Abstract

Excerpted From: Jordan Brooks, Jamarah Amani, Sannisha Dale and Karen A. Scott, Restoring the Soul to Birthing in Miami: A Call for Justice for Obstetric Racism in Miami--Dade County, 15 University of Miami Race & Social Justice Law Review 33 (Fall, 2024) (171 Footnotes) (Full Document)

By centering the voices of patients, caregivers, and community members most affected, marginalized, and minoritized, employing a rights--based framework, and bridging paradigms between obstetric quality, patient safety, and birth justice, this article aims to ignite transformational change in Miami--Dade County's approach to Black perinatal health. The authors also argue for the endorsement of obstetric racism as an adverse event that threatens the emotional and physical safety of Black reproducing bodies and Black births and violates human rights. Specifically, obstetric racism must be promptly named, identified, measured, monitored, and actively mitigated with community--driven solutions. Community--driven patient safety bundles, grounded in the historical context and contemporary manifestations and mitigations of obstetric racism, represent acts of resilience, resistance, refusal, and racial reconnaissance to affirm, activate, actualize, and protect the Black mothers' basic human rights and dignity, defined by Davis as responses to obstetric racism. When health systems, hospitals, health departments, local and state public health agencies, national health professional organizations, credentialing and accreditation organizations, insurance companies, and philanthropists fail to protect and safeguard Black life, liberty, and livelihoods, the government must effectively hold these systems and structures accountable for these gross violations of Black mothers' basic human and civil rights and standards of obstetric quality and patient safety. Ultimately, expanding access to culturally congruent, community-based obstetricians, midwives, doulas, community health workers, attorneys, social workers, and psychological support is critical.

Disrupting and redefining the obstetric quality and patient safety paradigm through Davis' obstetric racism framework and Scott's patient-defined obstetric quality framework, SACRED Birth, provides a precise method to uncover harm in interactions, communications, consent, decision-making, and healthcare documentation. This includes patient sign-outs, handoffs, health records, and patient safety reports. To address these issues, health systems, financial institutions, and governments must allocate sustainable funding to empower Black-led grassroots organizations, such as the Southern Birth Justice Network. The time for change is now!

As one obstetrician-advocate states: “[i]n our intense focus on mortality rates, we often overlook the obvious fact that childbearing women have goals other than emerging from birth alive and unscathed.” For too long, acts of abuse, control, and dominance have persisted and escalated against Black mothers through broken, unfulfilled, performative promises and media statements. Enough is enough. One cannot change what one fails to see. One cannot see what one fails to recognize, report, and monitor. Effectively and sustainably addressing obstetric racism with rigor, accuracy, precision, and accountability mandates employing human rights-based frameworks throughout the obstetric quality and patient safety paradigm. Restoring the humanity and soul to childbirth is a right that every mother deserves.

I. Obstetric Racism is Real and Deadly

In the U.S., a predictable and preventable crisis of Black maternal deaths, driven largely by obstetric racism, continues to escalate. Despite growing evidence that racism is an independent and critical risk factor for poor health outcomes; leading scholars, journalists, funders, and quality improvement organizations often fail to critically examine and address its impact--rather than that of race--on maternal health. Naming, defining, measuring, monitoring, reporting, and responding to acts of obstetric racism is critical to mitigating the crisis. Obstetric racism--first defined by Black feminist, anthropologist, doula, and public health scholar Dána-Ain Davis--is a term that encapsulates the unique experience Black birthing people face throughout provision and utilization of any pregnancy-related service; this often threatens positive outcomes due to the intersection of medical racism and obstetric violence. According to Davis, obstetric racism, as both an analytic and phenomenon, describes mechanisms of reproductive abuse, control, dominance, and subordination that track along histories of anti-Black racism and eugenics.

Medical racism occurs when a patients' race influences medical professions' perceptions, treatments, and/or diagnostic decisions placing the patient at risk; the culmination of interpersonal and of institutional and systemic racism. It is evidenced by Black mothers' subjective reported experiences, by the evidence of the effects of implicit bias, and ultimately, the disproportionately poor and disparate health outcomes Black mothers face when giving birth compared to their white counterparts. Medical racism is also embedded within and reflected by the institutionally and state sanctioned practices that leave Black mothers and infants vulnerable to harm and premature death. While many believe racism may only temporarily affect one's mental health, numerous studies demonstrate the profound and extensive health impact racism has on one physiologically and psychologically, a concept known as weathering.

