Serena Williams knew her body well enough to listen when it told her something was wrong. Winner of 23 Grand Slam singles titles, she’d been playing tennis since age 3—as a professional since 14. Along the way, she’d survived a life-threatening blood clot in her lungs, bounced back from knee injuries, and drowned out the voices of sports commentators and fans who criticized her body and spewed racist epithets. At 36, Williams was as powerful as ever. She could still devastate opponents with the power of a serve once clocked at 128.6 miles per hour. But in September 2017, on the day after delivering her baby, Olympia, by emergency C-section, Williams lost her breath and recognized the warning signs of a serious condition.
She walked out of her hospital room and approached a nurse, Williams later told Vogue magazine. Gasping out her words, she said that she feared another blood clot and needed a CT scan and an IV of heparin, a blood thinner. The nurse suggested that Williams’ pain medication must be making her confused. Williams insisted that something was wrong, and a test was ordered—an ultrasound on her legs to address swelling. When that turned up nothing, she was finally sent for the lung CT. It found several blood clots. And, just as Williams had suggested, heparin did the trick. She told Vogue, “I was like, listen to Dr. Williams!”
But her ordeal wasn’t over. Severe coughing had opened her C-section incision, and a subsequent surgery revealed a hemorrhage at that site. When Williams was finally released from the hospital, she was confined to her bed for six weeks.
Like Williams, Shalon Irving, an African American woman, was 36 when she had her baby in 2017. An epidemiologist at the U.S. Centers for Disease Control and Prevention (CDC), she wrote in her Twitter bio, “I see inequity wherever it exists, call it by name, and work to eliminate it.”
Irving knew her pregnancy was risky. She had a clotting disorder and a history of high blood pressure, but she also had access to top-quality care and a strong support system of family and friends. She was doing so well after the C-section birth of her baby, Soleil, that her doctors consented to her request to leave the hospital after just two nights (three or four is typical). But after she returned home, things quickly went downhill.
For the next three weeks, Irving made visit after visit to her primary care providers, first for a painful hematoma (blood trapped under layers of healing skin) at her incision, then for spiking blood pressure, headaches and blurred vision, swelling legs, and rapid weight gain. Her mother told ProPublica that at these appointments, clinicians repeatedly assured Irving that the symptoms were normal. She just needed to wait it out. But hours after her last medical appointment, Irving took a newly prescribed blood pressure medication, collapsed, and died soon after at the hospital when her family removed her from life support.
Viewed up close, the deaths of mothers like Irving are devastating, private tragedies. But pull back, and a picture emerges of a public health crisis that’s been hiding in plain sight for the last 30 years.
Following decades of decline, maternal deaths began to rise in the United States around 1990—a significant departure from the world’s other affluent countries. By 2013, rates had more than doubled. The CDC now estimates that 700 to 900 new and expectant mothers die in the U.S. each year, and an additional 500,000 women experience life-threatening postpartum complications. More than half of these deaths and near deaths are from preventable causes, and a disproportionate number of the women suffering are black.
Put simply, for black women far more than for white women, giving birth can amount to a death sentence. African American women are three to four times more likely to die during or after delivery than are white women. According to the World Health Organization, their odds of surviving childbirth are comparable to those of women in countries such as Mexico and Uzbekistan, where significant proportions of the population live in poverty.
Irving’s friend Raegan McDonald-Mosley, chief medical director for Planned Parenthood Federation of America, told ProPublica, “You can’t educate your way out of this problem. You can’t health-care-access your way out of this problem. There’s something inherently wrong with the system that’s not valuing the lives of black women equally to white women.”
Speaking at a symposium hosted by the Maternal Health Task Force at the Harvard T.H. Chan School of Public Health in September 2018, investigative reporter Nina Martin noted telling commonalities in the stories she’s gathered about mothers who died. Once a baby is born, he or she becomes the focus of medical attention. Mothers are monitored less, their concerns are often dismissed, and they tend to be sent home without adequate information about potentially concerning symptoms. For African American mothers, the risks jump at each stage of the labor, delivery, and postpartum process.
Neel Shah, an obstetrician-gynecologist at Beth Israel Deaconess Medical Center in Boston and director of the Delivery Decisions Initiative at Ariadne Labs, recalls being struck by Martin’s ProPublica-NPR series Lost Mothers, which delved into the issue. “The common thread is that when black women expressed concern about their symptoms, clinicians were more delayed and seemed to believe them less,” he says. “It’s forced me to think more deeply about my own approach. There is a very fine line between clinical intuition and unconscious bias.”
For members of the public, the experiences of prominent black women may prove to be a teachable moment. When pop superstar Beyoncé developed the hypertensive disorder pre-eclampsia—which left untreated can kill a mother and her baby—after delivering her twins by emergency C-section in 2017, Google searches related to the condition spiked. According to the U.S. Agency for Healthcare Research and Quality, pre-eclampsia—one of the leading causes of maternal death—and eclampsia (seizures that develop after pre-eclampsia) are 60 percent more common in African American women than in white women, and also more severe. If it can happen to Beyoncé—an international star who presumably can afford the highest-quality medical care—it can happen to anyone.
