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Opinions | Dobbs may exacerbate our racially disparate infant mortality rates

The Washington Post logo The Washington Post 8/18/2022 Shannon Withycombe
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Antiabortion activists and lawmakers continue to celebrate the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision as a win for America’s infants. Yet, many of the states that have recently banned or severely restricted abortion access have the highest infant mortality rates in the country. Louisiana, for example, which now bans nearly all abortions, has a higher infant mortality rate than 66 countries — and a Black infant mortality rate higher than 82 countries.

U.S. Sen. Bill Cassidy (R-La.) garnered public attention on the issue last spring. “If you correct our population for race,” he claimed, “we’re not as much of an outlier as it’d otherwise appear.” Despite Louisiana having the second-highest infant mortality rate and the fifth-highest maternal mortality rate in the nation, Cassidy seemed to be saying that somehow only looking at the deaths of White infants and mothers is the “correct” viewpoint when addressing health statistics.

Those like Cassidy — who profess to be pro-life but seem unconcerned about disproportionate Black infant death rates — are following in a long tradition. In many ways, Cassidy, who is White and a physician by trade, sounds like the public health officials, doctors and lawmakers who set up America’s prenatal care system over 100 years ago. These predominantly White men and women did so with the explicit goal of saving White infants. They likewise informed Black families and other families of color that their children’s deaths were due to biological inferiority built into their bodies — alleged deficiencies that could never be remedied.

These were not new ideas. Many of these biological narratives about Black Americans were established to legitimate slavery. White enslavers and physicians argued that the inherited physical nature of African Americans made them particularly suited to grueling manual labor. They claimed that Black women had no natural sexual morality and “exceptional” fertility, justifying rape and forced pregnancy in both moral and economic terms, since, by law, children inherited their mother’s enslaved status. Enslavers also maintained that Black women gave birth with little pain and needed no recovery time afterward.

These ideas persisted after slavery ended. Dr. George Engelmann, a White physician in St. Louis, wrote in 1881, for instance, that Black and Native women in the United States were “primitive” people who experienced childbirth that was “short and easy, accompanied by few accidents and followed by little or no prostration.”

America’s racially skewed prenatal care system was built on these ideas in the 1910s, when Americans learned two things that surprised them: More infants died in the United States than in most European countries, and the majority of those deaths took place in the first month of life.

These findings created a storm of concern among politicians and medical practitioners over the nation’s health and international power and prestige. Various groups, from doctors and wealthy White club women to the U.S. Children’s Bureau — a newly formed federal health agency — began researching why so many infants died, and how medicine and public health measures could remedy the problem.

These groups strongly advocated for a medical surveillance system for pregnant women, what we now know as prenatal care. Their purported goal was to monitor a woman’s pregnancy from the start to ensure babies were born healthy and had a greater chance of surviving through infancy. Doctors and public health agencies claimed that this sustained scientific attention was necessary, even though most of the advice under the new label of “prenatal care” was in countless health guides in the 19th century under the title “pregnancy hygiene.” In addition to repeating traditional advice on diet, exercise and clothing, promoters of prenatal care argued that only male doctors could properly analyze a woman’s urine for signs of preeclampsia, a newly developed tool to combat a very old pregnancy complication. But even physicians admitted that eclampsia accounted for a very small proportion of infant deaths, and the real value of urinalysis and prenatal care was bringing women into the offices of doctors, where they might decide to use them for delivery assistance — as opposed to traditional female midwives.

The White leaders of this new prenatal care system produced study after study on infant mortality to build public trust and interest in prenatal care — and to compel state and federal agencies to provide funding. Yet, their conclusions reflected their own racial biases.

J. Whitridge Williams, for example, was a White physician who investigated infant mortality in Baltimore and published his findings in 1914. He looked at 705 infant deaths within a population he estimated was 46 percent Black. In reporting his findings that syphilis accounted for the majority of deaths among Black infants, he found a way to discount this as a cause of concern because it “only” accounted for 14 percent of the deaths of White infants. He argued that Black Baltimoreans lacked proper intelligence and care to prevent syphilis, and that these deficiencies were ones that “so frequently characterize[d] that race.” As he saw it, biological inferiority caused syphilis in Black Americans, which no amount of funding or treatment could change.

Similarly, after examining the death of every infant in Detroit in 1919, the Detroit Health Department also concluded that public funds for prenatal care should primarily be directed toward preventing the deaths of White infants. The survey found that the highest rates of respiratory disease were among Black and Italian infants, which the authors attributed to “climactic influence,” because both groups were “used to warm climates.” Relying on the association of Black Americans with African ancestry (regardless of how long they had lived in Detroit or elsewhere in the United States, which was typically their whole lives), the Health Department determined that their bodies were genetically unsuited to cold Detroit winters and therefore Black deaths could not be helped.

Owing to medical advances over the next 100 years, America’s infant mortality rate has declined for both Black and White infants, but the racial disparity has actually increased. Black Americans gained more legal rights, and the establishment of Medicare and the Civil Rights Act of 1964 desegregated medicine. Yet, these great advancements did little to change the racial gaps in medical care or to increase concern for Black women and their children.

Throughout the civil rights era of the 1950s and 1960s, Black women still were disproportionately subject to nonconsensual sterilization by White medical providers. And as late as the 1990s, multiple states, including Louisiana, created legislation that tied welfare benefits to the use of the long-acting contraceptive Norplant with the hopes of stemming Black reproduction, especially among young Black women. As legal scholar Dorothy Roberts illustrated, Norplant was promoted in predominantly Black and low-income schools in cities, even though nationally teen mothers were more likely to be White.

In other words, America’s prenatal health-care system was established with the health of White mothers and infants foremost in mind — a history with repercussions today.

In celebrating the Dobbs v. decision, Cassidy likewise proclaimed: “Being pro-life means being pro-mothers, pro-babies, and pro-healthy futures.” While we can criticize antiabortion politicians like the senator from Louisiana for their callous and hypocritical words and actions, we cannot forget the role of medicine and public health in constructing a society that devalues Black life.

Since Black Americans rely on abortion more than any other racial group, Black women will be forced to give birth at disproportionate rates. And with racial disparities in prenatal care still prevalent in America, a disproportionate number of those women will also be forced to experience the deaths of the babies they birth.

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