Chapter three
The Relf case happened in another century, but reports of racial bias in health care remain distressingly common. Though they are often dismissed as an aberration or the work of a few bad players, in fact piles of data, including research published in the world’s top science journals, exhaustive reports by government agencies and nonprofit organizations, and evidence revealed during legal actions, all point to a medical system riddled with deeply rooted bias and discrimination, most of it implicit, that affects people the second they venture into our health-care system. Though the problem has been well documented, each new report is met with shock and surprise. After an initial media splash and a round of outrage, the evidence recedes into history, failing to drive significant action or policy. That leaves questions of discrimination in the health-care system ignored, denied, under-examined, misunderstood, and tragic.
Because of the way I saw my father treated by health-care providers in 1999, this issue is far from academic for me, and I understand from my personal vantage the real-world consequences. Nearly twenty years later, in the process of reporting a 2018 New York Times Magazine cover story, “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis,” I would witness another instance of mistreatment of a Black person by medical providers who were tasked with a bare minimum of “first, do no harm.”
The story came to me by happenstance. One Saturday afternoon in the late spring of 2017 during my weekly pickup soccer game in Brooklyn, Katrina Anderson, who was then a lawyer with the Center for Reproductive Rights in New York City—and a very good soccer player—suggested I write an article about women who die or almost die related to pregnancy and childbirth. Her organization had recently collaborated with the reproductive justice group SisterSong in Atlanta to form the Black Mamas Matter Alliance, which was tasked with bringing attention to what she referred to as the growing crisis of maternal mortality. As she pitched me her idea for a feature in the Times magazine, where I had just become a contributing writer, I argued her down, using all of the familiar assumptions about racial health disparities. “Maternal mortality is a problem of poor countries, a concern of another era,” I said, attempting to pry myself loose from her to enjoy the sunny day and fresh air. “American women hardly ever die in childbirth anymore.”
“No, I’m talking about today, in our country,” she insisted.
“Well, in the U.S., only extremely poor women die related to pregnancy and childbirth,” I argued.
But she grabbed my arm and insisted, “Actually, the United States is the only wealthy country where the numbers of women who die or almost die related to pregnancy and childbirth are increasing. This problem is driven by the deaths of Black women. Didn’t you used to work at Essence magazine?” She refused to allow me to look away as she continued. “Did you know that a Black woman with an advanced degree is more likely to die related to pregnancy and childbirth, or almost die, than a white woman with an eighth-grade education? Don’t you have a master’s degree?” She had my attention. Several weeks later, the Times magazine assigned me the story.
Over the next few months, I set out to understand why in our country with the most expensive and advanced medical technology in the world, growing numbers of American women, disproportionately Black women, were dying as a result of pregnancy and childbirth, including African American women whose income and education should protect them. I collected reams of studies and interviewed at least thirty medical experts, historians, and advocates. To keep the story more hopeful and inspirational and less frightening and depressing, I decided to lift up the work of doulas, people, generally women, who are trained to advocate and support women during pregnancy, labor, delivery, and in the weeks after the birth of a baby. As with other health-care providers grouped under the catchall term “community health workers,” I saw their work as one solution to the crisis and began looking for an individual or group who worked with women of color and accepted clients regardless of their ability to pay to use as a narrative thread to wrap around the data, studies, and interviews I had gathered. At the Decolonizing Birth Conference in Brooklyn in September 2017, a convening of health-care providers, researchers, and activists interested in reproductive and birth justice, I got lucky. One of my sources tracked me down at the meeting of about two hundred people and pointed to a striking young Black woman wearing a T-shirt with an abstract swirl of a pregnant belly on the front. She was surrounded by a mixed-race group of women wearing the same shirt and juggling several babies and toddlers. “That’s Latona Giwa,” my source explained. “She’s trained as a labor and delivery nurse but became disenchanted with the medical system and started a social justice doula collective in New Orleans.” By the end of the day, Latona had invited me to New Orleans to learn more about her work with the Birthmark Doula Collective and shadow her for a week.
