This is part one of a three part series and excerpt from the new book, Battling Over Birth: Black Women and the Maternal Health Care Crisis.

Battling Over Birth: Black Women And The Maternal Health Care Crisis – Part Two

This is part two of a three part series and excerpt from the new book, Battling Over Birth: Black Women and the Maternal Health Care Crisis.

Please support our 20 year old, award-winning, nonprofit work to “Share the New Story of Childhood, Parenthood and the Human Family”

Part One: Prenatal Care Barriers

Part Two: Stress, Pregnancy and the “Strong Black Woman” Syndrome

Part Three: Midwifery Model of Care

Battling over Birth is a critical and timely resource for understanding black women’s birthing experiences in the United States, a country where black women’s lives—and the lives they create—are at much greater risk of death and injury than those of non-black women … By distilling the common and diverse threads from over 100 black women, the BWBJ researchers have woven a multi-faceted tapestry that reflects what black women view as important and central to optimal birth experiences. Their recommendations for improving care and outcomes are grounded in black women’s authoritative knowledge. … This wonderful, important, necessary research by and for black women points in the direction that black women think we should go to ensure they have safe, healthy, and satisfying birth experiences and outcomes. We need to listen and act.”

—Christine Morton, PhD, author, Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America


Battling Over Birth: Black Women and the Maternal Health Care Crisis

Part Two

Stress, Pregnancy and the “Strong Black Woman” Syndrome

Chronic stress and psychological distress have numerous impacts on women’s health, including negatively affecting reproductive health. Researchers have found that stress and traumatic life events during pregnancy contribute to preterm birth (less than 37 weeks), and low birthweight. 14 Researchers have also investigated the impact of racism, including lifelong experiences of racism, chronic stress and posttraumatic stress disorder. Several studies suggest a complex relationship between lifetime exposure to racism, stress, trauma and prenatal depression that may trigger pregnancy complications.15

The participants in our study were very aware of the impact of stress on their wellbeing in general and on their pregnancies in specific. Participants identified four sources of significant stress in their lives: racism and environmental stress, economic and job related stress, parenting stress, relationship and intimate violence-related stress. For the women in our study, stress is not related to one stressful incident, such as the loss of a job or death in the family. Instead, their lives are marked by interlocking stress factors related to their multiple roles as workers, providers, homemakers, parents and elder caregivers. Malika articulates how navigating these multiple responsibilities in the context of a society structured by racism/sexism can lead to feelings of overwhelm and depression:

My husband didn’t have a job, I was working for this terrible, racist school, I was pregnant and not feeling well because I was so tired and I was working two jobs… I would fall asleep while driving. I would come home from work and fall asleep at 4 and not wake up ‘til the next day at 6 am… It was a very stressful pregnancy because not that long after my husband lost his job, he got a new job thankfully out here. He left and it was me and my older son, and my mom was sick. I was driving back and forth between Atlanta and Savannah, which is about 4 hours, to help her. She was going through chemo. It was just, like, my world was ending. It felt like my world was ending while I was pregnant. I cried a lot. I mean, I would just come home from work and get into bed and cry because my mother was dying and I was alone and we were going to lose our house and who cares about a house, but at that point it felt like we were—none of us comes from a lot so we felt like we were, I guess, upwardly mobile—we were going to have things for our kids that we never had. So, it just felt like our whole world, you know like I was losing my whole world. So I couldn’t even focus on my pregnancy. It was just a kind of another thing on the list of things that were stressful. — Malika, 33, hospital birth

Despite an end to formal residential segregation, continuing race and class barriers mean that black women are more likely to live in neighborhoods impacted by poverty, substandard housing and violence. This can lead to stressors related to the environment in which a pregnant individual lives:

It was such a hard year. My husband and I moved out of our home in Oakland that year. Because we had a stray bullet hit the house. It went through four walls and landed on our piano. And we come home looking at this bullet on the piano, thinking, we got children in this house. This is supposed to be our safe space, our home. We’d been burglarized two times so we moved from this big house to 800 square feet student housing. Four of us already and we wanted to add a fifth one. — Dalia, 40, home birth, vaginal birth

