As I was preparing to interview Linda Villarosa, the author of a new book, “Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation,” I saw a headline that reinforced how urgent her book’s message is: “CDC: Maternal mortality disparities have worsened.” The story, from Axios, showed in stark graphics how the maternal mortality gap between Black mothers and mothers of other races has only become larger since 2018. In 2020, the most recent year for which we have data, the maternal mortality rate per 100,000 births was 55.3 for Black women, 19.1 for white women and 18.2 for Hispanic women.
Villarosa has been sounding the alarm on this topic for years. Her 2018 story for The New York Times Magazine, “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis,” described the harrowing experience of a New Orleans woman named Simone Landrum. Landrum’s third child was stillborn, and her medical treatment during that pregnancy was neglectful. “It was like he threw me away,” Landrum said of her doctor at the time. Villarosa followed Landrum through her fourth pregnancy and described the subpar treatment, both subtle and overt, that Landrum received. For example, Villarosa reported, Landrum was mistakenly given a larger dose of anesthesia than was necessary for her epidural, and couldn’t feel her legs and had a terrible headache as a result. When Landrum questioned the dose, “one nurse said, ‘You ask a lot of questions, don’t you?’ and winked at another nurse in the room and then rolled her eyes.”
After that article was published, Villarosa was invited to speak to a group of white ob-gyns at a hospital in a small Midwestern city. As a group, they didn’t take any of her conclusions at face value despite the studies she cited to show how systemic racism affected Black maternal health. In “Under the Skin,” she writes that the head of the ob-gyn department had this takeaway: Villarosa shouldn’t have been allowed into the delivery room with Landrum in the first place. That interaction helped convince her to expand her article into a book.
When we spoke, Villarosa told me that she still gets pushback from physicians, who think she’s calling them racist. They say things like, “I didn’t go into medicine to hurt people,” Villarosa explained to me. “And I say, ‘I know no one goes into medicine to harm people,’ I don’t think that’s a thing. But I think there is an implicit bias. Racism and discrimination bias is baked into the systems, the institutions of America,” she said. “By refusing to even examine it, that is causing more harm.”
Villarosa, who is a novelist and educator, had an excerpt from “Under the Skin” adapted for The Times Magazine, for which she is also a contributing writer, earlier this month, about the Relf sisters of Alabama. Minnie Lee and Mary Alice Relf “were taken from their home in Montgomery, cut open and sterilized against their will and without the informed consent of their parents by a physician working in a federally funded clinic,” Villarosa writes. The Relf sisters have never been compensated by the state for this eugenic horror, but Villarosa hopes they might be.
In the condensed and edited interview below, Villarosa and I talked about the Relf sisters, how she realized that all the bubble baths in the universe cannot fix discrimination, and how her own first experience giving birth helped inspire her work.
Jessica Grose: I’d love for you to talk about your professional journey. In particular, you describe how you went from producing a lot of service journalism, as a health editor at Essence, to realizing there were limits to that kind of self-help-style advice. As you put it, “Today, I’m chagrined to think I believed that the impact of insidious discrimination associated with the lived experience of being Black in America can be washed away in a bubble bath or calmed with journaling or meditation or me time.”
Linda Villarosa: I was the child of striving Black parents and the grandchild of striving Black people. My grandparents came from Mississippi to a Promised Land of Chicago. Then Chicago didn’t work for my parents anymore, so we moved to suburban Denver, and our mantra was just: Get education and just take care of yourself. If you work very hard you will get ahead in all ways, including to be healthy. By the time I got to Essence magazine in the late ’80s, I still had that mantra in mind. Essence was a magazine that had tremendous reach — it still does — with Black women. So I thought, if I can only get Black women to know better, then they’ll do better.
In the middle of my term as health editor of Essence, I got this public health fellowship at the Harvard School of Public Health. It was transformative for me, because I didn’t understand the tenets of public health that looked beyond self-help. While I was at Harvard, one of my professors gave me a study on educated Black parents and low birth weight from The New England Journal of Medicine. And it was clear that even with education, Black parents still had worse health outcomes. I was really surprised, because I was so indoctrinated with the idea that if you just do everything right, you won’t have a poor birth outcome.
