to practice in regions where there is a dearth of provider options.
Two years after her traumatizing birth, Keyser had another child. She delivered vaginally, at home, with a midwife. The gap between her two experiences highlights how effective, or dangerous, different modes of care can be.
“I had really wonderful care from a midwife who came to my house, talked to me, gave me real informed consent,” Keyser says. “I never felt like a number or a problem or anything with her. She thought to find out how things were going, rather than just looking at the chart, and looking at me, as I felt my previous care providers did: they looked at a chart, looked at me, and made up their minds.”
Rachel Somerstein is a writer in New York.