The white nurse grimaced at me as her pale fingers prodded my arm, bruised in so many places from her failed attempts to find a “good vein” for a new IV line. She sucked her teeth, then twisted my arm without warning, eyes squinting and scrutinizing my brown skin from another angle. Without warning, she dropped my arm.

“I can’t find anything on you.”

She walked out of the hospital room, leaving me alone with my aching arm.

* * * * * *

This wasn’t the first time a white nurse had told me they had a hard time with my veins, sighing or frowning when I winced in pain as they poked through my skin. Their tone made it clear that they felt I was just trying to make their jobs harder when I let them know it hurt. Sometimes I would try to make light of it or shrug it off as bad luck. Sometimes I would try to suppress my wincing reflex when they tightened the rubber strap another notch, as if turning my arm purple would improve their aim.

But that time in the hospital, I wasn’t getting routine blood work: I had gone into early labor with triplets at 17 weeks. One of the babies had already died in utero. I needed that IV replaced—fast—to deliver antibiotics to keep infection from harming my surviving babies. I was terrified that a delay in medication might reduce the already slim chances that any of my children would make it out alive. And all that first nurse did for me was complain that my veins were too difficult to find.

Black Maternal Health in Crisis

April 11-17 is Black Maternal Health Week. Unfortunately, many Black women have had experiences like mine during pregnancy and childbirth. Headlines about tennis great Serena Williams and mega celebrity Beyoncé not getting the postpartum care they needed shocked many, but stories like these aren’t just media hype: statistics show that Black women are three to four times more likely die in childbirth, and twice as likely to suffer infant loss than white women. Regardless of age, education, wealth or health care resources, Black women and their babies are dying at alarming rates. Indeed, Black women with PhDs are more likely to die during childbirth or have their infants die than white women with only a high school degree.

Why doesn’t an increase in education and income result in better health outcomes for Black women? That’s the usual pattern for other people.

Why doesn’t an increase in education and income result in better health outcomes for Black women? That’s the usual pattern for other people. New research suggests that systemic racism as well as health workers’ erroneous racial beliefs diminish Black maternal health outcomes.

Racism Makes You Sick

To be sure, the United States is way behind its developed counterparts for maternal and infant health. Regardless of race, women in the U.S. are twice as likely to die in childbirth than Canadian women, and the U.S. is usually at the bottom of the list for infant death risk, ranking 33 out of 36 nations in the Organization for Economic Development and Cooperation. But while all women in the U.S. are at risk due to the overall inequities in our health care system, Black women are at greater risk because of the legacy and impacts of structural, systemic racism and implicit bias.

Allostatic Load

Even when Black people have consistent access to health care resources, we are still impacted by the persistent stresses of living in a racially stratified society. Research into racial differences in allostatic load—defined as the “cumulative wear and tear on the body’s systems owing to repeated adaptation to stressors”—shows that exposure to racism (such as micro and macro-aggressions, stereotyping, overt and covert job discrimination) causes earlier markers of health deterioration.

Research into racial differences in allostatic load—defined as the “cumulative wear and tear on the body’s systems owing to repeated adaptation to stressors”—shows that exposure to racism causes earlier markers of health deterioration.

In other words, racism contributes to the racial disparities in health: Black people have higher rates of hypertension, high cholesterol, and type-2 diabetes than White people. Black women—whether rich or poor—have the highest probability for high allostatic loads. And women with these health issues are more likely to experience difficult pregnancies and require more medical monitoring.

Stereotypes and Implicit Bias

Unfortunately, those staff doing the monitoring are likely to be under the influence of stereotypes and implicit racial biases. Significant numbers of white people—including medical students and professionals—still believe racial biological myths that were disproven decades ago.

Significant numbers of white people—including medical students and professionals—still believe racial biological myths that were disproven decades ago.

These false beliefs about biological differences are associated with racial disparities in pain assessment and treatment recommendations.  Some of these false beliefs include: “blacks’ skin is thicker than whites,’” “blacks’ nerve endings are less sensitive than whites,’” and “blacks have stronger immune systems than whites.”

The Center for American Progress’s Maternal and Infant Mortality Report reviewed multiple studies and found that Black women and other women of color consistently report that they experience “bias and discrimination based on their reach and gender in health care settings…feeling invisible or unheard when asking medical providers for help and when expressing issues with pain or discomfort during and after the birthing process.” The same studies found correlations between implicit bias and lower quality of care for women of color. Shockingly, the report reveals that this bias extends to infants, even those at most risk, such as premature or seriously ill babies in neonatal care. White infants receive higher quality of care than infants of color.