My professor said maybe it has something to do with stress. But for me, that stress, what we knew about stress at the time was more like, “Oh, I’m stressed out.” It’s not a kind of long-term, toxic stress that we later found out was associated with preterm birth, low birth weight and infant mortality.
Then in 1996, when I got pregnant with my first kid, I was surprised that I had something called intrauterine growth restriction [“a condition in which the unborn baby is smaller than expected for his or her gestational age”]. I was eating right. I was exercising. I was publicly talking about good health. I had a really good doctor. I had great health insurance. So I was very surprised when I had a condition that is usually associated with someone that is maybe using drugs and alcohol. I was sent to a perinatologist, a really high-end person, who right away was asking me questions. Do you drink? Do you smoke? Do you use illicit drugs? And I’m looking at her like, are you kidding? No. And because this was such a rare condition, my baby was born right at term, just the day of term. And she was four pounds, 13 ounces. She could fit in the palm of my hand.
I remember thinking back to that low birth weight study and wondering, does this have something to do with that toxic stress that I read about in the earlier research? Since then, I have heard about so many Black women who have had the same condition.
Grose: Along with the toxic, cumulative stress of racism on the health of Black Americans that you talk about in the book, you cataloged so many instances of casual and aggressive disrespect from medical providers, especially toward Black women, during pregnancy and birth. How does it affect Black mothers and babies as they’re experiencing this?
Villarosa: Birth for anyone is difficult, but if you’re being treated unkindly, if you’re not being listened to, if you are meeting your doctor for the first time — which disproportionately happens to Black women — then it makes the birth harder. It makes the birth more difficult and more dangerous. And we’ve seen that. We look no further than Serena Williams. She is someone who should have had every advantage, and also every kind of knowledge about her body, because she’s a professional athlete. But she wasn’t listened to during the birthing process. [In a 2018 profile of Williams, Vogue reported that she experienced shortness of breath while at the hospital recovering from an emergency C-section and worried it was related to her history of blood clots. When she spoke up, a nurse thought that Williams’s pain medication was making her confused. After telling a doctor she needed a CT scan, not the ultrasound that was initially performed, blood clots were found in her lungs and she was put on the heparin drip she had asked for all along.]
If she can’t get this kind of care, then how are average people, average Black women, supposed to get good care in a medical system that, evidence shows, doesn’t always treat us fairly?
Grose: Is there anything that didn’t make it into the book that you would like people to know about?
Villarosa: The thing that I’m most excited about is that covering the Relf sisters, and having their story excerpted on the cover of the magazine, will help something happen with them. The magazine story pushes the idea further than I did in the book. My editor at the magazine is Jessica Lustig, and she said, let’s really look at what happened in Virginia, in North Carolina, two states that had reparations for people who were sterilized against their will or without consent. And the magazine story lays out the steps for a state like Alabama to do the right thing for people like the Relf sisters. And I really hope that can spark some kind of change, or some kind of justice.
In October 2020, Erica Chidi and Erica Cahill collaborated on a guide for The Times called “Protecting Your Birth: A Guide for Black Mothers.” Crucially, the guide outlines steps for mothers and for medical providers, because, as Villarosa’s work shows, Black mothers need their doctors to be aware of their own biases to provide the best care.
Check out some of Villarosa’s other work on the intersection of race and health in The Times Magazine: “Black Lives Are Shorter in Chicago. My Family’s History Shows Why.”; “Myths about physical racial differences were used to justify slavery — and are still believed by doctors today.”; “‘A Terrible Price’: The Deadly Racial Disparities of Covid-19 in America.”
In addition to seeing the recent C.D.C. data about Black maternal mortality when I was getting ready to interview Villarosa, I also read this report, by The Times’s Roni Caryn Rabin, “Uterine Cancer Is on the Rise, Especially Among Black Women,” which explains that Black women are both more likely to get uterine cancer and more likely to die from it.
Parenting can be a grind. Let’s celebrate the tiny victories.
Changing the diaper of my 19-month-old is a screaming wrestling match. One day I gave her a wipe and told her to “change” one of her stuffies. She changed its diaper and was then much happier to have her own changed.
— Kirsten Bowen, Philadelphia
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