Birthing While Black: An Interview With Midwife Jennie Joseph

Since the 1980s, our welfare net for vulnerable women, families and communities has been eroded, while massive government funding has gone into a war on drugs that has pursued punishment rather than treatment as a strategy for addressing substance abuse, and the construction of a multi-billion dollar prison-industrial complex. Low-income black women are impacted by this shift in public spending in a number of ways: we pick up the caring labor for family members that the state no longer provides, we do healing work in families and communities shattered by drug use and gun violence, and we are disproportionately incarcerated for “survival crimes” such as welfare fraud, sex work and low-level drug sales. Dana’s tragic story speaks to the stress that this hostile environment can create for pregnant individuals:

I lost the baby. At two months. I went to the bathroom and went to pee and some chunks came out.  And when I’m walking some more comes out in my panties. I just lost my father last year four days after my birthday… My brother was murdered in March. Shot 34 times so its like ALL of this. My sister just recently got out the hospital. She got a spinal infection that was going to her brain. The whole time she is going back and forth to work and the hospital thinking she’s having headaches and they just sending her back home. Next thing she knows she can’t get up and walk!…  So ALL of this is last year… I went to jail over and over again last year.  I just finished fighting my case the day before my birthday. — Dana

As workers and providers, black women have to navigate the work world during their pregnancies. Several of our participants described work as a site of considerable stress, in particular where they experienced racism and pregnancy-related discrimination. One participant shared a saga of job discrimination that started when she told her employer that her “high risk” pregnancy could require additional time off work:

Over 40 and the third pregnancy in a year, my doctor was watching me very closely. So I told my manager because I had to go to more appointments and a week after I told him I was pregnant, he demoted me. So he demoted me, I’m going to say three levels. I’m a project manager and he basically made me an admin assistant for my group. — Maha,40+, hospital, vaginal birth.

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Maha subsequently went on disability leave when she was two-and-a-half months pregnant, she returned to a hostile workplace where she was targeted with close monitoring and ultimately accepted a severance package to avoid further stress:

This is how it is. I’m a woman of color and this is just how it is and I’m just dealing with it. And I never really cried or got upset because I didn’t want to impact my baby. [baby gurgling][Sniffs] Sorry. But if I think about it now, and its been six weeks now. I think its now that I can actually have these emotions because I was just like, the whole time, I’m not going to let this bother me. I’m going to have my baby. So I was discriminated against quite a bit during my pregnancy. — Maha, 40+, hospital, vaginal birth.

Relationships with partners and parents were also sources of significant stress in the lives of some of our participants. Several women reported experiencing intimate partner violence and sexual abuse during their pregnancies. For one participant, the domestic violence she was living in was a factor in choosing to terminate a pregnancy, however after inadvertently getting pregnant again, she felt unable to leave her abusive husband:

I had an abortion.  My ex-husband was really— As soon as we got married his temper just increased.  And the idea- I just kept picturing being pregnant and being thrown down the stairs or being slapped or just I couldn’t imagine being pregnant and bringing another child in and so I got an abortion.  And right when I was getting a divorce, well we were talking about getting a divorce, I found out I was pregnant, so we stayed…  — Kaela, 31, hospital, vaginal birth

Our sexual intimacy was very violent and he would like hold pillows over [my face] and it was just like really, really messed up.  And so that was like a very depressing–I just kind of like went into another place, just tell myself just to survive because I didn’t have anywhere else to go because, you know, I had already broken my family’s heart because you know, I changed everything, you know. Just a little bit of background of how I was raised in the church, I just didn’t know how to survive in the world, and so even when I got pregnant with her, I just left my job.  I didn’t know anything about leave of absence. I didn’t know anything about pregnancy leave. I just left. I was just like “Oh well I done did it. I done messed it all up.’’ And I just went into this other place just to survive and so he was the only person that I could depend on, so I just had to deal with it, you know? — Sage, 36, hospital, vaginal birth

