Two weeks before her due date, Stephanie Watson-Lewis began feeling ill. She went to the hospital multiple times asking doctors to use a fetal monitor to check on the health of her baby.
But staff there would tell Watson-Lewis her baby was healthy, or they’d say the end of a pregnancy is simply uncomfortable, before sending her home. Within 48 hours of her final visit to the hospital to ask for help in November 2014, her unborn baby, Cassius, stopped moving and died in her womb.
An autopsy report confirmed baby Cassius had been healthy. But the umbilical cord was wrapped through his legs and around his neck multiple times, Watson-Lewis said.
“It should have never happened,” she said in an interview earlier this month. “My son should not be dead.”
Watson-Lewis’ experience is eerily similar to accounts from other pregnant people of color, who have been speaking up for decades about callous medical treatment during their pregnancies.
Doulas and researchers interviewed for this story said medical providers often do not notice their own biases, and therefore, don’t recognize the ways in which they contribute to a system still providing racist and dangerous care.
Obstetric care is often still centered on the needs of white pregnant people, according to a recent study led by researchers at the University of Colorado, which found racist care is leading to increased labor inductions in Colorado and across the country.
The foundation of the American medical system is rooted in experimentation and exploitation of Black people especially, the researchers wrote.
“And that reverberates today in how medical providers learned,” said Lauren Smith, Black civil engagement and policy manager for Elephant Circle and Soul 2 Soul Sisters, racial and reproductive justice organizations. “There are still textbooks out there that say that Black people have a higher pain tolerance, for example.”
Medical anthropologist Dána-Ain Davis first coined the term “obstetric racism” in 2018 after spending years interviewing Black women about their birthing experiences, which included accounts of being disrespected, discounted, neglected and ignored — and in even more extreme cases — they described being coerced to undergo unwanted procedures or said doctors performed procedures without their consent.
The CU study builds on the groundbreaking work of Davis, who works at City University of New York, but study leaders did not interview her or any pregnant people of color who have experienced obstetric racism, said Indra Lusero, director at Elephant Circle.
“The study had — from what I can tell — all white authors. So that’s a great example of how any system can focus on the needs of white folks and not people of color,” Lusero said. “Nobody ever thinks to talk to a Black woman or a Latina woman and say, ‘Hey, what do you need?’ But the other sad truth is that this system was not built for any pregnant person. It’s not structured around the needs of pregnant and laboring people. It’s much more structured around providers and the facilities.”
The study focused on population analyses and aimed to add to existing anecdotal research about obstetric racism already discussed in interviews, said Ryan Masters, an associate professor of sociology studying health and mortality at CU and senior co-author of the study. It’s always important to include researchers who are people of color, he said, but that’s often a challenge in a profession with its own inequities and little racial diversity.
Increasing labor inductions
Systemic and interpersonal racism are drivers of inadequate obstetric care and are responsible for devastating health outcomes for pregnant people of color in the U.S., according to the study Masters helped lead, which was recently published in the Journal of Health and Social Behavior.
“The story about my son dying is terrible,” Watson-Lewis said. “But dealing with my daughter was also crazy.”
About a year and a half after Cassius died, Watson-Lewis was nearing the delivery date for her daughter. Near the end of her pregnancy, she told hospital staff she feared her daughter may have turned into a breech position, which occurs when the baby’s butt, feet or both are positioned to come out first during birth rather than their head.
Hospital staff told Watson-Lewis she had recently had a sonogram and that it was unlikely the baby was breech. She was sent home where she called a friend who is one of a few obstetricians willing to deliver breech babies in Colorado.
When Watson-Lewis arrived at that doctor’s office, she and a midwife discovered the baby was indeed breech, and that her child was wrapped in the umbilical cord. Her daughter was safely delivered during an emergency cesarean section.
“I am so lucky because I had a friend,” said Watson-Lewis, whose daughter is now 7 years old and healthy. “Nobody should have to call in a personal favor to be heard. I could have had another fatality.”
The recent CU study examines the increasing use of inductions to deliver babies, which have nearly tripled since 1990, and have shortened U.S. pregnancies by about a week on average. Induced labor requires medicine to initiate uterine contractions. The procedure speeds up the birth and can be necessary if the baby’s or parent’s life is in danger, among other reasons, according to the American College of Obstetricians and Gynecologists.
CU researchers used state-level data from the National Vital Statistics System to analyze single-child first-births to more than 45 million Black, white and Latina women, tallying whether they were induced and when, and noting the overall health of the pregnant person.
From 1990 to 2017, the average induction of labor rate among Black mothers in the U.S. increased to 33.8% from 10.7%. For Latina mothers, the average rate increased to 31.2% from 10.5%. And for white mothers, the rate increased to 35.9% from 13.9%, according to the National Vital Statistics System.
