Why do black women have a higher risk of death during pregnancy?
Then in 2019, it was almost a reality for her.
When she started experiencing severe abdominal pain, her first pregnancy transformed from a cause for celebration into a living nightmare.
Despite her numerous requests for assistance, she was discharged from the hospital, she claimed. She claimed that even as her belly discomfort grew and she began to vomit bile, doctors and nurses assured her that she was experiencing normal contractions. Angelica claimed no one took her seriously until she experienced excruciating agony and her baby’s heart rate dropped dramatically.
She had to have a cesarean surgery months before her due date because an untreated case of sepsis nearly killed her.
Worse yet, Angelica was employed by the University of Alabama at Birmingham, which was connected to the hospital where she received care.
Her ordeal is emblematic of the discrimination, bigotry, and lack of attention Black Americans receive from the medical community. According to the CDC, the maternal death rate for black women in the United States is 69.9 per 100,000 live births in 2021, over three times the rate for white women.
Black infant mortality is higher, and preterm birth is far more common, both of which put the child at risk for future health problems.
According to Angelica, “race plays a huge part, especially in the South, in terms of how you’re treated,” with disastrous results. Somebody said, “People are dying.”
Asthma, diabetes, high blood pressure, Alzheimer’s disease, and the newly discovered COVID-19 are just some of the chronic illnesses that disproportionately affect Black people in the United States. Black Americans have lower access to quality healthcare, resulting in a shorter life expectancy.
From birth to death, regardless of economic or social status, people have a much higher risk of contracting and dying from everyday illnesses.
A variety of variables associated to racism, such as restrictions on where individuals might reside and a historical lack of access to care, play key roles in Black Americans’ health difficulties, but these have often been attributed to genetics or behavior.
Negative outcomes have been linked to discrimination and bias in healthcare settings.
Tragically, the gaps in health care in the United States have led to 1.6 million more deaths among black Americans than among white Americans during the past two decades. More than 80 million years of life were lost as a result of the increased mortality rate, along with countless billions of dollars in wasted healthcare and missed opportunities.
A yearlong investigation by the Associated Press discovered that many of the health problems experienced by Black Americans began even before birth.
In dozens of interviews, doctors, medical experts, campaigners, historians, and scholars explained how racism’s roots in the early days of the United States’ establishment contributed to the current state of inequality.
In the first trimester of her pregnancy, Angelica Lyons experienced terrible nausea and acid reflux. She was given medication to assist relieve her symptoms, but unfortunately, it made her extremely constipated.
While administering a test to her class in the latter week of October 2019, she experienced severe stomach pain.
Angelica recalled, “You don’t look good, Ms. Lyons,” comments made by some of her kids.
Angelica called the University of Alabama at Birmingham Hospital’s labor and delivery unit to report that she was experiencing difficulty urinating and abdominal pain due to her pregnancy. The woman who answered the phone reassured Angelica that these symptoms were usual and that she shouldn’t worry.
As Angelica explained, “she made me feel like my concern wasn’t important,” and since this was her first pregnancy, she was unsure and worried that she was overreacting.
She eventually went to the hospital because of the ongoing agony and was admitted a few days later.
Angelica had a technique called an enema, in which fluids are used to cleanse or encourage the emptying of the bowels, but she still insisted that she was in agony.
She explained that the doctors told her to “just ignore it because it’s the Braxton Hicks contractions.” “They totally disregarded me.”
She was discharged, but the pain in her stomach persisted, so she returned to the clinic the next day. Even MRIs and other diagnostic procedures failed to pinpoint the problem’s origin.
Angelica was transferred to the maternity ward so doctors could keep an eye on her son’s heart rate, which had slowed down slightly. Another enema was administered at the clinic, and this time it relieved the agony. She was also told she had preeclampsia, a condition that can lead to death or very serious complications during pregnancy.
Then she started throwing up what looked like bile.
“The pain just kept getting worse and I kept telling them, ‘Hey, I’m in pain,'” Angelica explained. When I complained, they’d offer me Tylenol.But it wasn’t doing any good.
Dinner that night was very difficult for her. Pain shot through her entire body the moment she got out of bed to use the restroom.
She explained that she “started hollering because I had no idea what was going on,” adding, “I told my sister I was in so much pain and to please call the nurse.”
What transpired after it is a mystery. While Angelica’s family and ex-husband tried to make sense of the commotion surrounding Angelica’s emergency C-section, she vividly recalled the hospital staff hurrying her to labor and delivery and draping a blue sheet over her to prepare for the procedure.
