The United States has the highest rate of death in pregnancy and childbirth. According to a 2023 report, it is one of the “most dangerous developed nations” for childbirth. Data from the Centers for Disease Control and Prevention revealed that the rising US maternal death rate grew significantly in 2021, reaching 32.9 deaths per 100,000 live births, up from 23.8 in 2020. Though rates have lowered slightly in the intervening years, they are still alarmingly high compared to other developed nations. In addition to high maternal mortality, maternal morbidity is also a serious public health issue.
Not surprisingly, maternal mortality and morbidity are not distributed equally in the US, where there are significant racial and ethnic disparities in maternal health outcomes. In 2021, the maternal mortality rate for Black women was 69.9 deaths per 100,000 live births, 2.6 times the rate for white women (26.6). A 2021 report released by the DC Maternal Mortality Review Committee found that the highest morbidity rates were in Washington, DC, where 90% of all pregnancy-related deaths were among Black mothers, even though they constituted around half of all births there.
The good news is that people are taking note of this dangerous situation, and consequently, policies are being introduced to address the maternal health crisis. For example, at the federal level, the 2021 Black Maternal “Momnibus” Act is an extensive, historic, bipartisan package of bills aimed at providing pre- and post-natal support for Black mothers. It includes investing in social determinants of health that influence maternal health outcomes, like housing, transportation, and nutrition; extending WIC eligibility in the postpartum and breastfeeding periods; providing funding to community-based organizations working to improve maternal health outcomes and to promote equity; and many others. For the past two years, the Biden-Harris administration has been developing and implementing a “Blueprint for Addressing the Maternal Health Crisis,” which includes policy initiatives that establish the first-ever federal standards for health and safety requirements for maternal emergency and obstetric services in hospitals, extend postpartum Medicaid coverage from 2 to 12 months, and more. These structural-level interventions are key to improving the dire situation of Black maternal mortality and morbidity in this country.
But in addition to structural-level changes, we also need clinical- and individual-level interventions if we are going to make any serious improvements in maternal health outcomes. In our recently published book, Microaggressions in Medicine, and within the context of the structural problems just mentioned, we discuss an important phenomenon that contributes to high mortality and morbidity rates for Black pregnant people that tend to be far less commonly discussed alongside the structural-level dimensions of the problem. These are microaggressions.
Microaggressions and Black Maternal Health
Microaggressions are comments, actions, gestures, or even features of physical spaces that subtly and often unintentionally communicate bias or hostility toward members of marginalized groups. They can be particularly pernicious because they are frequent and subtle, and therefore tend to be written-off as insignificant, or altogether ignored. Importantly, for members of marginalized groups, microaggressions never happen just once. Rather, they are continual, and this compounds their harms.
In her book, Thick, writer, professor, and MacArthur “genius” Award winner Tressie McMillan Cottom recounts her experience with pregnancy. Despite her social standing and intellectual and academic achievements, as a self-described fat, Black woman, she knew that in any medical context – but especially, as a fat, Black, pregnant woman – she would face an array of discriminations. For this reason, she chose her physicians carefully–or so she thought.
When Cottom was four months pregnant, bleeding and in terrible pain, she knew that something was wrong. When she and her then husband arrived at her doctor’s office, instead of being seen immediately, she was told to sit patiently in the waiting room, like everyone else. After insisting that she get some privacy since she was bleeding all over the chair, she was brought to an examination room. But when her doctor arrived, he simply looked at her and said that she was probably “just too fat.” For women like her, he proclaimed, spotting was normal. She was sent home and told not to worry.
But her pain escalated. When she described it to a nurse over the phone, she was told that it was probably just constipation and that she should try to go to the bathroom. She did this for the next 36 hours, with no luck. So, she tried the hospital. There, they implied that she’d probably just eaten something that was “bad” for her. Finally, and begrudgingly, they agreed to perform an ultrasound, which showed not one, but three growths in her uterus. In addition to the fetus, there were two large tumors. Upon learning this, the nurse scolded Cottom: “You should have said something.” Eventually, Cottom went into early labor and gave birth to her daughter, who died shortly thereafter. While making plans for how to handle her daughter’s remains, another nurse said: “Just so you know, there was nothing we could have done since you never told us that you were in labor.”
Though there are so many egregious issues with the way that Cottom was treated, we will focus on how racial and gender epistemic microaggressions combine in ways that are unique to Black women, what we call the misogynoir of microaggressions. Before doing so, it’s crucial to emphasize that the result of these microaggressions was nothing micro.
At every stage, Cottom knew that there was something wrong, tried to convey this knowledge to her healthcare team, and consistently was not recognized as a credible knower of her body. Cottom writes:
“The assumption that black women’s incompetence – we cannot know ourselves, express ourselves in a way that the context will render legible, or that prompts people with power to respond to us as agentic beings – supersedes even the most powerful status cultures in all of neoliberal capitalism.”
Cottom experienced what we call epistemic microaggressions which are intentional or unintentional verbal or gestural slights made by healthcare professionals or others that dismiss, ignore, or otherwise fail to recognize knowledge claims made by patients about their bodies. These are the often subtle, passing comments that suggest or imply that someone does not – or cannot – know what they are talking about: in this case, about their own body, symptoms, or pain levels. Epistemic microaggressions occur as a result of stereotypes about race, gender, and their relation to expectations about knowledge, namely, to who can be a reliable knower, or not.
On account of the entrenched biases and stereotypes about Black women (and particularly Black women who are fat), Cottom experienced a complex kind of racialized gendered epistemic microaggression. A pregnant woman who was bleeding and in pain, her bleeding was attributed to her fatness. Later, her pain was dismissed as resulting from something “bad” that she’d eaten, where “bad” has racist undertones about what Black people eat and where the immediate connection to something she ate could be attributed to her being fat. Finally, after the death of her daughter, she was blamed for not having spoken up sooner, with the implication that the death was in part her fault and could have been prevented had she only said something.
In each instance, though Cottom knew that something was wrong, she was powerless relative to the healthcare professionals. Over and again, healthcare professionals assumed they knew better. Because of her race, gender, and body size, Cottom suffered the epistemic harm of not being recognized as a credible knower; the practical harms of severe physical pain; and ultimately, the death of her daughter, as well as the enduring trauma of the whole experience.
The racialized gendered epistemic microaggressions that Cottom experienced reflect imbalances in social power that are present both in healthcare and in society. Resisting the kinds of microaggressions Cottom experienced – as well as the resulting harms she endured – requires recognizing how these imbalances in power manifest in interpersonal exchanges, and how individuals and institutions might work to avoid them. If we are to make progress on the serious inequities in Black maternal health, we need all the tools in the toolkit to change the current situation: we need to tackle structural gaps in healthcare access, to address inequitable policies, and we need to improve interpersonal dynamics, which shape clinical encounters and impact communication and trust. To achieve the latter, we must attend to microaggressions and their serious consequences for marginalized patients. To do so is an essential step toward health justice.
Lauren Freeman, PhD is a Professor of Philosophy at University of Louisville.
Heather Stewart, PhD is an Assistant Professor of Philosophy at Oklahoma State University.