Birth In America For Black Mothers – A Documentary “the AMERICAN dream”

The women in our study who experienced violence from an intimate partner had very few choices in dealing with the violence in their lives. None of the women reported knowing about support services or resources for black women living with intimate violence, and reporting the violence to the authorities (police or medical professionals) was not considered a safe option.16 As Dana shares:

I’m like, “What you trying to say? That this ain’t your baby? Cause you’re the only I’ve slept with you know and all this.” Next thing you know and I’m you know just do whatever you gotta do. He watching me. Do whatever you gotta do. Bop. [Punches her fist] Knocks me. [All gasp].  He knocks me to the ground. So I just–I tumble. I didn’t know what I looked like. I get up. I check to make sure all my teeth was there. I wasn’t going to look up without no teeth so I’m like all right.  I don’t realize this was all swollen [gesturing to face].  It was close to my nose, which affected all of this.  So all of this was all like two black eyes, bruises all over my cheeks.  But I don’t know this though… So I am going from my mom’s house to my adoptive parents’… I got there and realized–Yeah. They’re like, “You gotta check the baby and make sure the baby is okay. You fell pretty hard and stuff like that.” And I’m just like, “No.” Cause I didn’t even want to face the fact if something is wrong.  So I didn’t go to the doctor. — Dana

An important mitigating factor in assessing the impact of stress is the amount of support that a pregnant person receives in her social environment. Many of our participants reported that they found it difficult to ask for help, and believed that they should be able to handle things on their own. This belief can be traced to the “Black Superwoman” or “Strong Black Woman” syndrome.17 Abrams et al define the “Strong Black Woman” as a socialized and internalized cultural gender schema with the following characteristics: “a provider and caretaker who is resistant to vulnerability or dependency, displays strength, suppresses emotions, succeeds despite inadequate resources, and assumes responsibility as a community agent.”18 Rosario clearly articulated her adherence to the SBW schema:

Other races be killing themselves over stuff. We’re strong people, we’re not gonna kill ourselves cause a man wants to leave us. And we have to raise our kid on our own. We just really strong. And we get it done. — Rosario, 20, hospital, vaginal birth

While strength is an important attribute in navigating racism/sexism and economic injustice, and at the time supporting family members and maintaining community responsibilities, the need to be strong at all times can also lead to depression, isolation and self-judgment, as well as unhealthy coping/stuffing strategies. The Sharing Circles that we conducted for this research were a space in which women often felt their feelings about difficult or traumatic experiences for the first time, and found a supportive space where their pain could be held and honored:

Three weeks prior to my birth, I had buried my mother. [Tearfully] I wasn’t supposed to cry… I was working fulltime. And I was looking for a house and I was painting my bathroom, and I was trying to be superwoman. Everything I taught my clients not to be. And I have sisters and I have support and I still have not learned to ask for help. I was trying to be strong for my dad, because this was his life partner of almost 50 years. And although I was the youngest, I’m the one that took care of my mom and I didn’t want my dad to join her, so I didn’t cry when we buried my mom. I delivered the obituary. I didn’t cry because I didn’t want my father to fall apart. And I didn’t realize I was grieving during my labor. — Amina, 42, hospital, unplanned cesarean

Given the significant stressors and lack of support in their lives, some of our participants terminated or considered terminating an unplanned pregnancy. Other women looked for ways to bring as much self-care and calm into their lives as possible. For many of our participants, their spiritual practice or belief in a Higher Power and/or ancestors provided them with a source of strength, peace and guidance.