Many Black mothers throughout the country report medical racism, and Miami-Dade County (MDC) is no different. In MDC specifically, local grassroots birth justice organizations, like Southern Birth Justice Network (SBJN) report that many Black mothers who have given birth in MDC report discrimination and obstetric violence, throughout the peripartum period.

Systematically, Black mothers are significantly more likely to experience preventable pregnancy-related complications and death than their white counterparts. In MDC, Black mothers were over three times more likely to die giving childbirth compared to white mothers. Alarmingly, over eighty percent of pregnancy-related deaths are preventable. Black MDC mothers also experience more severe pregnancy-related complications, with Black mothers being over two times more likely to experience severe maternal morbidity. The ill health of mothers affects their children as well, as maternal pregnancy complications are the fifth leading cause of infant mortality in the county; ultimately leading to worse outcomes for Black infants. In MDC, not only were Black mothers more likely to die giving birth, but Black infants were a three times more likely to die in their first year of life. According to the CDC, when maternal pregnancy-related deaths occur after mothers have given birth, twenty-two percent occur during birth, twenty-five percent within a week after delivery, and fifty-three percent between after a week of delivery, but before one year. In sum, the data emphasizes the need for preventative measures implemented throughout the peripartum period, and with critical attention paid to Black mothers' unique experiences.

Black mothers also disproportionately report obstetric violence. Yet, obstetric violence lacks an analysis of harm enacted against Black mothers and birthing people that includes the historical contextualization of U.S. chattel slavery and plantation colonialism and contemporary implications of anti-Black racism and anti-Black misogyny. Obstetric violence is a form of gender-based violence and refers to the abuse, disrespect, and coercion mother face while giving birth. According to Davis, both medical racism and obstetric violence limit the understanding, examination, and interpreting of subjugation, control, dominance, and abuse enacted by health care professionals against Black mothers and birthing people and their babies. Thus, she coined obstetric racism to move beyond the general analysis offered by each framework and offers a more accurate and precise race and gender specific exploration of the harms animated by histories of racial science and racial subjugation adversely impacting how medicine views, portrays, and treats Black reproducing bodies, Black women, and Black births. Davis' concept of obstetric racism extends beyond the boundaries of medical racism and obstetric violence, offering a more culturally and scientifically robust, relevant, and responsive framework. It is particularly valuable for designing, evaluating, and training reproductive and perinatal care for Black women and gender-expansive individuals seeking pregnancy-related care, including (in)fertility treatments, surrogacy, and lactation support.

Davis examined the experiences of affluent Black women navigating premature births, racism, and reproductive injustice in neonatal intensive care units (NICUs). From this research, she identified seven key manifestations of obstetric racism in interactions between Black mothers, birthing people, and health care professionals. These manifestations, which occur regardless of the professional's race, gender, or position, include neglect, disrespect and dismissiveness, diagnostic lapses, ceremonies of degradation, medical abuse through coercion, and the intentional infliction of pain.

Black mothers consistently report facing more discrimination during childbirth than any other racial or ethnic group, often felling unheard compared to white mothers. Davis' concept of obstetric racism provides a nuanced framework for understanding and interpreting acts of reproductive subjugation, control, and dominance enacted against Black mothers.

Traditional measures of obstetric care quality have long relied on quantitative outcomes, such as maternal mortality rates and severe maternal morbidity rates. These metrics primarily assess data from deceased or severely diseased Black bodies, overlooking the experiences of those who survive obstetric racism. Scott critiques this paradigm, arguing that it perpetuates anti-Black racism and misogynoir across various facets, including ethics, leadership, measurement strategies, and community participation. By doing so, the existing framework silences the voices of Black mothers and birthing people who endure obstetric racism.