Colorado rates within that same timeframe for each racial group are slightly lower but the numbers may not be comparable. The analytic sample for births to white women included all 50 states and the District of Columbia, while the sample for births to Black mothers was limited to 43 states and the District of Columbia, and the sample for Latina mothers was limited to 47 states and Washington, D.C.
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The spike in labor inductions for white women is explained by changing demographics, such as the age of the mother, and an increase in higher-risk pregnancies such as from hypertension, obesity, diabetes and drinking or smoking while pregnant.
But increases in labor inductions among Black and Latina mothers are not associated with changes in demographics or risk factors and the trend appears to be medically unexplainable, study leaders wrote.
Instead, increases in national labor induction rates among Black and Latina women were strongly shaped by changes in the demographics and risk factors of the white childbearing population, researchers wrote.
In other words, decisions about care for Black and Latina mothers appear to be based on trends in the white childbearing population, which shows obstetric racism persists, adding to a growing body of literature that implicates the pervasiveness of racism across U.S. institutions, according to the findings.
“The development of norms, culture, training, institutional-level practices and hospital policies are very much oriented in a way that tries to standardize care, and they standardize that care on what they perceive to be the typical or the normative patient, which, within the U.S. context historically and contemporarily still is the dominant white population,” said Masters, the study’s co-leader.
Increasing mortality rates
Racism in health care has contributed to the perception that Black and Latina women are less healthy and more likely to have high risk pregnancies when compared with white women, according to the study. These biases, the researchers said, may be causing health providers to intervene in pregnancies unnecessarily and induce labor in pregnant people of color more often than needed.
Increasing mortality rates, the continued heightened attention that comes with the trend, and a health care education system rooted in a history of racism that continues to inform training and guidance received by providers are likely influencing clinicians’ perceptions of the health and needs of pregnant patients of color in delivery rooms. As a result, some providers are likely assessing and treating patients based on their skin color or on racist perceptions of their family background and communities, rather than providing person-centered care based on individual risk factors and listening to the needs and preferences of patients, according to the study.
That trend is particularly concerning, study authors said, because their previous research has shown inducing early labor can lead to low birth weights among babies and subsequent health problems later in the child’s life.
The findings come amid rising concerns about maternal mortality rates, especially among Black mothers, who are three times more likely to die from pregnancy-related complications compared with white mothers, according to the Centers for Disease Control and Prevention.
The “medicalization of birth” has left little room for nuances in pregnant people’s individual experiences and allows racism and systemic inequities to proliferate when a patient is seen as a number on a chart, said Smith, from Elephant Circle and Soul to Soul Sisters.
The “medicalization of birth” has also meant a hospital’s financial interests are often directly at odds with allowing labor to unfold naturally, she said.
Study authors said reducing obstetric racism requires everyone, including clinicians, to acknowledge and work toward dismantling their own implicit biases.
But that’s easier said than done, Smith said. “How do we hold people accountable to recognizing what actions they’re taking that they don’t even realize are part of their implicit biases? We can’t really do that if we don’t have that accountability loop.”
There are few ways to hold doctors accountable for initiating a high number of labor inductions, or for racking up too many complaints about obstetric racism, aside from proving that they were involved in malpractice, said Lusero, who also is an attorney specializing in birth justice.
“It is hard, verging on impossible, to prove that something like initiating labor inductions is malpractice,” Lusero wrote in an email.
While Jasmine Ellington was pregnant, her obstetrician recommended that she have a cesarean birth in case she had complications from diabetes or any other health emergency. So when Ellington went to the hospital, shortly before she was expecting to be induced and told doctors that she was feeling ill and wanted them to use a fetal monitor, she expected her obstetrician to be there to deliver the care.
But when Ellington got to the hospital, a different obstetrician was there, and he declined to perform the cesarean section because, he said, Ellington has diabetes, and that her disease — even if it was under control — could cause complications. A cesarean birth, he said, would also likely keep her out of work for more than nine weeks.
“I was taken aback because I had had diabetes the whole pregnancy and my original doctor did write an order in case of an emergency saying they can perform a C-section,” Ellington said. “I don’t care how long I’m out of work. He prioritized me being out of work over my baby’s life.”
Soon after, a different obstetrician came in to deliver Ellington’s baby vaginally. But by then, Ellington knew her baby — who hadn’t moved in hours — had probably died. Ellington said the second doctor was rude and condescending and ridiculed her for not pushing hard enough during contractions. He said she was much weaker than the other 8,000 moms whose babies he had delivered during his career.
At one point, he asked doctors and nurses to push down on Ellington’s stomach to drive the baby out. Ellington said she still has pain from the birth in October 2018.
Hospital staff allowed about 35 people into Ellington’s delivery room that day without her consent, she said. And at one point, a nurse told Ellington she was the only Black patient on the obstetrics floor that day.
“I feel like that was her way of letting me know that they were going to handle me differently,” Ellington said. “And I feel like she died because of the doctors’ decisions. They didn’t really give me a choice. I would have rather had a C-section.”