Because I was working full-time as a college professor, it took me several months to synthesize my reporting and pull together a rough draft of my article. So, by the time I was ready to join Giwa in New Orleans, other media outlets had begun to cover the issue, largely thanks to the advocacy of the Black Mamas Matter Alliance. What I noticed in most of the other pieces, however, was a disconnect between the uptick in the deaths of American women in childbirth—including the disproportionate number of Black women who were dying or almost dying—and the racial gap in infant mortality. One widely read, celebrated, and well-executed investigation on maternal mortality that rolled out while I was still deep in the reporting on my article focused on a white nurse who had tragically died in childbirth. This piece, part of Lost Mothers, an excellent multimedia series produced by journalists from ProPublica and NPR, seemed to blame her death—and the maternal mortality crisis—on a hyper focus on saving babies using advancements in neonatal technology, at the expense of their mothers. Though it made sense on the surface, that framework assumed that maternal mortality was largely a clinical/technical problem that could be remedied with clinical/technical solutions. But given my knowledge about the ongoing crisis of low-birth-weight, preterm births and infant mortality among Black babies—and my own low-birth-weight baby girl despite my good health and gold-standard health care—the idea that Black mothers were on the losing end of a tug-of-war with their babies in the delivery room didn’t make sense to me. According to that theory, as more Black mothers were dying, shouldn’t more and more Black babies be saved? In fact, as I was reporting, I came across a paper in the journal JAMA Pediatrics that noted that despite sustained progress in reducing the overall infant mortality rate in America over the previous two decades, in 2014 the Black rate had started to inch up even as the white rate continued its decline. What’s more, my friend Dána-Ain Davis, an anthropologist and doula who has written extensively about reproductive justice, pointed me to statistics that showed the racial disparity in infant mortality was actually greater in the present day than in 1850, when Black women were human chattel and babies of all races died so frequently that parents hesitated to name them.
As I tried to think through my story, a quotation from Fannie Lou Hamer came to mind: “A Black woman’s body was never hers alone.” I began to ask doctors and researchers a different set of questions—not just about maternal mortality, but about the connection between the deaths of mothers and the deaths of their babies. I knew that prenatal care alone had not been enough to spare my daughter from being born smaller than expected. Could something be going on with Black women’s bodies that began even before pregnancy that affected not just the mother’s health but also the health of her baby? I also thought hard about the racial disparities in the deaths and near deaths of both mothers and infants: Why were Black women three to four times more likely to die and Black infants twice as likely to die compared with white mothers and infants? Why is the current Black-white disparity in both maternal and infant mortality widest at the upper levels of education? And what was it about our health-care system that exacerbated this problem?
As my reporting continued, I realized that the interwoven crises of Black maternal and infant mortality offered me a chance to explore decades of data about the connection between societal racial discrimination, bias in our health-care system, and racial health disparities. I slogged my way through dozens of studies and the footnotes of those studies examining the ways toxic stress, triggered by discrimination, affected the bodies of Black women, which I will discuss in the next chapter of this book. I also assembled a large and damning file of studies and reports about racial bias and mistreatment of Black patients in the health-care system dating back to slavery. I was homing in on a new understanding of what was going on in maternal and infant mortality, laying out how discrimination and bias led to a disproportionate number of poor birth outcomes in Black women. The well-being of American mothers and babies matters: it determines the health of the next generation and can predict future public health challenges for families and communities.
I was particularly intrigued by studies out of Columbia University. Over the years, international researchers have gathered copious examples of disrespect and abuse of women during childbirth, primarily in developing countries. These include shouting at, scolding, or humiliating patients; requesting bribes; conducting medical procedures without consent; and detaining mothers and babies for the inability to pay. Women have also reported being slapped, pinched, hit, or tied down while in labor. Needless to say, this kind of mistreatment erodes trust and drives pregnant women in poor countries away from delivering their babies in health-care facilities.
Lynn Freedman, director of the Averting Maternal Death and Disability Program at Columbia University’s Mailman School of Public Health, decided to apply the lessons she and her colleagues learned studying disrespect and abuse in maternal care in Tanzania—where problems in pregnancy and childbirth lead to nearly 20 percent of deaths occurring in women aged fifteen to forty-nine—to her own backyard, New York City. Freedman, a Harvard-trained former practicing attorney, explained to me that disrespect and abuse mean more than just somebody not being nice to another individual person. “There is something structural and much deeper going on in the health system that then expresses itself in poor outcomes and sometimes deaths.”
Though the study had not been completed in 2017 when I was reporting my story, early focus groups made up of some fifty women who recently delivered babies in Washington Heights and Inwood, and of doulas who work in both Washington Heights and central Brooklyn, revealed a range of grievances—from being ignored, scolded, and demeaned to feeling bullied or pushed into having C-sections. For example, most women in the study had to wait one to two months before an initial prenatal appointment, not because they didn’t understand the importance of proper care during pregnancy, but due to a lack of availability. After she finally received an appointment, one pregnant woman says she sat in a clinic waiting area from 10:00 a.m. to almost 6:00 p.m.
In another instance, when a laboring woman cried out in pain, a nurse told her, “No one is forcing you to have children [so] you shouldn’t be complaining.” Another, also in the throes of labor, was asked, “Why do you have so many kids anyway? Mexican women do nothing but have kids here.” A doula reported that when her client squatted to alleviate pain during labor—a suggested practice all over the world—a health-care provider said, “We don’t do that here; do you think we’re in the jungle of Africa?”
