This has been reprinted with permission from the Columbia Missourian on July 16, 2018, written by Alexis Allison with input from Community Commons.
Halfway through Mattina Davenport’s first trimester, she named her daughter Maliyah Rose. Maliyah — like Obama’s Malia — and Rose, a bringer of beauty.
It was 2015, and though Davenport wanted Maliyah, she hadn’t yet meant to get pregnant. A graduate student at MU, she was working two assistantships, juggling a clinical rotation and putting the finishing touches on her master’s thesis, not to mention completing qualifying exams to pursue a doctorate.
She was the only African-American student in her graduate program, and racial tensions on the MU campus were boiling over with the Missouri heat.
Her relationship with her boyfriend, a coach who lived in Kansas, felt strained, and the quality of their relationship changed day to day.
Even her body felt off. As her pregnancy progressed, Davenport was swollen from nose to ankle, and she suffered severe back and stomach pain — telltale signs that it could be a high-risk delivery.
At first, it made sense to blame it on stress. Davenport was 23. It was her first baby. Her doctor insisted that what she was experiencing was normal.
At her 21-week checkup, her blood pressure was “clinically elevated,” but her doctor told her not to worry.
Within five days of the appointment, something was definitely wrong. Davenport felt a sharp, deep pain and noticed a discharge. By the time she got to the hospital, she was told she was too far gone.
“I’m sorry to tell you this, but your baby’s going to die,” a doctor at the hospital said.
Within several hours, on Nov. 8, 2015, Maliyah Rose Johnson was born. She had hair and some weight to her, but she was premature — 22 weeks to the day. The doctor said it was not enough and chose not to provide life-saving measures.
Maliyah lived only a few hours, and then she was gone.
It was only later that Davenport began to understand that what happened to Maliyah was not unusual for black babies. Not in Columbia, not in the United States.
Widespread health gap
The infant mortality rate is often heralded as a measure of the overall health of a nation, according to the Centers for Disease Control and Prevention. And at first glance, it seems as if American health is getting better and better.
In 1995, close to eight babies out of every 1,000 live births died before their first birthday. Fifteen years later, only about six babies per 1,000 were dying each year.
But a 2014 study from the CDC provides a more troubling narrative. In 2010, the United States had one of the highest infant mortality rates among other advanced countries, worse than the United Kingdom, Germany, Israel, Japan and Finland. This is humbling for a nation that far outspends the same countries on health care per person.
Within the U.S., the infant mortality rate differs across place and race. States in the South and Midwest, such as Missouri, tend to have the highest infant mortality rates. In 2016, Alabama had the highest infant mortality rate, about nine babies per 1,000. That same year, Missouri’s rate was 6.5 babies, higher than the national rate of 5.9.
Many of these same states also have higher populations of black Americans, which contributes to the disparity. Across the country, black Americans have perennially experienced higher infant mortality rates than their white peers.
In 1995, almost 15 black babies were dying out of every 1,000. For white babies that same year, that number was about six. Although both rates have declined since, the gap remains.
In 2015, the black infant mortality rate was 11.3 babies. The same year, the white rate was 4.9. Consistently, black babies are more than twice as likely to die before their first birthday than white babies.
For black babies born in Boone County, their chances at survival are worse.
Complications from preterm birth and low birth weight are the second leading cause of infant death behind birth defects, according to the CDC. As a baby’s weight increases, so does their chance of survival. The baby’s gestation period, closely linked with birth weight but not directly correlated, can be a similar predictor. The longer the baby is in the womb, the more likely he or she will live.
Between 2011 and 2015, around 15 percent of black babies in Boone County were born with low birth weight, or under 5.5 pounds, according to the Missouri Department of Health & Senior Services. For white babies during that same time period, that number was closer to 6 percent.
When it came to race, weight and gestation period, Maliyah was unlucky on all counts.
A mother’s health
Low birth weight is partially linked with a mother’s health during pregnancy. Moms who eat poorly, drink, smoke or abuse drugs increase their chances of delivering a baby with low birth weight.
One way local public health agencies have tried to mitigate these behaviors is to increase early access to prenatal care.
The Columbia/Boone County Department of Public Health and Human Services offers a pipeline of education and resources to low-income pregnant women that can extend from a positive pregnancy test to the child’s fifth birthday.
“One of the disparities we’re trying to address is the incredible and sad and maddening disparity in birth outcomes for African-American folks,” said Steve Hollis, human services manager at the department. “What we’re hoping to do is increase access to affordable health care. That’s really our primary push — to get early access to health insurance and WIC.”
WIC, or Women, Infants, and Children, is a federally funded program that helps pregnant mothers, babies, and children with nutrition for up to 5 years. It’s one of the final steps in the pipeline of resources that the local health department offers, one that social services specialists at the department recommend to everyone who qualifies.
If a woman thinks she might be pregnant, she can drop into the department’s clinic for a pregnancy test. If the test is positive, a social services specialist will review her choices for health insurance.
“We’ve long been the gateway for lower-income pregnant women in Boone County because we’re the primary Temporary Medicaid provider,” Hollis said.
