A new webinar series highlights how failing to address the historical exploitation and oppression of Black women, girls, and gender expansive people directly drives higher rates of deaths and near deaths. “The Intersection of Misogynoir, Obstetric Racism, and HIV,” a three-part series featuring speaker Karen A. Scott, MD, MPH, FACOG, identifies how structural and societal power imbalances not only destroy self-worth but in doing so, negatively impact physical health.

Dr. Scott is the chief Black feminist physician scientist, founding CEO, and owner of Birthing Cultural Rigor, LLC. Over the last 12 months, she acted as maternal quality improvement expert for the Black Mamas Matter Alliance, where she continued to learn how negative self-image and societal perceptions of Black women especially have helped create gaps in equitable sexual and reproductive health care.

Throughout the series, Dr. Scott offers a deep dive into the history of Black women’s reproductive and sexual health care and the role structures, systems, and social determinants of health play in preventing equitable care. “We as Black women, girls, and gender expansive people are not pathologically designed to die or nearly die from sex, reproduction, pregnancy, or childbirth,” Dr. Scott said. “We must always trace back to the origins, which always go back to slavery.”

The Treatment of Black Mothers and Birthing People

Part one of the series, “From Slavery to Sovereignty: Reclaiming our Time, Narratives, Bodies, Lives, Families, and Futures,” explored how Black mothers and birthing bodies, as well as midwives and doulas, have been deemed unfit and in need of saving. The experience of one doula which she shared deemed the hospital a place that continues colonization of Black bodies, wombs, and breaths.

The history of the medical industrial complex and the relationships between slave owners and medical practitioners to expand the slave economy and labor force directly impacts the disparate health care we see towards Black women and birthing people today. Dr. Scott encourages people to be especially curious about the role of white men OBGYNs and white women midwives within the context of controlling and eliminating Black bodies and births.

The 1911 publication of the American Journal of Obstetrics featured commentary regarding Black midwives as “dirty, dark, untrained, unfit, incompetent, and evil”, among other descriptors. Dr. J. Clifton Edgar, a white OBGYN, wrote of Black midwives: “She is evil, though a necessary evil, and must be controlled. We must save our women.”

According to Dr. Scott, the language and stereotypes surrounding the treatment of Black women and gender expansive people expanded to broader professions. The association of Black people with being unfit, incompetent, and evil helped develop the societal ideas that prevent them from getting the care they need, due to assumptions about their individual behaviors and intent.

“We are trained across various professions that the individual choices and behaviors are the primary contributors to individual health status, and risk for disease, disability, discomfort, and death,” Dr. Scott said. But the truth, she pointed out, is that health care utilization only contributes to 20% of the sum of an individual’s health. The remaining 80% are due to social and structural determinants of health.

Access barriers and constraints — coupled with the maze Black women and girls must navigate to receive quality care — create, sustain, and worsen the risk and rates of HIV infection and spread, particularly among poor Black women. “All HIV risk among Black women and people is not the result of individual behavioral risk,” she said. “Even when the sexual behaviors are equal, the impact, the outcome, and experiences are unequal and inequitable.”

HIV and Mortality Rates Among Black Women

According to Dr. Scott, in 2019, 46.8 million people self-identified as Black, representing 14% of the U.S. population. Black women continue to be disproportionately affected by HIV, accounting for  more than half (57%) of new HIV diagnoses in 2018, compared with White (21%) and Hispanic or Latino (18%) women. Perinatal HIV infections also disproportionately affect Black children (65%), compared with White (14%) and Hispanic or Latino (9%) children.

Similar inequities appear in the access and utilization of Assisted Reproductive Technology (ART). Asian and Pacific Islander women and people received about 6,000 procedures, the greatest number of procedures per million women and people ages 15-44. White non-Hispanic women received around 3,000 procedures, while Black non-Hispanic women, American Indian women, and Alaskan Native women received 1,400, 1,000, and 800 respectively.

ART usage has been found to be much higher in states where insurance is required to cover it than not. Researchers have also observed that state infertility insurance mandates are an effective tool in reducing race-based differences in access to care. “Structural solutions – not individual-level interventions – such as state mandates that cover infertility insurance policies eliminate the impact or goal of structural racism as a driver of inequities and utilization of ART,” Dr. Scott said.

The American Society of Reproductive Medicine states that creation of a family is a basic human right. Dr. Scott adds that access to and utilization of ART is crucial to protecting and advancing this right, to create not only biological children, but social kin as well.

According to Dr. Scott, on average, 41 deaths occur among Black mothers and birthing people each year. For every maternal death, 100 women or birthing people suffer a maternal morbidity – a life-threatening diagnosis with severe complications requiring life-saving procedures. This means an additional 4,100 Black mothers and birthing people experience a near death, or as Dr. Scott says, “survive nearly dying.”