She found out after the fact that she was really close to passing out.
“I was on life support,” Angelica, now 34, recalled. What I did was “I coded.”
After three days in a coma, she awoke with a ventilator in her mouth and no ability to communicate. She angrily waved her arms at her mother and demanded to know where Malik was.
It turned out he was fine. However, Angelica felt that a lot had been taken away from her. She was deprived of the thrill of holding her newborn child for the first time. She had no idea of her son’s appearance.
In the United States, sepsis in pregnant women is a major contributor to maternal mortality. When compared to white women, black women are at twice the risk of developing severe maternal sepsis. Fever and localized pain may also be present as common symptoms. Because of how rapidly sepsis can progress, prompt treatment is essential.
Symptoms of early-stage sepsis can be similar to those of pregnancy, making a diagnosis challenging. Some medical professionals miss vital signs because they were never taught to do so. However, patients, especially Black women, are often not heard, which can lead to a delay in diagnosis or an incorrect diagnosis altogether.
Dr. Laura Riley, chief of obstetrics and gynecology at Weill Cornell Medicine and New York-Presbyterian Hospital, has observed, “The way structural racism can play out in this particular disease is not being taken seriously.” To paraphrase, “We know that delay in diagnosis is what leads to these really bad outcomes.”
Angelica pressed the medical team for answers in the days and weeks that followed the incident. The explanations she was given, however, were vague and contradictory to her.
In a statement to The Associated Press, a University of Alabama at Birmingham spokesman claimed that the institution was prohibited from discussing Angelica’s situation due to confidentiality regulations. They noted a recent survey conducted within the department of Obstetrics and Gynecology that indicated the vast majority of patients were pleased with their care and “are largely feeling respected,” and they added that the university and hospital “maintain intentional, proactive efforts in addressing health disparities and maternal mortality.”
Eight weeks premature, Angelica gave birth to a baby boy named Malik who weighed less than 5 pounds. A full month was devoted to his treatment in the ICU. His development was tracked through home visits throughout his first year of life.
Although he is now a healthy 3-year-old who is eager to learn about the world, Angelica still feels bad about the time she spent away from her son in the intensive care unit.
“It’s scary to know I could have died, that we could have died,” Lyons remarked through snotted cheeks.
Birth advocates and medical professionals have been sounding the alarm about the medical system’s failures to meet the needs of Black mothers for decades. Racist medical practices that Black people faced during and after slavery have been linked to this mistreatment, according to historians.
Deirdre Cooper Owens, a historian and author, has argued that the United States cannot begin to understand the maternal mortality and infant mortality crises facing Black women and newborns unless it confronts the shady origins of gynecology.
Owens explained that the origins of this medical specialty can be traced back to a slave farm in Alabama. The development of obstetrics and gynecology “was literally built on the wounds of Black women,” as one historian puts it.
Slave Black women were routinely subjected to reproductive procedures, including the then-novel cesarean delivery.
Formerly renowned doctors like J. Alabama physician Marion Sims, sometimes called the “father of gynecology,” subjected enslaved Black women to painful surgical procedures without anaesthetic in the 1840s.
Even after slavery was abolished, hospitals continued to sterilize Black women through needless hysterectomies as part of eugenics projects.
There is still a significant racial health gap, and health care segregation is a major contributing factor.
Before the Civil Rights Act of 1964, African-American families faced discrimination and exclusion from well-resourced white institutions, where they often got inadequate, substandard, or inhumane care. Even after the new safeguards were put in place, the hospitals that were originally reserved for Black families remained under-resourced, and Black women still didn’t get the same support that white women often had. This was despite the best efforts of Black-led clinics and doctors, who worked hard to fill in the gaps.
Because of this long history of mistreatment, many people in minority groups have come to distrust the medical establishment as a whole.
Associate professor of History at the University of Illinois, Urbana-Champaign, Rana A. Hogarth, said, “We have to recognize that it’s not just some racist people or a few bad actors.” “People need to stop thinking about things like slavery and racism as just these features that happened that are part of the contours of history,” the author writes. “Maybe think of them more as foundational and institutions that have been with us every step of the way.”
Today’s medical professionals still incorrectly believe that Black people have biological differences from White people, such as “less sensitive nerve endings, thicker skin, and stronger bones,” which leads them to rate Black patients’ pain lower and recommend less relief.
