BIRMINGHAM, Ala. (AP) — Angelica Lyons knew it was dangerous for Black women to give birth in America.
As a public health instructor, she taught college students about racial health disparities, including the fact that Black women in the U.S. are nearly three times more likely to die during pregnancy or delivery than any other race. Her home state of Alabama has the third-highest maternal mortality rate in the nation.
Then, in 2019, it nearly happened to her.
What should have been a joyous first pregnancy quickly turned into a nightmare when she began to suffer debilitating stomach pain.
Her pleas for help were shrugged off, she said, and she was repeatedly sent home from the hospital. Doctors and nurses told her she was suffering from normal contractions, she said, even as her abdominal pain worsened and she began to vomit bile. Angelica said she wasn’t taken seriously until a searing pain rocketed throughout her body and her baby’s heart rate plummeted.
Rushed into the operating room for an emergency cesarean section, months before her due date, she nearly died of an undiagnosed case of sepsis.
Her experience is a reflection of the medical racism, bias and inattentive care that Black Americans endure. Black women have the highest maternal mortality rate in the United States — 69.9 per 100,000 live births for 2021, almost three times the rate for white women, according to the Centers for Disease Control and Prevention.
Black babies are more likely to die, and also far more likely to be born prematurely, setting the stage for health issues that could follow them through their lives.
“Race plays a huge part, especially in the South, in terms of how you’re treated,” Angelica said, and the effects are catastrophic. “People are dying.”
To be Black anywhere in America is to experience higher rates of chronic ailments like asthma, diabetes, high blood pressure, Alzheimer’s and, most recently, COVID-19. Black Americans have less access to adequate medical care; their life expectancy is shorter.
From birth to death, regardless of wealth or social standing, they are far more likely to get sick and die from common ailments.
Black Americans’ health issues have long been ascribed to genetics or behavior, when in actuality, an array of circumstances linked to racism — among them, restrictions on where people could live and historical lack of access to care — play major roles.
Discrimination and bias in hospital settings have been disastrous.
The nation’s health disparities have had a tragic impact: Over the past two decades, the higher mortality rate among Black Americans resulted in 1.6 million excess deaths compared to white Americans. That higher mortality rate resulted in a cumulative loss of more than 80 million years of life due to people dying young and billions of dollars in health care and lost opportunity.
A yearlong Associated Press project found that the health challenges Black Americans endure often begin before their first breath.
The AP conducted dozens of interviews with doctors, medical professionals, advocates, historians and researchers who detailed how a history of racism that began during the foundational years of America led to the disparities seen today.
It was only after her baby was born that Angelica, 34, learned she nearly died.
“I was on life support,” she said. “I coded.”
She woke up three days later, unable to talk because of a ventilator in her mouth. She remembers gesturing wildly to her mother, asking where her son, Malik, was.
He was OK. But Angelica felt so much had been taken from her. She never got to experience those first moments of joy of having her newborn placed on her chest. She didn’t even know what her son looked like.
Maternal sepsis is a leading cause of maternal mortality in America. Black women are twice as likely to develop severe maternal sepsis, as compared to their white counterparts. Common symptoms can include fever or pain in the area of infection. Sepsis can develop quickly, so a timely response is crucial.
Sepsis in its early stages can mirror common pregnancy symptoms, so it can be hard to diagnose. Due to a lack of training, some medical providers don’t know what to look for. But slow or missed diagnoses are also the result of bias, structural racism in medicine and inattentive care that leads to patients, particularly Black women, not being heard.
“The way structural racism can play out in this particular disease is not being taken seriously,” said Dr. Laura Riley, chief of obstetrics and gynecology at Weill Cornell Medicine and New York-Presbyterian Hospital. “We know that delay in diagnosis is what leads to these really bad outcomes.”
For decades, frustrated birth advocates and medical professionals have tried to sound an alarm about the ways medicine has failed Black women. Historians trace that maltreatment to racist medical practices that Black people endured amid and after slavery.
To fully understand maternal mortality and infant mortality crises for Black women and babies, the nation must first reckon with the dark history of how gynecology began, said Deirdre Cooper Owens, a historian and author.
“The history of this particular medical branch … it begins on a slave farm in Alabama,” Owens said. “The advancement of obstetrics and gynecology had such an intimate relationship with slavery, and was literally built on the wounds of Black women.”
Reproductive surgeries that were experimental at the time, like cesarean sections, were commonly performed on enslaved Black women.
Physicians like the once-heralded J. Marion Sims, an Alabama doctor many call the “father of gynecology,” performed torturous surgical experiments on enslaved Black women in the 1840s without anesthesia.
And well after the abolition of slavery, hospitals performed unnecessary hysterectomies on Black women, and eugenics programs sterilized them.
Health care segregation also played a major role in the racial health gap still experienced today.
Until Congress passed the Civil Rights Act of 1964, Black families were mostly barred from well-funded white hospitals and often received limited, poor or inhumane medical treatment. Black-led clinics and doctors worked to fill in the gaps, but even after the new protections, hospitals once reserved for Black families remained under-resourced, and Black women didn’t get the same support regularly available for white women.
That history of abuse and neglect led to deep-rooted distrust of health care institutions among communities of color.
“We have to recognize that it’s not about just some racist people or a few bad actors,” said Rana A. Hogarth, an associate professor of History at the University of Illinois, Urbana-Champaign. “People need to stop thinking about things like slavery and racism as just these features that happened that are part of the contours of history and maybe think of them more as foundational and institutions that have been with us every step of the way.”
Some health care providers still hold false beliefs about biological differences between Black and white people, such as Black people having “less sensitive nerve endings, thicker skin, and stronger bones.” Those beliefs have caused medical providers today to rate Black patients’ pain lower, and recommend less relief.
The differences exist regardless of education or income level. Black women who have a college education or higher have a pregnancy-related mortality rate that is more than five times higher than that of white women. Notably, the pregnancy-related mortality rate for Black women with a college education is 1.6. times higher than that of white women with less than a high school degree.
Efforts to address problem
There are indications that the sufferings of Black mothers and their babies are being recognized, however late.
In 2019, U.S. Rep. Lauren Underwood, an Illinois Democrat, and Rep. Alma Adams, a North Carolina Democrat, launched the Black Maternal Health Caucus. It is now one of the largest bipartisan congressional caucuses. The caucus introduced the Black Maternal Health Momnibus Act in 2019 and again in 2021, proposing sweeping changes that would increase funding and strengthen oversight. Key parts of the legislation have been adopted but the bill itself has yet to be approved.
President Joe Biden’s budget for fiscal year 2024 includes $471 million in funding to reduce maternal mortality and morbidity rates, expand maternal health initiatives in rural communities, and implicit bias training and other initiatives. It also requires states to provide continuous Medicaid coverage for 12 months postpartum, to eliminate gaps in health insurance. It also includes $1.9 billion in funding for women and child health programs.
U.S. Secretary of Health and Human Services Xavier Becerra told The Associated Press more must be done at all levels of government to root out racism and bias within health care.
“We know that if we provide access to care for mother and baby for a full year, that we probably help produce not just good health results, but a promising future for mom and baby moving forward,” he said.
More from this series
This story is part of an AP series examining the health disparities experienced by Black Americans across a lifetime.