In response, Scott applied a Black feminist praxis to develop the PREM-OB Scale suite, a groundbreaking tool that translates Davis' anthropological framework into a patient-defined quality framework for obstetric care. This measure was created with the equitable and compensated participation of over 900 Black women, including patients, community members, and content experts, across 348 birthing hospitals in 34 states and Washington, D.C., with the involvement of 15 Black women-led community organizations. The PREM-OB Scale suite, piloted during the SACRED Birth During COVID-19 Study, could be utilized in additional studies by providing three independent and validated measures--Humanity, Kinship, and Racism--that assess the quality of care during childbirth hospitalization based on the perspectives of Black mothers and birthing people.

Data collected from 806 Black mothers who gave birth between January and December 2020 revealed significant findings. Obstetric racism, as measured by the PREM-OB Scale, was shown to be independent of clinical risk factors, including body mass index, gestational age, and mode of delivery. Mothers who expressed a desire to have Black birth professionals, such as physicians, midwives, or doulas, were three times more likely to report experiences of racism, disrupted kinship, and dehumanization. Those who felt the hospital dismissed their experiences because they and their baby survived birth were six times more likely to report racism and disrupted kinship, and eight times more likely to report dehumanization. In contrast, mothers who reported that hospital staff were attentive and responsive experienced significantly fewer acts of racism, disrupted kinship, and dehumanization; such as 87% fewer acts of racism, 90% fewer acts of disrupted kinship; and 97% fewer acts of dehumanization. Scott concludes that the PREM-OB Scale suite is a valid tool for characterizing and quantifying obstetric racism, providing a critical framework for perinatal improvement initiatives aimed at addressing and mitigating harm in obstetric care; and the prioritization of clinical outcomes over patient-reported experiences is not an evidence-based approach to evaluating hospital performance or mitigating harm, particularly obstetric racism.

Research continues to show that healthcare professionals hold implicit biases that negatively affect Black mothers, while Black obstetricians report that their patients increasingly express concerns about being unheard and mistrustful of the care they receive. Further, policymakers and healthcare providers often prioritize clinical outcomes over the lived experiences of Black mothers, neglecting their voices and perspectives. Moreover, scholarly and clinical focus often remains on objective outcomes, sidelining the intellectual insights, spiritual knowledge, and political activism of Black women; which Critical Race Theory, Black Feminist Theory, Research Justice, Cultural Rigor, and narrative medicine all affirm the validity of such lived experiences as essential data. In Miami-Dade County (hereinafter “MDC”), Black women frequently report abuse and trauma after giving birth in hospitals, highlighting systemic failures in maternal care. While ensuring safety is essential in childbirth, respectful maternal care embodies far more than safe outcomes. Mothers must be truly cared for, heard, and empowered, not coerced, to make healthy decisions for their health.

Acting in concert with medical racism and obstetric violence, the interrelated overmedicalization and commercialization of childbirth leads to dire consequences for Black mothers. Overmedicalization refers to the overuse of medical practices with no clear benefit and associated complications (e.g. Caesarean section), and the underuse of effective, safe healthcare practices (e.g. midwife-assisted birth). Childbirth is overmedicalized in the United States, with the key indicator of this being exemplified by the fact that over ninety percent of births occur in hospitals, attended by obstetricians, trained surgeons. In contrast, in many other developed countries with better maternal health outcomes, seventy percent of women have a midwife-assisted hospital birth, and for low-risk pregnancies, midwives were the only caregivers European women see.

The commercialization of maternal care further worsens maternal health outcomes in MDC. For example, hospitals--citing economic reasons--closed maternity wards in MDC, creating maternal deserts, most recently between downtown Miami and Hollywood. In Miami, much of the onus falls onto Jackson Memorial Hospital. In 2023, Jackson Memorial Hospital, in collaboration with Southern Birth Justice Network, Magnolia Birth House, and Metro Mommy Agency, launched the Black Maternal Infant Health Equity Collaborative. Led by Black birth workers, the initiative's goal is to train doulas, promote Birth Justice, and establish Jackson as a “doula-friendly hospital” through institutional policy changes addressing preventable outcomes and training for residents and nurses on physiologic birth and community birth transfers. Ultimately, the effects of the commercialization of childbirth on Black mothers reflects biocapitalism and reproductive racial capitalism, phenomena that ultimately remain deadly for Black birthing persons in the United States.