In November 2017, I made it to New Orleans to shadow Latona Giwa. On a sunny Friday, the air thick with humidity, she and I pulled up to the home of her twenty-three-year-old client, Simone Landrum. Landrum lived in Broadmoor, a section of New Orleans that battled back from a green dot designation, which meant the community was initially destined to be abandoned after Katrina, razed instead of rebuilt. Still dealing with the aftershocks of a traumatic delivery the previous year that ended in the death of her baby daughter, Harmony, and nearly took her life, Landrum was thirty-two weeks pregnant, fragile, and afraid. She had connected with Giwa, who worked with her pro bono, through a nonprofit organization that provided services for survivors of domestic violence and sexual assault. Landrum sought the group’s help after fleeing an abusive relationship. Once counselors explained the role of a doula, Landrum, who also had two young sons, requested one; her primary goal was to avoid going through pregnancy and childbirth alone.
Giwa walked up the steps and reached toward the doorbell, then thought twice about the shrill sound and called her client instead. Landrum opened the door, relieved to see the smiling, fresh-scrubbed Giwa, a lissome slip of a woman, who at thirty-one looked years younger than her client. I followed Landrum and Giwa through the living room, empty save a tangle of disconnected cable cords lying on the bare floor like black snakes. She left behind most of her belongings when she managed to get away from her abusive partner. The two women sat at the kitchen table, where Giwa reviewed her client’s last doctor visit, prodding her for details—her blood pressure and weight as well as the baby’s size and position.
Landrum shared the story of her stillborn baby and her own brush with death with Giwa and me in fits and starts. In the spring of 2016, she remembers feeling tired and both nauseated and ravenous at the same time and knew she was pregnant. But as her pregnancy progressed, she noticed something different this time. The trouble began with constant headaches and sensitivity to light. Landrum described the pain as “shocking.” As her January due date grew closer, she noticed that her hands and feet were swollen and her face looked “puffy” in selfies that she posted on Instagram. But her doctor brushed aside her complaints, recommending Tylenol for the headaches. At a prenatal appointment on November 11, 2016, a few days before her baby shower, Landrum told her doctor that the headache had intensified and Tylenol did not help and that she also felt achy and tired. A handwritten note from the appointment, sandwiched into a printed file of her electronic medical records that she and I would later track down, shows an elevated blood-pressure reading of 143/86. Combined with headaches, swelling, and fatigue, the reading should’ve pointed to the possibility of preeclampsia, dangerously high blood pressure during pregnancy. High blood pressure and cardiovascular disease are two of the leading causes of maternal death, and hypertensive disorders during pregnancy had been on the rise over the previous two decades. Preeclampsia and eclampsia, the seizures that develop after preeclampsia, are more common in Black women than women of other races.
At the appointment, when Landrum complained more forcefully about how she was feeling, her doctor told her to lie down and scolded her to “calm down.” He also warned her that he was planning to go out of town and told her that if she wished, he could deliver the baby by C-section that day, six weeks before her early January due date. Landrum says it felt like an ultimatum, centered on his schedule and convenience. Aside from the handwritten note, Landrum’s medical records don’t mention the hypertensive episode, the headaches, or the swelling, and she says that was the last time the doctor or anyone from his office spoke to her. Later she would tell me that she felt as though “he threw me away.”
Four days later, Landrum had a severe backache and felt so tired she couldn’t get out of bed. That evening, she packed a bag and asked her boyfriend to take her sons to her stepfather’s house and then drive her to the hospital. In the car on the way to drop off the boys, she felt wetness between her legs and assumed her water had broken. But when she looked at the seat, she saw blood. By the time she was lying on a gurney in the emergency room of Touro, the public hospital located in uptown New Orleans, the splash of blood had turned into a steady stream. In the ER, with doctors and nurses hovering over her, everything became both hazy and chaotic. Her medical records show that her blood pressure had shot up to 160/100. When a nurse moved a monitor across her belly, Landrum couldn’t hear a heartbeat. She remembers asking the nurse, “Is she okay? Is she all right?” but nobody said a word. The emergency room doctor dropped his head and then looked into her eyes and explained that the baby was dead inside her. Landrum then turned her head to the side and threw up.
Sedated but conscious, Landrum felt her mind growing foggy. She felt exhausted, like giving up. But then she pictured the faces of her two young sons and thought, “Who’s going to take care of them if I’m gone?” That’s the last thing she recalls clearly. When she became more alert some time later, a nurse told her that she had almost bled to death and had required half a dozen units of transfused blood and platelets to survive. A few hours later, a nurse brought Harmony, who had been delivered stillborn via C-section, to her. Wrapped in a hospital blanket, her hair thick and black, the baby looked peaceful, as if she were dozing. Landrum recalls holding her, and through the sedation wondered, “Why doesn’t she wake up?” Later, she felt angry and thought, “Why is God doing this to me?”