Next, they’ll determine if the woman is eligible and interested in the Healthy Families Home Visiting Program. Once she’s in the program, a social services specialist will regularly visit her home, offering resources and counsel during the months leading up to birth and afterward, gradually tapering off until her baby is 3 years old.
Currently, the program serves around 40 local families, about half of them black.
An American problem
“Nobody gets pregnant in a vacuum,” said Sandi Miller, the health department’s social service supervisor. “When people find out they’re pregnant, they still have all of life’s other stressors to deal with, too.”
Encouraging women to quit smoking or eat well is easier than addressing a more haunting reality. A growing body of research suggests that stress related to the day-in, day-out experience of racism may be a key factor contributing to the infant mortality rate.
“We know that stress causes things to happen inside your body and brain. When we think about the very long history of racism in America and we think about black moms experiencing racism and stress, that baby’s going to have effects in utero,” said Kari Utterback, a social services specialist at the health department.
“This is an American problem.”
A 2006 study published in the American Journal of Public Health concluded that American black women, regardless of income level, have higher rates of stress-related “wear and tear” on their bodies than their white or male peers, leading to early health issues.
The study concludes that “Black women bear much of the responsibility for the social and economic survival of Black families, kinship networks, and communities. In fulfilling these responsibilities, Black women may face greater exposure than Black men to stressors that require sustained and high-effort coping.”
Another study, published a year later, explored the possible causes behind the disparities in the infant mortality rate, including genetic differences between white women and black women. The conclusion? Racism, rather than race, may have everything to do with the disparities.
Health planners should consider social and environmental differences between black and white women in “the campaign to eliminate health disparities,” the study reported.
And that’s what’s happening locally. Part of the city’s strategic goal of operational excellence is pursuing long-term diversity and inclusivity training to address implicit bias.
There’s been a lot of talk recently about “white privilege” at the health department.
“We’re doing some things operationally to work on our own unconscious biases, and that gives me some hope,” Hollis said.
An intersectional movement
Several months after Maliyah’s funeral, her family still felt off about how things had played out — about the final check-up when Davenport complained of cramps and swelling and the doctor sent her home. Or how the doctor hadn’t tried life-saving measures on Maliyah.
The American Academy of Pediatrics provides ethical guidelines for when to attempt life-saving measures on newborns, recommending doctors not do so if they “believe that there is no chance for survival,” according to a 2015 newsletter from the academy.
Another study for the academy notes the majority of very highly developed countries support “comfort care,” rather than “active care,” for a baby born at 22 weeks, like Maliyah.
The newsletter mentions the need for parental involvement in the decision:
“In conditions associated with a high risk of mortality … for the baby, caregivers should discuss the risks and benefits of life-sustaining treatment and allow the parents to participate in the decision whether attempting resuscitation is in their baby’s best interest.”
That conversation never happened for Davenport. Throughout her entire pregnancy, she said she felt unheard.
Maliyah’s paternal grandmother, Patsy Johnson, said she doesn’t know why. She’s wondered if her family’s race played a part. After all, they did everything they were supposed to do — secure health insurance, attend all the check-ups.
They were educated. Davenport was healthy and athletic. But, she was also African American, young, and unmarried in a racially divided environment that at times made her feel “disposable.”
“From the people I interacted with at the front desk all the way through to the doctor, it just felt like we weren’t treated with the same dignity as maybe a white woman coming in with her husband,” Davenport said.
Johnson had wanted to do some research, to see if other black women had similar experiences, but she couldn’t bring herself to do it. Some part of her didn’t want to know.
But then, late one night, a documentary came on TV: “The Naked Truth: Death by Delivery,” a look at why black women are more likely to die from pregnancy-related causes than white women.
“As I watched it, tears came. The pain was there,” Johnson said. “I understood it, I knew it, it was confirmation. I knew something had to be done, and I thought, this could be a teaching tool.”
Though the documentary focused on maternal mortality rates, rather than infant mortality rates, it spoke to a larger problem in the U.S. — disparities in health outcomes for black mothers and babies. The health of the mother is inextricably linked to the health of her baby.
And it’s not just a story of poverty.
“The system failed them,” Johnson said. “Society failed them.”
That night around 3 a.m., Johnson posted her feelings on Facebook about the film, about her outrage and sadness, and one of her friends responded. She told her she needed to talk to a young black woman named Evonnia Woods.
Woods is in her mid-30s, a doctoral candidate at MU studying sociology and women’s and gender studies, and the leader of Reproaction’s Maternal & Infant Mortality Campaign in Missouri. The campaign, which Reproaction and Capital Area Missouri NOW launched in 2017, focuses on disparities between white and black women and seeks to “connect maternal and infant mortality rates with other issues more broadly.”
Woods’ approach is what she calls “intersectional.” A term coined in the late 1980s, “intersectionality” refers to the overlapping and multiplicative effects of oppressive systems on those marginalized in a society. The legal scholar who first wrote about the term in 1989 criticized movements that focus solely on a black woman’s gender or race, rather than considering them both.
For Woods, thinking intersectionally requires an awareness of how systems entwine.