The overmedicalized and overly commercialized maternal healthcare system in MDC leads to increased medical interventions that require further interventions, leading to an increased risk of complications, and ultimately increased sickness and death for birthing persons and their children. One important example of the overmedicalization of childcare is the extremely, limited utilization and access to midwives and doulas in the United States. Although the World Health Organization recommends keeping the C-section rate below fifteen percent, overmedicalization and commercialization of medicine has led to an astronomical C-section rate in MDC of forty-five percent, many of which are unnecessary, ultimately leading to increased maternal morbidity and mortality. In contrast to the medical model of birth, both midwives and doulas practice the physiological model of childbirth, offering an approach that seeks to minimize medical interventions and that empowers birthing persons in the natural birthing process.

The impact of a mother's death and illness, reach far beyond impacting the mother and her children. There is also a profoundly traumatic, ““aftershock” to the family of mothers and of children that face these adverse birthing outcomes. When a birth-mother passes away, this can place significant emotional damage and economic pressures on the non-birthing parent, and both parents' families and extended families, creating further devastating intergenerational health consequences. Accordingly, the incorporation of truly family-centered care and solutions is vital.

The increasing racial wealth gap further increases the barriers to quality healthcare for the Black MDC community. Nearly one-third of Black people in MDC live below the federally designated poverty level. Access to health care, housing instability, food insecurity, gender-based violence, and the digital divide all exacerbate existing maternal health disparities. For instance, Black adults are least likely to have health insurance amongst adults in MDC compared to white, non-Latino residents and Latino residents. Accordingly, Black women are less likely to have access to prenatal care. Housing instability, both before and during pregnancy, leads to increased toxic stress in expecting mothers, leading to increased sickness and death for both the woman and her children. Accordingly, the disproportionate gentrification, displacement, and resegregation of Black communities significantly exacerbates maternal health disparities. Generally, the toxic stress associated with the lack of access to mothers' basic needs (i.e. safety from gender-based violence, housing, and food), and the informational barriers like the digital divide, causes Black mothers physiological and psychological damage is extremely detrimental to their health, their newborns' health, and their family's health. The US Maternal Vulnerability Index (MVI) indicates that Miami has a high MVI and struggles primarily with general access to healthcare and SDOH. Accordingly, recognizing and addressing the complex interplay of social determinants of health and structural barriers to quality health care is critical to understanding obstetric racism and eliminating maternal health disparities. The complex nature and causes of obstetric racism and disparate Black maternal health outcomes highlight the urgent need for holistic, compassionate, culturally congruent, and accessible healthcare to provide Black mothers with a respectful birthing environment and long-lasting beautiful memories about their childbirth. Ultimately, the current maternal care system deprives all mothers, particularly Black mothers, of the profound psychospiritual experience it should be. However, this is not new for Black mothers. The next section will illustrate how these barriers are an afterlife of slavery, and directly tied to the atrocities that have been systematically carried out on Black women for centuries.

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This article provides a comprehensive approach towards maternal health equity and birth justice for MDC and for all other counties in the United States. By implementing the above initiatives, we can work towards reducing maternal and infant mortality rates and improving health outcomes for all mothers and babies. While a similar approach has been attempted before in MDC, the problem has been ensuring proper stakeholder commitment and execution of the implementation.

This is not another scholarly work intended to merely inform and educate, but rather a call to action and a call to justice. Childbirth is the fundamental and first step in each of our lives. What will come of a society that has failed to protect young mother and their children in their first steps in lives? We can and we must do better to care for our young Black mothers and babies; no birthing person, child, or family can be left behind. This paper calls for healthcare providers, for hospitals, for banks, for related governmental organizations and public health departments in MDC to convene to institute correctional measures and to increase support for community-led organizations blazing the trail towards birth justice and maternal health equity. The fragmented medical and public health response has not provided better outcomes, and it is evident that serious, substantial measures must be institutionalized and financially and practically supported to change the trajectory of birthing outcomes for Black women and birthing people and for Black infants. This paper provides a critical critique and blueprint for how to do so: a human rights-based, community-led coalition using a collective-impact based approach to implementing patient safety bundles to explicitly address obstetric racism. It is time to restore the soul to birthing in MDC, as every mother and birthing person deserves a more humane, respectful, dignifying, caring, and safer experience and outcome during their divine endeavor to bring forth life.