The hardest part was going to pick up her sons empty-handed and telling them that their sister had died. Choking up, she explained to me that she felt as if something had been taken from her, but also from them.
As we sat across the table from each other, I was extremely moved by Landrum’s story and grateful that she had had the wherewithal to tell me, in graphic detail, what had happened to her. For me, she offered a real-life example of what happens when the twin and interrelated crises of infant and maternal mortality land in the body of one woman. I felt a rush of empathy for her when later in the visit she expressed strong and legitimate fears about what might happen during the birth of the baby inside her, given her traumatic experience from only a year ago. Though she was scheduled to deliver this baby at a different hospital and with a new ob-gyn, a woman this time, she was still terrified. “I’m trying not to be worried, but sometimes…” she said haltingly, looking down at the table. “I feel like my heart is so anxious.”
Giwa, with her calming tone and sensitive physical touch, worked to talk through and ease her client’s anxiety. As Landrum let loose a litany of her fears—rumors about the hospital where she heard “they kill people,” bleeding again during labor, coming home empty-handed, worries about dying and leaving her sons motherless—Giwa leaned across the table, speaking evenly with a kind of sisterly spirituality. “I know that it was a tragedy, and a huge loss with Harmony,” she said, “but don’t forget that you survived, you made it, you came home to your sons.” Giwa then handed Landrum a crayon from the bag she had brought with her, purple, Landrum’s favorite color. She suggested they write affirmations for Landrum to post, one on the fridge, another on the bathroom mirror. As Landrum scribbled some of her worries in tight, tiny letters, Giwa wrote down an affirmation for her to post. “I know God has his arms wrapped around me and my son,” Giwa wrote in large purple letters, outlining “God” and “arms” in red, as Landrum watched. She took out another sheet of paper and wrote, “Harmony is here with us, protecting us.” After the period, she drew two purple butterflies. Landrum’s eyes locked on the butterflies. “Every day, I see a butterfly, and I think that’s her. I really do,” she said. For the first time, I saw Landrum’s shoulders drop.
As I was leaving after our two-hour visit, I thanked Landrum and hugged her, feeling a real connection, grateful for her honesty, inspired by her courage, and angered by the callous treatment that most likely resulted in Harmony’s death and Landrum’s near death. As I untangled myself from the embrace, I noticed Landrum looking at me intently. Something told me to ask, “Who will be with you when you have the baby this time?” “Just me and the doula,” she said. Impulsively, I told her, “I’ll be there too,” and she smiled. I had had two children of my own, and had attended the births of my two godchildren, so it might be nice for her to have another supportive person by her side during labor. I also figured I would write a first draft of my story, then return to New Orleans to be with her during her delivery and add what I hoped would be a happy ending to the piece. I had no idea that what would happen to Landrum in the delivery room—and the treatment I would observe—would actually turn out to be the heart-gripping centerpiece of my article.
—
Many thought the attention paid to a 1999 study published in The New England Journal of Medicine would cause doctors and other health-care providers to face up to their own bias at work. Rarely has an article with a title as dry as “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization” received as much notice and generated as much controversy. The study, published in the February 25, 1999, issue of the journal, addressed the issue of physician bias directly and was the first large-scale study to do so focusing exclusively on treatment decisions made by doctors.
Kevin A. Schulman, MD, a physician with an MBA from Wharton and an interest in health services research and policy, and his colleagues chose this topic for a reason: Blacks in the United States have the highest rate of hypertension, with more than half affected, and African Americans aged eighteen to forty-nine are twice as likely as whites to die from heart disease. But studies had shown they are less likely than other groups to be referred for cardiac catherization when complaining of chest pain. Cardiac “cath” is a common procedure used to evaluate heart function in order for heart specialists to diagnose coronary artery disease and to decide whether to perform cardiac surgery.
To understand the role of race in this decision making, Dr. Schulman developed a standardized computer program that included videotaped interviews with patients—two Black men, two Black women, two white men, and two white women—but unbeknownst to the physicians taking part in the study, the patients were actually eight actors, dressed in the same generic hospital gown, reading from identical scripts. The researchers standardized most aspects of the patients’ medical and social histories; half were fifty-five, half seventy years old. All had the same insurance and the same occupation—assembly supervisor for the fifty-five-year-old patients, retired assembly supervisor for the seventy-year-olds. Each patient had a father who had had a heart attack at age seventy-five. The 720 participating physicians, the majority of them white men, took part in the survey at two different national medical conferences.