“Police brutality is a reproductive justice issue, having clean water is a reproductive justice issue,” Woods said in speech she gave to the Boone County Muleskinners in February. “It’s not something very simple, and we have to be thinking intersectionally at all times.”
When it comes to decreasing infant mortality, Woods said leaders will need to address racism at a systemic level. But she knows it’s difficult to do.
In an interview, Woods said she blames “Western European thought” for how hard it is for Americans to think intersectionally.
“We’re trained to think of things individually and not see how things are connected,” Woods said. “And not only how we see issues, but how we see ourselves in connection to each other and the planet.”
Comeback of midwifery
One unlikely avenue that seeks to address health disparities holistically, Woods said, is midwifery.
A midwife is a trained health professional who gives personalized care to women during pregnancy, delivery, and recovery. Midwives work to deliver holistic care, considering not only a woman’s physical health, but also her emotional, spiritual, and cultural needs.
A midwife serves as an ally and guide for women, “empowering them to make informed decisions,” said Kim James, a recently retired midwife who practiced in Columbia for more than 30 years.
Through the many babies she delivered, as well as the births of her own children, James knows giving birth is both intensely powerful for the mother and intensely vulnerable. She calls it an “altered state,” one that allows a woman to “access a power she didn’t know she had. To reach beyond perceived limitations.”
The practice of midwifery has been around as long as maternal care has been around, with the rise of obstetrics propelling its decline. For black women, who were denied the same medical services given to white women even into the 20th century, midwifery became a crucial art, leading to maternal care that was also spiritual and social, according at a 2017 study in The American Journal of Economics and Sociology.
Although the use of midwives eventually decreased for women of all races, things are changing. The number of births attended by midwives in the U.S. each year has been on the rise, according to the American College of Nurse-Midwives.
In 2015, MU Women’s and Children’s Hospital began offering a Low-Intervention Birth Program to give expectant mothers more choice before and during delivery. The program is the only one of its kind in mid-Missouri, according to MU Health Care.
Women within the program can opt for a “natural birth experience,” with fewer medicines and interventions. During delivery, they can be accompanied by a certified nurse midwife and give birth in a “labor suite,” designed to feel more like home and less like a hospital room.
Davenport had wanted something like this early in her pregnancy, but at that time, her closest options were too far away. MU Women’s and Children’s Hospital unveiled two labor suites less than 10 days after Maliyah was born.
When Rokeshia Renne Ashley, a recently graduated doctoral student at MU, found out she was pregnant in August 2016, she knew what she wanted: a holistic, natural birthing process. Ashley, now 27, came into her pregnancy more informed than most, but also skeptical.
As a doctoral candidate, her research focused on black women’s bodies, health communication and how journalists and medical providers may overlook context when talking about minority health. She’s aware of the historical “mistreatment of black bodies in health care,” and she knew the importance of advocating for herself.
So, she pulled out all the stops: She registered for MU’s low-intervention birthing program and, by the end of her pregnancy, she’d hired a midwife and two doulas in addition to her OB/GYN.
Early in her second trimester, Ashley was diagnosed with a shortened cervix — a condition black women are more likely to develop than white women, though no one knows why, according to the Mayo Clinic. A shortened cervix can lead to premature birth, so Ashley went on bed rest from November 2016 to April 2017. When she finally delivered, she didn’t stop bleeding and lost “volumes” of blood, enough to fill a gallon of milk.
During that time, she said her doulas were invaluable. Ashley describes them as protectors, counselors, cheerleaders and advocates. She speaks adoringly of her midwife, her doctor and MU. Despite her village of health providers, though, and her knowledge of the health care system, she said she still wasn’t prepared for the difficulties she faced in pregnancy and delivery.
She and her baby girl, Emery, are both healthy now. Still, Ashley worries that other black women, like her pregnant sister, won’t know enough about the struggles black mothers face to self-advocate, to do their research, and to seek a team of health providers they know and trust. She also knows that some won’t be able to afford doulas and midwives, since insurance doesn’t always cover them.
Her recent research in health communication speaks to a simpler solution: how health care providers talk about disparities, and how they listen. She recommends they open up lines of communication before and during delivery, allowing the patient to feel heard, informed and included — so even if things go wrong, a new mother won’t feel as lost and alone.
For Davenport, those feelings haven’t fully gone away. But nearly three years after she lost Maliyah, she uses the memory of her daughter to fuel her clinical work, research and advocacy for vulnerable populations.
At 26, she now provides psychological services. Davenport channels her grief into practicing daily empathy for each client she sees. She’s especially attentive to the parents of children with disabilities. She notices the dark circles they have under their eyes, checks to see if they understand and stands by them when they have to make a phone call to other healthcare providers.
She practices daily self-care, treats her patients like she wants to be treated, and faces each new day with strength, power and grace, despite the grittiness of what she’s left behind.
To this day, both Davenport and Johnson believe Maliyah should not have died. But life doesn’t always match wishes, and Johnson knows she’s meant to tell her granddaughter’s story.
For Woods, the stakes aren’t just high for black babies like Maliyah, or for black women like Davenport. They’re high for everyone.
“If you understand intersectionality,” Woods said, “then you understand that we don’t all win — unless we all win.”