The gaps occur independent of one’s level of education or financial stability. Pregnancy-related mortality among black women with a college degree or higher is more than five times greater than among white women. Black women with advanced degrees had a significantly lower risk of death during pregnancy than other women. higher than that of white women without a high school diploma by a factor of 3.5.
About 40 moms in Angelica Lyons’ home state of Alabama die within the first year after giving birth. Black moms bear a disproportionate share of the burden.
In 2021, there were 7.6 baby deaths for every 1,000 births in the state. The infant mortality rate for white mothers in 2021 was 5.8, while the rate for Black mothers was 12.1, a rise from the 10.9 recorded the previous year.
In Alabama, black infant mortality is approximately 47 percent despite making up only 29 percent of births.
More than 55 percent of the 80 pregnancy-related deaths assessed by the Alabama Maternal Mortality Review Committee in 2016 and 2017 may have been avoided, according to a report published in 2020.
In 2018, Alabama established the Maternal Mortality Review Committee to inquire into such deaths. However, Dr. Scott Harris, the State Health Officer for the Alabama Department of Public Health, noted that more research is needed to fully understand the root causes of the discrepancies.
Dr. Harris noted, “We certainly know that from national numbers as well, and it is pretty startling that Black women have worse maternal outcomes at every income level.” Both age and general ZIP code matter. Sadly, the location of where these babies are born has a significant impact on their chances of dying as infants. I predict a similar pattern with regards to maternal outcomes.
And there are still worries about access and hurdles to care.
More than 240,000 women call counties without any maternity care in Alabama home. This amounts to 37% of the state’s counties. One study found that 39% of counties had no obstetricians at all.
This is a problem not exclusive to Alabama. More than 2.2 million women of childbearing age in the United States reside in areas without adequate access to maternity care, while another 4.8 million women of childbearing age live in counties with inadequate access to maternity care.
Angelica Lyons said the University of Alabama was the only hospital near her home that could treat her high-risk pregnancy, which included high blood pressure early on.
Dr. Harris admitted that Black women in remote areas of the state face difficulties getting medical attention. The rural Black Belt of the state is where much of the state’s public health initiatives are focused. This area got its name because of the black, fertile soil found there, but it was also home to many plantations.
The Black Belt has been a low-income, predominantly Black area for centuries. The South is home to significantly more than half of the United States’ Black population.
The impact of institutional racism on African American women has been discussed at length, as has Harris’s belief that such racism has no place in modern society. To quote a friend: “I think we have to publicly call it what it is.”
There was more than one member of Angelica Lyons’ family that had a difficult delivery.
Her younger sister Ansonia had a tough pregnancy in 2020 after experiencing two miscarriages.
The Lyons sisters, Angelica and Ansonia.
Even though she was vomiting blood, the doctors said she just had ordinary morning sickness.
She was diagnosed with hyperemesis gravidarum, a condition characterized by severe vomiting during pregnancy, and was found to be very dehydrated. Ansonia was a frequent visitor at the same hospital where her sister had been hospitalized for a considerable amount of time.
“Welcome to the pregnancy, dear,’ they greeted me. That’s pregnancy,'” Ansonia, now 30, remembered thinking. To paraphrase, “I told her, ‘No, this is not normal for me to be throwing up 10 to 20 times a day.’ My own primary care wasn’t listening to me.”
As Ansonia recounts, she was subjected to racist comments from medical staff throughout her pregnancy. They referred to the father of her child as “baby daddy,” a common slur directed at Black parents.
What does your baby’s father do for a living?””, Ansonia reflected. She seemed shocked when I told her that the father of my child worked two jobs, so I added, “I don’t know what a baby daddy is, but the father of my child is at work.”
Ansonia said that her coworkers assumed she lacked health coverage despite the fact that she was covered by her company.
Ansonia’s gestation was complicated by her Type 2 diabetes, high blood pressure, and cardiac problems. By the time she was 21 weeks along in her pregnancy, she had been seeing a cardiologist and had been diagnosed with congestive heart failure. Her physicians opted to induce labor early and perform a C-section, and they treated her with a cocktail of drugs.
After seeing what her sister went through nearly two years previous, Ansonia was understandably terrified.
“I told my boyfriend I was dying a few times,” she confessed.
The C-section was successful. Adrien, Ansonia’s first child, was born toward the end of May 2021, even though he was expected in July.
After initially having some respiratory issues, he was admitted to the hospital and spent the first five days in the intensive care unit.
