Addressing Today's Racial Health Inequities Requires Understanding Their Roots

Tara Haelle

May 19, 2021

The health disparities seen in today's high rates of Black infant and maternal morbidity and mortality are rooted in health inequities and generational stress dating back centuries in the United States, but today's obstetricians can make changes in their own practices to address this inequity, according to Haywood L. Brown, MD, professor of ob.gyn. and associate dean of diversity at the Morsani College of Medicine and vice president of institutional equity at the University of South Florida, Tampa.

Brown delivered his remarks during the Benson and Pamela Harer Seminar on History at the annual meeting of the American College of Obstetricians and Gynecologists on May 2. His talk focused on the origins of perinatal and maternal health inequities and how those original factors play out today in increased maternal and neonatal morbidity and mortality among Black women and their babies.

"Racial and ethnic disparities and inequity in maternal and child health are prevalent and persistent. We have to move beyond the documentation," Brown told attendees. "We have to adopt uniform care standards, recognizing our own biases and understanding that the contribution of social determinants of health are important in the care and outcome of women. And we have to work on decreasing the stress of women who give birth."

Evelyn Nicole Mitchell, MD, faculty chair of the ob.gyn. diversity and inclusion committee at the University of Southern California, found Brown's talk compelling and hopes it opens the eyes of others who attended.

"You really have to understand the why behind the problems we have, and it really goes back to slavery and this historical distrust that's been here from the beginning," Mitchell said in an interview. "I hope this allows people to open their eyes and think about this situation from their patients' shoes, to really put their guard down and explore, 'how can I contribute to fixing this system that has been here from the beginning?' I think a lot of people get defensive and think: 'Oh, I'm not a racist. I just don't want to talk about this,' but it's about a system being racist." The question then, Mitchell said, is: "So how do I contribute to that system?"

Brown frequently returned to the theme of high stress levels in Black mothers contributing to poorer outcomes, such as preterm birth. That stress arises originally from the generational stress brought on by racism and oppression over the centuries but has been compounded by poverty, racial injustice, lack of access to adequate nutrition, lower education levels, environmental factors, and other determinants of health.

"The bottom line, as Brown said, is that we need to decrease the stress level of Black mothers giving birth," Mitchell said. "How can I, as a provider, decrease the stress level of my patients? Well, No. 1, I can identify and eliminate implicit bias that I may harbor."

Slavery Husbandry Laid the Groundwork for Today

The most surprising aspect of Brown's lecture for Mitchell was the fact that enslaved women received a measure of protection that other enslaved people did not to "ensure that they were healthy and that they were able to reproduce in the future," Mitchell said. "It was for the wrong reasons – to keep slavery going – but in a sense they were prioritizing Black women to take advantage of their reproductive capacity, compared to nowadays where Black women are facing severe disparities."

To safeguard enslaved women's fecundity, plantation owners attempted to reduce stressors in the women's lives, such as allowing them to cohabitate with a husband and nuclear family, though sexual assault and abuse still occurred. The owners also tracked the enslaved girls' menstrual cycles after menarche to maximize their "breeding" potential, especially between the ages of 15 and 24. Slave owners delegated older enslaved women as maternity caregivers and midwives, leading to the passing down of midwifery skills through generations of Black American women.

"Pregnant women received the best medical care on the plantation because of the premium placed on reproduction," Brown said. Wealthier planters called in doctors for complicated deliveries, which provided J. Marian Sims the ability conduct surgical experiments on Betsey, Lucy, and Anarcha to treat vesicovaginal fistula since fistula "limited her ability to do the maximum work she could in the house or on the plantation," Brown said.

After slavery ended, health care access did not improve for Black people. In 1920, there was approximately 1 Black physician for every 3,000 Black people, compared with 1 in 500 for the White population, and grannie midwives continued to be the primary birthing attendants for Black women. Over the next several decades, however, both maternal and infant mortality across all races began steeply dropping. Reasons for the drop included the incorporation of the American Board of Obstetrics and Gynecology in 1930, a shift from home births to hospital births, and the legalization of abortion, which led to an 89% decline in deaths from septic illegal abortions from 1950 to 1973.

Still, Black maternal and infant mortality remained higher than White, and the poverty gap further exacerbated outcomes.

"Substandard maternity care really is the origin of many of the Black maternal and infant morbidity and mortality" complications, such as low birth weight, small for gestational age, growth restriction, and intrauterine starvation, "which we now believe are the origin of things like hypertension, diabetes, and obesity," Brown said.

Today, inequities persist because of the systemic racism throughout this history.

"As we talk about health disparities, prematurity, growth restriction, and maternal morbidity, the fetal origins for adult disease in diabetes and hypertension and obesity have generational implications over the last 400 years," Brown said. "Generational stress and stresses in lack women from slavery to present times are some of the origins of the things that we see today, including segregation, economic inequities, eugenic sterilizations, the quality of education, and of course, systemic racism on health care access and quality."

It is this long arc of history that Mitchell hopes attendees will begin to grasp.

"If you don't understand all that and have that depth, there's no way for you to truly understand the problems that are going on and how to solve them," Mitchell said. She hopes that especially those who have been more "resistant to accepting these truths" can start to see the big picture. "Hopefully, they can look at it as a systemic problem and then focus on how they can change the system."

Brown is a contributor to UpToDate and the Merck Manual and serves on the advisory boards of Merck for Mothers Global Women's Health and BabyScripts. Mitchell has no disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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