The researchers found that men and whites had a significantly higher probability of being referred for cardiac catheterization than women and Blacks. The largest gap was between Black women and white men, who served as the reference category. The study never accused doctors, nurses, and other health-care providers of being racist. Instead, they concluded that while multiple factors influence physicians’ decisions, bias and stereotypes cannot help but play a role. “Bias may represent overt prejudice on the part of physicians,” they wrote, “or, more likely, could be the result of subconscious perceptions rather than deliberate actions or thoughts. Subconscious bias occurs when a patient’s membership in a target group automatically activates a cultural stereotype in the physician’s memory regardless of the level of prejudice the physician has.”
The minute the findings became public, Dr. Schulman, who was still early in his career, found himself in the glare of the media spotlight and at the center of feverish controversy. Though the role of what is now generally called implicit bias in medical care is widely acknowledged as a problem today, twenty years ago it was barely recognized in the fields of medicine and science, which were assumed to be purely objective and color-blind. ABC’s World News This Morning warned viewers, “How your doctor treats your heart may depend on the color of your skin.” Nightline devoted an entire segment to the study, introducing it this way: “Last night we told you how the town of Jasper, Texas, is coming to terms” with the racially motivated murder of a Black man. “Tonight we will focus on [doctors] who would be shocked to learn that what they do routinely fits quite easily into the category of racist behavior.” Aubrey Lewis, MD, a Black cardiologist who appeared on the segment, noted that “if this continues on, you’re looking at literally a decimation of the African American population.” An editorial in the British medical journal The Lancet characterized the results “as close to a definition of institutionalized racism as doctors and health care providers may dare to get.”
The backlash was nearly as swift. Physicians and scientists took offense, criticizing Dr. Schulman and his associates over their statistical methods, reporting of the results, and interpretation of the findings. Five months after publication of the study, a group of doctors from Dartmouth Medical School accused Dr. Schulman of exaggerating the findings, which, they wrote in the July 22, 1999, issue of The New England Journal of Medicine, “serves to fuel anger and undermine the trust between physicians and their patients.” The journal editors also published a note in the same issue, taking responsibility for the media’s “over-interpretation of the original article”—though they had vetted the statistical measure before publishing the work. Even as the controversy swirled and the scientists bickered about statistics, in October of that year a survey published by the Henry J. Kaiser Family Foundation found that African Americans were more than twice as likely as whites to state that discrimination in health care is a major problem, almost three times as likely to report that African Americans receive lower-quality health care, and fourteen times as likely to report that they had been treated unfairly because of race when seeking medical care in the recent past.
I spoke to Dr. Schulman, now a professor of medicine at the Stanford University School of Medicine, in 2020 about the 1999 study, and he continues to be proud of his work, unmoved by the criticism. He recalls President Bill Clinton being intrigued and inspired by the study, which he encouraged his cabinet members to read. In 2000, Clinton signed legislation establishing the National Center on Minority Health and Health Disparities to take a deeper dive into the issues Dr. Schulman had unearthed. Dr. Schulman also provided congressional testimony about physician bias along with the African American doctors Louis Sullivan, MD, and David Satcher, MD. Dr. Schulman says he remains most moved by an experience shared by Bennie Thompson, a congressman from Mississippi who came of age in the 1950s, during a closed-door session with the Congressional Black Caucus in 2000. “When he was growing up in Mississippi, no white doctor would ever touch a Black patient,” Dr. Schulman recalled. “So, my work wasn’t surprising to him or any of them in the room.”
—
As Landrum’s December 21, 2017, due date moved closer, I stayed in touch with Giwa from New York City, where I live. Landrum was doing fine, but Giwa expected her to go into labor early, since that’s what had happened with her other pregnancies. I kept a bag packed so I could jump on a plane and get to New Orleans once her labor started. On Saturday, December 9, Giwa texted me that she thought Landrum was in early labor. I was reading the text at a very raucous holiday party and managed to sober up and call Giwa. “I think you should get here in the next forty-eight hours,” she told me. I somehow pulled it together and got a ticket to fly to New Orleans early the next morning. As I was boarding the flight, I received a text from Giwa: “May be a false alarm. Cramping and discomfort have died down for now.”
I went anyway. I rented an Airbnb a few blocks from Landrum and spent the next week and a half driving her to doctor’s appointments, taking her for walks, and cooking dinner for her and the kids as we waited for the baby to come. “This is not what I expected, but I’m going with it,” I told Giwa. During that time, Landrum and I got to know each other better, and we discovered that we had a similar sense of humor and no sense of direction and the same taste in mushy rom-coms. I was also able to share some of my reporting on maternal and infant mortality and the connection to race and discrimination with her. She was very inquisitive and interested in the experts I had interviewed who were studying the issue. “White people care about this, for real?” she asked me.