Arline Geronimus, SD ’85, has been talking about the effects of racism on health for decades, even when others haven’t wanted to listen. Growing up in the 1960s in Brookline, Massachusetts, Geronimus, who is white, absorbed the messages of the Civil Rights movement and the harrowing stories of her Jewish family’s experiences in czarist Russia. When she headed off to Princeton as an undergraduate, she resolved to find a way to fight against injustice. Her initial plan to become a civil rights lawyer gave way when she discovered the power and potential of public health research.
Geronimus worked as a research assistant for a professor studying teen pregnancy among poor urban residents, and, as a volunteer at a Planned Parenthood clinic, witnessed close-up the lives of pregnant black teens living in poverty in Trenton, New Jersey. She felt a chasm open up between what some of her white male professors were confidently explicating about the lives of these adolescents and how the young women themselves saw their lives.
According to the conventional wisdom at the time, Geronimus says, teen pregnancy was the primary driver of maternal and infant deaths and a host of multigenerational health and social problems among low-income African Americans. Researchers focused on this issue while ignoring broader systemic factors.
Geronimus sought to connect the dots between the health problems the girls experienced, like asthma and type 2 diabetes, and negative forces in their lives. She visited them in their crumbling apartments and accompanied them to medical appointments where doctors treated the girls like props, without agency in their own care. And she noticed that they seemed older, somehow, than girls the same age whom Geronimus knew.
“That’s when I got the fire in my belly,” she says, her voice rising. “These young women had real, immediate needs that those of us in the hallowed halls of Princeton could have helped address. But we weren’t seeing those urgent needs. We just wanted to teach them about contraception.”
Geronimus came to the Harvard Chan School to learn how to rigorously explore the ways that social disadvantage corrodes health—a concept for which she coined the term “weathering.” Her adviser, Steven Gortmaker, professor of the practice of health sociology, provided data for her to correlate infant mortality by maternal age. While most such studies put mothers into broad categories of teen and not-teen, Geronimus looked at the risks they faced at every age. The results were surprising even to her.
White women in their 20s were more likely to give birth to a healthy baby than those in their teens. But among black women, the opposite was true: The older the mother, the greater the risk of maternal and newborn health complications and death. In public health, the condition of a baby is considered a reliable proxy for the health of the mother. Geronimus’ data suggested that black women may be less healthy at 25 than at 17.
“Being able to see those stark numbers was essential for me,” says Geronimus, who is now a professor of health behavior and health education at the University of Michigan School of Public Health and a member of the National Academy of Medicine. And the implications were staggering. If young black women were already showing signs of weathering, how would that play out over the rest of their lives—and what could be done to stop it?
Geronimus’ questions were ahead of their time. The press and the public—even other scientists—misinterpreted her findings as a recommendation that black women have children in their teens, she says, recalling with a sigh such clueless headlines as, “Researcher says let them have babies.”
In the 1970s, even researchers who broached the topic of racial differences in health outcomes—and few did—focused on small pieces of the puzzle. Some were looking at genetics, others at behavioral and cultural differences or health care access. “No one wanted to look at what was wrong with how our society works and how that can be expressed in the health of different groups,” Geronimus says. Over time, her ideas would become harder to dismiss.
The tide began to turn in the early 1980s, when former Health and Human Services Secretary Margaret Heckler convened the first group of experts to conduct a comprehensive study of the health status of minority populations. As the field of social epidemiology took off, the Report of the Secretary’s Task Force on Black and Minority Health (also known as the Heckler Report) brought Geronimus’ animating questions into mainstream debate.
Then, in 1993, researchers identified a physiological mechanism that could finally explain weathering: allostatic load. “We as a species are designed to respond to threats to life by having a physiological stress response,” Geronimus explains. “When you face a literal life-or-death threat, there is a short window of time during which you must escape or be killed by the predator.” Stress hormones cascade through the body, sending blood flowing to the muscles and the heart to help the body run faster and fight harder. Molecules called pro-inflammatory cytokines are produced to help heal any wounds that result.
These processes siphon energy from other bodily systems that aren’t enlisted in the fight-or-flight response, including those that support healthy pregnancies. That’s not important if the threat is short term, because the body’s biochemical homeostasis quickly returns to normal. But for people who face chronic threats and hardships—like struggling to make ends meet on a minimum wage job or witnessing racialized police brutality—the fight-or-flight response may never abate. “It’s like facing tigers coming from several directions every day,” Geronimus says, and the damage is compounded over time.
As a result, health risks rise at increasingly younger ages for chronic conditions like hypertension and type 2 diabetes. Depression and sleep deprivation become more common. People are also more likely to engage in risky coping behaviors, such as overeating, drinking, and smoking.
Geronimus’ foundational work in the 1980s and 1990s has been cited by David R. Williams, the Florence Sprague Norman and Laura Smart Norman Professor of Public Health at the Harvard Chan School, an internationally recognized expert in the ways that racism and other social influences affect health. His Everyday Discrimination Scale is one of the most widely used measures of discrimination in health studies. It includes questions that measure experiences such as being treated with discourtesy, receiving poorer service than others in restaurants or stores, or witnessing people act as if they’re afraid of you. As he explained in a 2016 TEDMED talk, “This scale captures ways in which the dignity and the respect of people who society does not value is chipped away on a daily basis.”
Amy Roeder is associate editor of Harvard Public Health.
Photos: Getty Images, Becky Harlan/NPR, Brian Lillie/University of Michigan, U.S. Centers for Disease Control and Prevention
Illustrations: Benjamin S. Wallace/Harvard Chan School