There was so much anxiety throughout the pregnancy, so much stress, and I think the birthing process also reflected that stress. But there was a lot of luck, or divination. The Creator looking out, ancestors looking out for us in the process too. — Dalia, 40, home birth, vaginal birth

I did the Hypnobabies program. I don’t know if anybody’s heard of it. It’s really just like self-guided meditation. They say it’s hypnosis, but if you are familiar with meditating, it’s like a woman guiding you through a deep meditation and giving you positive affirmations the entire time. You kind of get the idea… You just put yourself in a deep relaxation.  And I think that is also–It’s when I started doing that that I kind of like let go.  Like all of those anxieties about being pregnant, having a baby, and it not being the right time and all of that just kind of dissipated because I was able to ground myself. — Tyra, 26, hospital, vaginal birth

For other women, the knowledge that they could create a safe space for their child’s birth and first year was a source of inspiration:

I wanted a birth that was quiet, because everything was so chaotic outside of—inside my body I felt very calm, but outside my body it was very chaotic. So because I felt like God had given me this gift, that he was… not going to make it more difficult than I could handle. I wanted it, I wanted my son to be born into peace. — Joanna, 32, birth center, vaginal birth

Black women experience multiple stressors during pregnancy, including adverse life events that are caused or exacerbated by structural and interpersonal racial/sexual discrimination and violence. Black women’s strength and ability to survive and navigate these stressors is a considerable asset. However, the “Strong Black Woman” syndrome can also be detrimental, where it prevents us from honoring our feelings or seeking or accepting help. Accessible, culturally-humble prenatal services for pregnant black women should address women’s barriers to seeking help. They should also include referrals for counseling and practical assistance for dealing with intimate partner violence, parenting challenges, racial/sexual discrimination in the workplace, finding adequate housing, and dealing with trauma and loss.

Miscarriage, Stillbirth and Resiliency

The U.S. has been described as a “death-phobic society”, in which deep, meaningful engagement with the dying, grief and loss is replaced by the voyeuristic consumption of graphic violence and mass death in TV and movies.19 As a result, the fact that every pregnancy does not end with a healthy baby is a reality that is rarely spoken about. The U.S. National Center for Health Statistics defines fetal death, or miscarriage, as the spontaneous death of a fetus any time during pregnancy. A stillbirth is defined as a fetal death later in pregnancy, after at least 20 weeks of gestation. In the U.S., black women are twice as likely as white women to experience a stillbirth. Even where black women receive similar prenatal care, we experience higher rates of stillbirth, especially preterm stillbirth.20

Several of the participants in our study reported having experienced unwanted/“spontaneous” pregnancy loss. Pregnancy loss carried a wide range of meanings for our participants. For Shelly, a miscarriage in her 13th week was the welcomed and accepted conclusion of a clearly unhealthy pregnancy:

You know there’s like twenty different kinds of miscarriages? My first one was a missed miscarriage. So the fetus passed at eight weeks, but my body did not let me know ‘til 12/13 weeks. So for a whole month, I am carrying around something that is not supposed to be there.  That’s toxic and I’m feeling like shit. I couldn’t wait for it to end.  I was like I’ve never been pregnant before but I know it ain’t supposed to feel like this. This is some bullshit!  So when I realized what was happening, I was like, “Praise Jesus. I am drinking soon as I get home!”  — Shelly, 40, hospital, planned cesarean birth

In sharp contrast, Adrienne’s two stillbirths represented the tragic loss of her children and her hope of becoming a mother. Her religious belief allows her to look forward to being reunited with her lost children, and she keeps their memory alive through prayer:

It’s just been really a process but my strong belief is I will see my son again. I believe in an after life and I believe that he’s waiting for me there so I do have a lot of hope. And I did have a second miscarriage after that. It was earlier in my pregnancy but too early to tell what the sex was or anything but in my mind I feel like it’s a little girl that’s in heaven and her name is Hope. And that’s for me, it’s like… and I have this urn with my son’s ashes and it’s a teddy bear so I can sleep with it whenever like I’m into ritual for healing and so we had a whole altar devoted to family. There was like an altar with the teddy bear and things and so that’s been really helpful for me but I have a little bear one of those tiny little bears, it’s a prayer…it’s a bear praying on its knees and the name of the bear is Hope so I have the two bears together. — Adrienne, 27, birth center, vaginal birth