A few days before her due date, I took Landrum to the hospital for her last ultrasound before the birth. Because of the stillbirth the previous year, her doctor did not want to let the pregnancy go past forty weeks, to avoid the complications that can come with post-term delivery, so an induction had been scheduled in forty-eight hours. Landrum was lying on the table as we listened to the sound of her baby’s heartbeat fill the room. A few minutes later, the technician returned and looked at the monitor. The heart rate appeared less like little mountains and more like chicken scratching. The baby was also either not moving consistently or not breathing properly. A nurse left the room to call Landrum’s doctor. When she returned twenty minutes later, she gave us the news that the baby would be induced not later in the week but now. Both of us were terrified. “We need to call Latona,” I told her.
An hour later, the doula arrived, wearing purple scrubs, her cloth bag filled with snacks, lavender lotion, and clary sage oil. She made sure the crayon-drawn affirmations were taped on the wall within Landrum’s line of vision, then settled into a chair next to the bed, calm but watchful. Both of us were wearing “Team Simone” T-shirts my partner had made. A medical resident, who was white, like every single person who would attend Landrum throughout her labor and delivery, walked into the room with paperwork. Right away, she asked Landrum briskly, “Have you had any children before?”
“Yes, I’ve had three babies, but one died,” Landrum explained warily, for the third time since she had been told she would need to be induced that day. Her voice was flat. “I had a stillbirth.”
“The demise was last year?” asked the resident without looking up to see Landrum flinch at the word “demise.”
“May I speak to you outside,” Giwa said to the nurse caring for Landrum. In the hall she asked her to please make a note in the chart about the stillbirth for the parade of providers attending Landrum. “Each time she has to go over what happened, it brings her mind back to a place of fear and anxiety and loss,” said Giwa later. “This is really serious. She’s having a high-risk delivery, and I would hope that her care team would thoroughly review her chart before walking into her room.”
Over the next ten hours, Giwa left Landrum’s side only briefly. Several hours in, Landrum requested an epidural. According to hospital policy, no visitors can be in the room while an anesthesiologist administers it. When we returned about half an hour later, Landrum was angry and agitated, clenching her fists and talking much faster than usual. She had mistakenly been given a spinal dose of anesthesia—generally reserved for abdominal surgery—rather than the epidural dose used in childbirth. Now she had no feeling at all in her legs, and a splitting headache, which made her fearful that she had again developed preeclampsia. When she questioned the incorrect dose of anesthesia, Landrum told us that one of the nurses had said, “You ask a lot of questions, don’t you?” and winked at another nurse in the room, then rolled her eyes. After Giwa questioned the nurse, she admitted the error.
As Landrum continued to loudly complain about what occurred, her blood pressure shot up, while the baby’s heart rate dropped. Giwa glanced nervously at the monitor, the blinking lights reflecting off her face. She texted me, “Baby’s not looking awesome right now. She needs to stay calm.”
“What happened was wrong,” Giwa said to Landrum, lowering her voice to a whisper and encouraging her to take deep breaths. “But for the sake of the baby, it’s time to let it go.”
She asked Landrum to close her eyes and imagine the color of her stress.
“Red,” snapped Landrum, before finally laying her head on the pillow.
“What color is really soothing and relaxing?” asked Giwa, massaging her hand with lotion.
“Lavender,” Landrum replied, taking a deep breath. Over the next ten minutes, Landrum’s blood pressure dropped within normal range and the baby’s heart rate stabilized.
At 1:00 a.m., a team of three young female residents bustled into the room; the labor and delivery nurse followed them, flipping on the overhead light. They were accompanied by an older man none of us had ever seen before. He briefly introduced himself as the attending physician. I was then shocked to see him plunge his hand between Landrum’s legs to feel for the baby. We had been told that her ob-gyn might not deliver her infant, but a nurse had reassured us earlier in the day that if her doctor were not available, her doctor’s husband, also an ob-gyn, would cover for her. This doctor, however, seemed a bit old to be the husband—and he wasn’t—but no one explained the switch. Giwa raised an eyebrow and mouthed, “What’s going on?” The Listening to Mothers III survey, a national sampling of twenty-four hundred women who gave birth between 2011 and 2012, found that more than a quarter of Black women meet their birth attendants for the first time during childbirth, compared with 18 percent of white women.
“He’s ready,” the doctor said, snapping off his gloves. “It’s time to push.”
One of the residents stepped forward and took his place, putting her hand into Landrum’s vagina, feeling for the baby. Landrum gripped the side of the bed and closed her eyes, grimacing. The nurse, standing at her side, told Landrum, “Push! Now. You can do it.” After about twenty minutes of pushing, the baby’s head appeared. “This is it,” the nurse told her. “You can do this,” whispered Giwa on her other side. The nurse moved away, and I stepped in and held Landrum’s hand.