Changing Outcomes: Working Within and Outside the System

University of Minnesota Public Health professor Dr. Rachel Hardeman is one of a new a new generation of scholars leading efforts to change the odds for Black mothers. Her research on systemic racial inequalities in health care has led her to create new training tools for clinical staff with a dual aim: decreasing implicit bias and undermining structural inequalities. Hardeman emphasizes that one of the most important things that people need to acknowledge is that “implicit bias shows up within the context of systemic and structural racism. A lot of the work I do is helping folks make that connection so that you understand that these unconscious biases . . . is part of this larger framing and socialization that we are all part of and harmed by.”

Hardeman and her colleagues found that Black women who discontinued prenatal care visits were “more likely to cite reasons like not being heard by a provider.” Likewise, Black women who “reported that they refused some sort of procedure were more likely to report feeling discriminated against” afterwards. In other words, when Black women speak up for themselves or ask questions about their care, health practitioners often respond negatively, as if the women are being difficult. “[D]eclining procedures may brand these women as uncooperative or non-compliant patients. The potential consequences of this are likely worse for women of color, who already expend more effort to manage their image during healthcare encounters in order to avoid stereotypes (e.g. the “angry Black woman”).”

Hardeman’s research emphasizes that effective interventions go beyond the usual implicit bias protocols, which focus on individual beliefs, to integrate anti-racism, historical, and reproductive justice frameworks.

Hardeman’s research emphasizes that effective interventions go beyond the usual implicit bias protocols, which focus on individual beliefs, to integrate anti-racism, historical, and reproductive justice frameworks. For example, health care workers need to know that Black women were experimented upon by white doctors during slavery to develop gynecological techniques. Historian Deirdre Cooper Owens documents how white physicians were able to “lease” enslaved black women to use in experiments, denying them “their full humanity yet valuing them as ‘medical superbodies’” that could withstand the excruciating pain of surgeries and other invasive techniques. Well into the 20th century, Black and Latinx women were sterilized against their will by white medical staff with support of state agencies. These histories create a backdrop of stereotyping, tensions, and distrust.

Beyond retraining staff in conventional medical settings to understand the role of structural racism and implicit bias, Hardeman also suggests creating greater access to and support for “culturally sensitive and culturally concordant care” for black mothers. Roots Community Birth Center in Minneapolis, for example, is one place where Black mothers can seek care and not worry about toxic stereotypes. Places like Roots are still few and far between, but Hardeman is enthusiastic about how all practitioners can learn from Roots and other models of care “that can be built in more intentionally in a more clinical delivery setting.”

Work like Hardeman’s is crucial to reversing the long history of deadly outcomes for Black mothers and other mothers of color.

Unlearning racial stereotypes and accounting for implicit bias must become part of core medical education, lest we continue to produce doctors who believe that black patients feel less pain than white patients.

Unlearning racial stereotypes and accounting for implicit bias must become part of core medical education, lest we continue to produce doctors who believe that black patients feel less pain than white patients—as well as nurses like the one who treated me a human pincushion.

* * * * * *

Luckily, the nurse who found my skin difficult to deal with didn’t come back to my room. The next nurse gasped when she saw my swollen arm, dotted with failed needle punctures. “Oh wow. Okay, we’ve got to find a new vein.”

The new nurse looked a bit ashamed. It was clear she didn’t want to take on the task of finding a better vein for the IV. She lifted my arm, silently peering at my bruised skin.

I spoke quietly into the gap. “Please, can you please get someone who can do this on the first try?”

I wondered if I’d made a mistake. I would be depending on this nurse for care for as long as I was on mandatory bedrest. I didn’t want to offend her. I held my breath until I saw her smile at me.

“I think one of our best phlebotomists is on call tonight. I’ve seen him get needles into women in full-blown labor.” She took off her latex gloves and went back to the desk, leaving me to wonder why the first nurse hadn’t thought of this. Soon the phlebotomist came in rolling a small cart. He was a large man with a roly-poly stomach and round face. He looked too much like a giant teddy bear to cause pain with needles and tubes.

He smiled sympathetically. “I hear your veins are getting tired of us, huh? Can I take a look?”

I nodded. He examined my arms carefully, every so often tapping on my skin. Soon his eyes twinkled. “I think we have a winner right here.”

The chubby pads of his fingers tapped a promising vein on my right arm. I hoped he was right. I yelped a little when the needle went in, but I could tell the phlebotomist had found the vein on the first try.

“Thank you,” I sighed. I silently hoped that the IV and its antibiotic delivery weren’t too late. I hoped that my remaining babies would be safe.

And I prayed that I wouldn’t ever have to see the mean nurse again.