Most of the women who had experienced pregnancy loss used spiritual and religious understandings to give meaning to their experience. For Shelly, a deep desire to know and follow God’s will allowed her to feel cared for and loved during her miscarriage. Her beliefs helped her to see her several miscarriages as part of a Divine plan:

I feel like miscarriages are a natural part of our gynecological journey.  I feel like it is as natural as having periods. I had a miscarriage before I had [child]. And then I had [child] and then I had miscarriage after [child].  The way I am, I feel like God knows what’s best for me. The timing isn’t mine so even though it may have been my plan, it wasn’t His plan at the time. And whatever is meant to be is going to be.  It’s like when you move, I move, Lord. You say go to the left and cool, I am over to the left.  You say I am not pregnant, cool I am over to the right now. It wasn’t a— The hardest part about having a miscarriage for me was dealing with everybody else’s feelings around it.  Because you wind up being like, “I’m fine.” Now I am trying to comfort you because you’re stressed out about what is going on with me. I had friends who went into depression when they found out I had a miscarriage.  And I was like, “I can’t even deal with you right now because I am not depressed.  I am feeling relieved.  My body was suffering.” — Shelly, 40, hospital, planned cesarean birth

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Traditional African American and African cultures share a worldview in which the material and metaphysical worlds co-exist and are interrelated. For many black people in the U.S., traditional practices such as ancestral dreams continue to provide us with guidance, advice and even requests from the Spirit World.21 While ancestral dreams involve important elders who have passed on, such as a parent or grandparent, some of our participants also reported that the Spirit of their unborn child spoke to them. For Amara, a dream gave her notice that one of the twins that she was carrying was not going to make it. When she later suffered from bleeding, and learned that she was now only carrying one fetus, her dream served as a source of solace and meaning:

I had a dream, oh I forgot this part… I totally forgot! This is an important part. So I had this dream and in the dream there was these two little kids. It was a little girl and a little boy. And the little girl was saying “come on come on Let’s go come on it’s gonna be great!” And the little boy was pulling back and saying, “No, No, I don’t want to go.” And then I woke up and it was like I knew it was them. [Tearfully] you know in [African] spirituality we believe that some children are just spirit children they’re never meant to be here. Sometimes they get born into the world but they just want to be with their own kind they don’t want to be out here so…[tearfully] So that’s why I already had a name for him because I really felt like I had a relationship with both of them. I knew that [child] was on the way and that [African name]–that means God is merciful–was not gonna make it. — Amara, 41, hospital, vaginal birth

While the women in our study found ways to understand and cope with pregnancy and infant loss, they also struggled with external and internalized beliefs that made the experience of pregnancy or infant loss more painful. The first was the belief that they had done something to contribute to the death of their fetus or child. This belief may be the inadvertent result of public health messaging that encourages women to have a healthy pregnancy by avoiding unhealthy choices. For women who suffer pregnancy loss, this messaging can result in self-blame or blame by others close to her:

I was in excruciating, excruciating, excruciating pain. They told me I was pregnant and my fallopian tube had ruptured. The baby had latched on [sic] and she was like, “I can just give you some pills that we give cancer patients to kill radiation or something.”  I’m like, “That doesn’t even sound right! No!  I am not taking it.” She told me the only other way is to go into surgery and remove my fallopian tube. I said, “Do that.”  It was very sad.  He was there and I was just crying. My poor baby was trying to grow and it couldn’t grow- there was just not enough room.  I was thinking maybe because I smoked or did I drink something?  Did I drink too heavy one night?  Like what did I— Was it something I did?  But like she [participant] was saying, I think God has a plan. Some times it’s right, some times it’s not. — Kaela, 31, hospital, vaginal birth