Landrum bore down and pushed again. “You’re doing amazing,” said Giwa, not taking her eyes away from Landrum. The attending physician left the room to put on a clean gown. Landrum breathed in, closed her eyes, and pushed. More of the infant’s head appeared, a slick cluster of black curls. The senior resident motioned to the third and most junior of the women, standing at her shoulder, and told her, “Here’s your chance.” The young resident took the baby’s head and eased the slippery infant out. Though Landrum was oblivious to the procession of young residents taking turns between her legs without addressing her or looking her in the eye, or the fact that the attending physician wasn’t in the room at all, I wasn’t. It seemed like the height of disrespect. Landrum was now sobbing, shaking, laughing—all at the same time—flooded with the kind of hysterical relief a woman feels when a baby leaves her body and emerges into the world. A few minutes later, as she laid her hands across the baby’s back, still coated with blood and amniotic fluid, Landrum told us she had decided to name him Kingston Blessed.
I stayed in New Orleans until the end of the week, leaving the hospital only to shower and sleep. Since I had been too frantic and nervous—while trying to appear calm—to take notes during Landrum’s labor and delivery, as soon as I could, I spent about an hour writing down everything I remembered. I couldn’t shake the way the residents, interns, doctor, and nurses had treated Landrum. Though these people had no idea that I was a journalist, I was still amazed that they were behaving so thoughtlessly in front of Giwa and me. It was also shocking that not one person of color was part of Landrum’s medical team—in a hospital in New Orleans. That made me realize that they had absolutely no idea that anything they did was wrong. The sometimes subtle, other times heavy-handed ways that discrimination played out, exactly the way I had been reporting about it, was just business as usual.
After I went back to New York, I rewrote the story, now taking into account the week or so I had spent with Landrum before she went into labor and the scene in the delivery room. I also returned to New Orleans two months later to find Landrum settling into new motherhood with a cheerful, chunky Kingston. Giwa was still in the picture, making sure Landrum went to doctor appointments, giving advice about breast-feeding, and bringing the family food and supplies. For all of her work—before, during, and after the baby was born—Giwa was paid only $600.
—
In March 2002, the National Academy of Sciences, a private, nonprofit society of scholars, released a high-profile report documenting the unequivocal existence of racial bias in medical care, which many thought would mark a real turning point. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care was so brutal and damning that it would seem impossible to turn away. The report, authored by a committee of mostly white medical educators, nurses, behavioral scientists, economists, health lawyers, sociologists, and policy experts, took an exhaustive plunge into more than 480 previous studies. Because of the knee-jerk tendency to assume that health disparities were the end result of differences in class, not race, they were careful to compare subjects with similar income and insurance coverage. The report found rampant, widespread racial bias, including that people of color were less likely to be given appropriate heart medications or to undergo bypass surgery or receive kidney dialysis or transplants. Several studies revealed significant racial differences in who receives appropriate cancer diagnostic tests and treatments, and people of color were also less likely to receive the most sophisticated treatments for HIV/AIDS. These inequities, the report concluded, contribute to higher death rates overall for Black people and other people of color and lower survival rates compared with whites suffering from comparable illnesses of similar severity. Though the report looked at disparities in health care between white Americans and minorities—African Americans, Native Americans, Hispanics, and several Asian subgroups—the Black-white gap was the most well documented and long-standing.
A mention of Dr. Kevin Schulman’s 1999 experiment offered vindication of his work. “The real implication of the [Schulman] study was actually quite simple: doctors are human,” wrote Thomas Perez, a civil rights attorney who contributed to Unequal Treatment. “Like lawyers, businesspeople, and other professionals, doctors are fallible and may discriminate, consciously or subconsciously…This study simply concluded that racial bias can affect who gets to the operating room.”
The members of the committee of scientists and physicians who compiled Unequal Treatment were jolted by their own results, calling them both shocking and troubling. Black and other doctors and scientists of color were less surprised by what the report showed, since many had been shouting into the wind for years about the link between bias and racial health disparities. Unequal Treatment received widespread media attention. A New York Times editorial on March 22, 2002, was sharp in its rebuke. “To the extent that doctors are shaping their treatments based on subconscious biases or false stereotypes about how blacks or Hispanics will respond to their ailments or their treatments, the only lasting cure will be greater awareness and education for the medical profession, as the panel recommends,” the Times editorial board wrote. “Unconscious racism is every bit as damaging as the more overt forms of bigotry.”
A quotation by Goethe included in the first pages of the report would prove telling: “Knowing is not enough; we must apply. Willing is not enough; we must do.” The report was not enough. Since its publication, hundreds more studies have examined the explicit link between racial discrimination and the physical and emotional health of Black people and other people of color, yet we’ve seen little forward movement on solutions.