Mother and son Ansonia and Adrien Lyons enjoy some quality time together.
In 2021, the rate of cesarean section for black women is 36.8%, whereas the rate for white women is 31%.
Ansonia’s difficulties did not end with the birth. She had to have a transfusion, so she missed out on seeing her newborn boy for the first few days of his existence.
She was admitted to the hospital multiple times even after a few months had passed since she gave birth because she continued to have nausea, vomiting, and dizziness. Needles used to treat her during her pregnancy left permanent bruises on her arms. As is normal with diabetics, she took an unusually long time to recover from any kind of bruise.
A doctor who had been treating her for the duration of her pregnancy suddenly became suspicious of the woman’s bruised arms and asked if she “smoked weed” or used any other recreational drugs. Patient confidentiality rules led to the hospital’s silence.
She explained that she didn’t take medicines by telling the doctor that she was sick due to her frequent hospitalizations.
He still had blood samples taken from her checked out. All of the tests were negative.
The incident “just made me not trust them, made me not want to go back,” she explained.
There are signs that finally, albeit belatedly, the plight of Black mothers and their infants is being acknowledged.
In 2019, U.S. The Black Maternal Health Caucus was founded by two Democratic congresswomen: Illinois’s Lauren Underwood and North Carolina’s Alma Adams. It has grown to become one of the most influential cross-party groups in Congress. The Black Maternal Health Momnibus Act was submitted by the caucus in 2019 and again in 2021, proposing extensive reforms to boost spending and tighten monitoring. Despite significant progress being made, the full law has not yet been passed.
Biden has allocated $471 million in the fiscal year 2024 budget to enhance maternal health efforts in rural communities, reduce maternal mortality and morbidity, and provide implicit bias training, among other things. It also mandates that states give Medicaid coverage uninterrupted for 12 months after giving birth. Women’s and children’s health programs will receive $1.9 billion.
U.S. Xavier Becerra, the Secretary of Health and Human Services, recently told The Associated Press that more has to be done by governments at all levels to eliminate prejudice and bias from the health care system.
He affirmed that providing care to mothers and infants for a full year increases the likelihood of positive health outcomes and a bright future for both.
Shelonda Lyons made sure her two girls saw the harsh reality of racism growing up in Birmingham, a city in the Deep South that played a pivotal role in the civil rights movement.
“When we were young, she was showing us those images of all the Black people being hung, being burned on the trees,” Angelica recalled, referencing a book that still sits on the family coffee table. “She hoped that if we knew where we were and that racism was a possibility, we would be better prepared to deal with it.”
But Shelonda was unprepared for the way her girls were treated when pregnant. She recalled being frustrated and angry by her situation.
What I mean is, at what point do you recognize that you’re dealing with human beings, and it’s a slap in the face. That it makes no difference what hue they are,” she added, adding that she now frets whenever her children or grandchildren require medical attention because of this. As they say, “I don’t have a lot of trust.”
In the weeks after her C-section, Angelica had two operations to fix the damage and treat the infection. For months, she had to carry about a colostomy bag as she recovered.
Her stomach is still deformed more than three years later.
“I love my child, I love him all the same, but this isn’t the body I was born with,” she added. “This is the body that they caused from them not paying attention to me, not listening to me.”
After a brunch outing to celebrate their dad’s birthday, Angelica and Ansonia Lyons buckle their son Malik Lyons-Law into the car seat while their dad, James Lyons, kisses his grandson, Adrien Lyons, in the kitchen.
Samantha Shotzbarger, Josh Housing, and Wong Maye-E are the producers.
Angeliki Kastanis, Data Analyst
Investigations by Rhonda Shafner
Anna Jo Bratton & Andale Gross, Editors
Kevin S. Vineys & Angeliki Kastanis drew the pictures.
Kati Perry, Eunice Esomonu, and Linda Gorman did the designing and coding for this.
Edward Medeles, Elise Ryan, Almaz Abedje, and Sophia Rosenbaum did an amazing job coordinating the audience and producing the show.
Raghuram Vadarevu, Director of Creative Development
Andale Gross, Project Manager
Stafford, Kat, Project Conceptualization and Development
Based in Detroit, Stafford is an AP national investigative race reporter who attended the University of Michigan as a Knight-Wallace Reporting Fellow in 2022.
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The AP has gathered a small sampling of the history of medical racism that has led to the health inequities detailed in this study, and it spans every aspect of human existence.