We gotta normalize our language around miscarriages more.  When you go through and feel like you’re the only one, no one wants to talk to you about it.  It was people in my circle who had had ‘em but didn’t want to tell me about it.  That had to be what they were going through. It doesn’t have to be a community process, you know.  It would have been cool if you would have been like ‘It’s going to be ok, I have been there before’.  But I didn’t get that.  From anybody.  I was like my own personal- I just had to puff myself back up and get through it.  You know what I mean?  I don’t mind telling people I have been through it if they want to know.  It’s hormonal.  It’s not because I had that glass of wine.  It’s not because I got stressed out at work, you know what I mean? And they psyche us all out to think that all this stuff… was in our control and it never was. — Shelly, 40, hospital, planned cesarean birth

How Racism Harms Pregnant Women – And What Can Help

The second belief is the idea that the non-viable “fetus” is not a real “life” or child. In this era of fetal politics, where women with substance abuse issues are being prosecuted for “supplying drugs to a minor,” and home birthing women have been detained for “child endangerment,” it is vital that we do not separate out the legal identity of an unborn child/fetus from its mother. Doing so simply sets up the conditions for low-income pregnant people and pregnant people of color to be policed and punished.22 However, we also need to be careful not to utilize terminology and practices that pregnant women find dehumanizing. Most of the pregnant women in our study experienced an intense emotional and spiritual bond with their fetus/unborn child that deserves to be acknowledged. For Shelly (above) and Cindy, both of whom experienced a pregnancy that could not continue full term for medical reasons, the idea that their non-viable fetuses were going to be terminated and disposed of as medical waste was unacceptable:

We went in for an ultrasound, and it was supposed to be the one where if you want you can find out the gender, although we didn’t want to find out the gender. And the technician said, I’m going to need to call someone else in here. And she left. And this other guy came in and he was so short with words, and he basically said, “The baby’s spine stops at the neck, the baby has no brain.” [Tearfully] He said, “There’s just fluid in its head, and you’re going to need to see a specialist. “[Chokes] What? We had almost brought my older child with us to the ultrasound and we didn’t… I can’t even remember what its called right now, I think I’m blocking it out, but if your spinal cord doesn’t fully develop and there’s no brain, the children they don’t live, They might live a week or two, but they wouldn’t have any functioning, they’d be like a vegetable, they don’t have a brain so they can’t do anything. And so we had to decide fairly quickly because of how far we were along what to do. Whether to carry the baby to term and then deal with the baby dying. [Oh God] Or to terminate the pregnancy. And we made the decision that we were going to terminate the pregnancy and had to pay for a lot of that out of pocket. We had insurance but I felt, I’d carry this baby for so many months and they were going to flush it as medical waste? We wanted to have the remains and we wanted to at least bury it, or cremate it. We had to pay thousands of dollars for that. And its money we didn’t have. It’s on my credit card just rolling over year after year. But it was a part of us, and having gone through an abortion before I was just, I can’t. This isn’t medical waste. — Cindy, 35, hospital, vaginal birth, VBAC

One of BWBJ’s goals is to reduce infant and maternal mortality by transforming our nation’s maternal health-care system. At the same time, we recognize that miscarriage and stillbirth will always be a part of our pregnancy narrative. Black women who experience miscarriage and stillbirth need sensitive, non-blaming, culturally sensitive care that recognizes the meanings they ascribe to their pregnancies, and to pregnancy loss. Pregnant individuals who have to have a medically required abortion, rather than elective one, are likely to have a very different relationship to the fetus, experiencing it as a loved but unborn child, and caregivers should recognize this. In addition to providing counseling and support services, health insurance companies should provide coverage for dealing with the child’s remains in a culturally and spiritually appropriate way.

This is a three part series and excerpt from the new book, Battling Over Birth: Black Women and the Maternal Health Care Crisis.

Part One: Prenatal Care Barriers

Part Two: Stress, Pregnancy and the “Strong Black Woman” Syndrome

Part Three: Midwifery Model of Care

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