—
When my story “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis” was published in April 2018, I was thrilled by the widespread and largely positive response. Two weeks after the publication of the article, Governor Andrew M. Cuomo of New York announced a pilot program to expand Medicaid coverage for birth doulas, citing the need to target racial disparities in maternal mortality. His office explained that the story was instrumental in the decision. Inspired by the story, and by the Birthmark Doula Collective’s work, the Women’s Studies Department of Old Dominion University in Virginia launched a doula-training program as part of a service-learning requirement. When I visited the college in early 2020, ten students had been trained as doulas with a commitment to apply their skills to underserved populations in the Norfolk region.
Merck announced a commitment of an additional $10 million to support local initiatives addressing the racial disparity in maternal mortality in the United States. The piece was also a finalist for a National Magazine Award, the Oscars of our industry.
Most exciting for me, shortly after the publication of the piece, the State of Louisiana created the Perinatal Quality Collaborative to advance equity and improve birth outcomes in the state through the Safe Births Initiative. The organizers focused on a specific goal: to reduce severe maternal morbidity—near death—by 20 percent in women who, like Landrum, experience hemorrhage and/or severe hypertension/preeclampsia, in participating facilities. The facilities included both the hospital that employed the physician who ignored Landrum’s repeated concerns and led to the death of Harmony and to Landrum’s near death and the one where I observed her being treated so badly during the birth of Kingston. Those spearheading the project also hoped the work would narrow racial disparities in pregnancy outcomes.
But I was dismayed to receive dozens of negative comments from readers that were posted to the Times article or on Twitter or emailed to me directly. I know the evidence about the link between race, racism, and infant and maternal death is rock solid, and I offered a voluminous amount of it, including research on the role of toxic stress on the bodies of Black pregnant women, in a ten-thousand-word story—one of the longest ever run in the Times magazine. So I was surprised to receive aggressive notes marked by dismissal and denial, often fueled by explicit racism and drawing on racial stereotypes of Black women and the African American community. Readers, including health-care providers, called Landrum irresponsible, careless, and the victim of a dysfunctional culture. They accused her of lacking a healthy diet, which I never discussed and wasn’t true. They blamed her for making poor lifestyle decisions, essentially holding her responsible for being beaten and abused by a violent partner.
By and large, I chose not to reply. Simone Landrum is a bright, kind person whom I respect and care about and who works hard to be a good mother to her three sons. She decided to allow me to attend her birth and tell her story because she wanted to make a difference and help other people. It takes courage to share your painful experiences in order to contribute to social change and help save the lives of other women and their children. For Landrum, trauma began early; she has had a very difficult life. She almost died as a child, narrowly escaping Katrina, which without a doubt was a tragedy that disproportionately affected African Americans and was not related to “poor decision making.” She had to flee in water up to her chin; was that a choice? The dysfunction in this case was the choice of our government to abandon Black people in New Orleans and leave them to die. But no matter her circumstances, she deserved to be treated and cared for with respect and dignity by doctors and other health-care providers whose job it is to serve her.
Indeed, because I feared some people would judge Landrum and zero in on her disadvantaged background to explain away the loss of her baby, her near death, and her ill-treatment, I included the story of another Black woman whose legitimate concerns were ignored during the birth of her daughter, creating a harrowing and hectic near-death experience: Serena Williams. In January 2018, as I was putting the finishing touches on my article, the tennis champion shared the near-tragic story of the birth of her first child in Vogue magazine and on social media. In September 2017, the day after delivering her daughter, Alexis Olympia, via C-section in a hospital in Florida, Williams experienced a pulmonary embolism, the blockage of an artery in the lung by a blood clot. Though she had a history of this disorder, lived in fear of blood clots, understood how to diagnose and treat them—and was gasping for breath—she says medical personnel disregarded her knowledge and ignored her persistent concerns.
Williams—who was accompanied by her husband, Alexis Ohanian, the tech entrepreneur who co-founded Reddit—should have been able to count on the most attentive health care in the world. Still, her medical team seems to have been unprepared to monitor her for complications after her cesarean, including blood clots, one of the most common side effects of C-sections. Even after she received treatment, her problems continued when coughing, triggered by the embolism, caused her C-section wound to rupture. When she returned to surgery, physicians discovered a large hematoma, or collection of blood, in her abdomen, caused by medication, which required more surgery. Williams, who as an elite athlete knows her body intimately and has a net worth of hundreds of millions of dollars, spent the first six weeks of her baby’s life bedridden.
What happened to the tennis superstar provided a clear-cut case study of discrimination in health care based on race—not class. In the next chapter I ask whether Landrum and Williams were vulnerable even before they set foot in a medical facility. Is something else about being Black bad for a woman’s body and her baby?