Ellington began yelling at hospital staff when they offered her a list of funeral homes and expressed plans to discharge her soon after her daughter Azalia’s death. That was before she even got a chance to hold her baby and grieve, Ellington said.
Obstetricians eventually sent Ellington to a psychiatric hospital across the street because, they said, she became too aggressive after Azalia was born dead.
“I shouldn’t have been there,” Ellington said about the psychiatric facility where she was held for four days. “I needed grief help and no one was helping me.”
Ellington wrote a formal complaint to the Colorado Medical Board, which regulates doctors, and is also composed of doctors.
She shared a copy of the board’s response with The Colorado Sun, which says the facts Ellington presented do not amount to malpractice, and don’t warrant disciplinary action for the obstetrician who delivered her baby.
A representative from the Colorado Department of Regulatory Affairs said in an email, any information about complaints to the medical board board are confidential and are not available for public inspection if the board doesn’t impose public disciplinary action.
Ellington said she wouldn’t name the doctor or the hospital that delivered her baby in news articles because she fears legal retaliation.
“I take things day by day,” she said. “I am hoping that when I stand out and stand up for myself, it will bring people to want to do the same.”
Watson-Lewis has been a doula for 20 years, long before Cassius’ birth. And Ellington became a doula shortly after her daughter Azalia’s stillbirth.
Both mothers advocate for all pregnant people, especially people of color, who are most at risk for obstetric complications and death. Helping others move more smoothly through their pregnancies has helped Ellington and Watson-Lewis on their healing journey, they said.
Senate Bill 288, signed into law May 30, requires the state Department of Health Care Policy & Financing to create a process to promote the expansion and use of doula services for pregnant and postpartum people on Medicaid, no later than Sept. 1.
The law requires HCPF to seek federal authorization for Medicaid providers to begin supplying doula services to pregnant and postpartum people by July 1, 2024.
The law creates a doula scholarship program to provide financial assistance to people pursuing doula training and certification and requires the Colorado Division of Insurance to hire an independent contractor to study the potential health care costs and benefits of providing coverage for doula services in health benefit plans.
The bill also requires the Division of Insurance to submit a report to the Colorado General Assembly detailing the results and recommendations for fiscal year 2024-25.
“Doulas can help reduce the impacts of ethnic/racial bias in health care on pregnant people of color, by providing individually tailored, culturally appropriate, and patient-centered care and advocacy,” Rep. Junie Joseph, a Democrat from Boulder who co-sponsor of the bill, wrote in an email. “This policy will not only help women of color. It will help all women.”
A Colorado Department of Public Health and Environment report released July 1, showed hospitals, health systems, insurers, maternal care providers, pharmacies and other related sectors do not universally collect information on experiences, meaning there’s limited data on incidents of disrespect or mistreatment of people who are pregnant statewide.
Patient satisfaction surveys and complaint documentation are the primary methods for collecting information about disrespect or mistreatment toward pregnant people. However, the tracking mechanisms are not universal and the data often isn’t shared publicly, according to the report.
Recommendations in the report focus on improving collection and reporting of perinatal data by encouraging organizations to begin standardizing data collection and reporting those efforts.
Organizations that collect and share all critical data on perinatal conditions and outcomes can help influence state policy and resource allocations for maternal health, according to the report, which works to achieve equity in perinatal health experiences and outcomes.
When Kayla Greathouse learned she had a short cervix, doctors told her she needed a cervical cerclage, a procedure that closes the cervical opening with stitches to prevent premature birth.
When she woke up from the surgery, she vomited from the smell of anesthesia. A nurse who was standing near her was distracted and did not see that Greathouse was panicking and choking on her vomit because she was talking to another nearby provider about her personal life.
When a doctor saw Greathouse choking, he instructed the nurse to turn Greathouse and wipe vomit off her mouth. The nurse did, Greathouse said, but she did not clean all of it off. Greathouse said she feels the nurse would have been more attentive if she were a white mother.
During her pregnancy, Greathouse said she was swapped among at least five doctors, who often had drastically different ideas and recommendations for obstetric care. “I almost never saw the same doctor,” she said.
When she talked to white women in the hospital who were also pregnant, Greathouse said they were given clear directions by their doctors, and that they never seemed as confused as she was about obstetric care.
Irth, a new “Yelp-like app” allows people of color who are pregnant or new parents to review their care providers. The app aims to end racism in maternity care by creating accountability and meaningful data to push for a more equitable health care system, according to the website.
Watson-Lewis, the doula, is an ambassador for the app, and said people who have had bad pregnancy and delivery experiences feel it’s up to them to keep medical providers accountable when they provide inadequate care.
“There’s no (accountability), so now we have to do the work ourselves,” Watson-Lewis said. “We have to do the research. We have to tell the stories. We have to do all these things so that our community isn’t robbed.”