Overall, 60-70% of pregnancy-related deaths are preventable. More Black women and birthing people could be alive each year if U.S. health systems and professionals were held accountable for providing equitable care. “Instead, we continue to blame and burden Black mothers, birthing people, the families, and our communities, with the responsibility of preventing our own deaths or near deaths every hour, every day, every year,” Dr. Scott said. “We can no longer deny the historical and contemporary existence of reproductive and perinatal apartheid in U.S. health systems.”

Misogynoir and Obstetric Racism

Misogynoir, coined by Black feminist scholar and activist Dr. Moya Bailey, informs the stereotypes that disproportionately describe Black women, girls, and gender expansive people. Some of these stereotypes, Dr. Scott highlights, have directly impacted access to equitable sexual and reproductive health care. This includes being labeled as old, fat, sick, ugly, hyper-sexual, unfit, irresponsible, angry, bitter, controlling, lazy, lonely, drug-seeking, crazy, and untrustworthy.

Misogynoir directly aligns with Dr. Dana-Ain Davis’ Obstetric Racism framework which addresses the intersection of obstetric violence and medical racism. This framework describes how Black women and birthing people’s reproduction (from preconception through postpartum care) is subjected to subordination consistent with histories of anti-Black racism. “Obstetric racism is a threat to positive birth outcomes,” Dr. Scott said. “What we see is that racism is continuously recalibrated, a racism that is a re-interpretation of enduring processes of slavery.”

Sojourner Syndrome, as defined by its creator Black feminist Dr. Leigh Mullings, is an interpretive framework that allows for a more culturally rigorous understanding of why Black women and men die younger and have higher rates of morbidity and mortality for most diseases compared with white people. The framework provides intersectional analysis of how racism, class exploitation, and gender oppression interact in the lives of Black women to create differential power structures that lead to adverse health care experiences.

By recognizing intersectional oppression and control while illuminating Black women and people’s individual and community resilience, Sojourner Syndrome displaces the onus of death and dying as symptoms of power structures, rather than attributes of people. “Decolonizing perinatal quality improvement requires a dismantling of the hierarchy of power and dominance as structured by the medicalization and professionalization of birth and quality improvement,” Dr. Scott said. “A paradigm shift moves the epicenter of power and knowledge towards Black mothers, birthing people, and community leaders.”

Reframing Sexual Health and Identity for Black Women

To begin this paradigm shift, Dr. Scott argues we must begin by examining how attitudes towards sex, influenced by racist stereotypes, impact the sexual and reproductive health care of Black women and birthing bodies. “Sexual stereotypes originate from the institutionalization of slavery and the sexual reproductive exploitation, experimentation, extraction, and erasure of our virtue and value as full human beings,” she said.

Stereotypes of Black American Women Related to Sexuality and Motherhood” identified certain stereotypes, their origins, and how they influenced how Black women and girls are perceived, such as:

  • The mammy, who served as a nanny, housekeeper or cook. The mammy is thought of as self-sacrificing, asexual, and dark-skinned.
  • A jezebel, who is unable to control her sex drive. The jezebel is thought to be seductive, manipulative, hypersexual, animalistic, and “exotic.”
  • Superwoman, who is expected to provide for, serve, or support. Superwoman is seen as tough, strong, resilient, self-sufficient, and feels weak and vulnerable if in need of help.
  • Sapphire, a character from the 1940/1950s Amos and Andy radio and television shows. Sapphire is thought of as nagging, emasculating, shrill, loud, and argumentative.

“These sexual stereotypes of Black women create unfounded expectations and assumptions about our sexual expression, as well as place some of us in social boxes that limit our individual functioning,” Dr. Scott said. She points out that the societal expectations of certain people and their behaviors, such as being labeled a “gold digger,” limit one’s self worth and image. A 2019 study titled “Mental Representation of Self in Relationships Indirectly Affects Young Black Women’s Engagement in Risky Sexual Behaviors Through Psychosocial HIV/STI Risk Factors” identified how this negative self-image then directly impacts sexual and reproductive health.

Authors of the study found that poor self-worth was associated with lower partner communication including regarding sex, greater fears related to condom negotiation, greater endorsement of norms for risky sexual behavior, and lower partner trust among Black women. One of the most at-risk groups of people is at risk due to poor self-image, which stems from difficulty navigating experiences over a lifetime due to misogynoir and obstetric, structural, and internalized racism. Intertwined with these also are social determinants of health, which only continue to compound risk factors.

“Thinking about Sojourner Syndrome will hold us all accountable in understanding HIV risk and rates of infection and spread by assessing the direct impact of these structural, institutional, interpersonal, and internalized stressors on the constraints to access health care,” Dr. Scott said. “We must also consider the impact of these accumulation of stressors on the body, mind, and spirit of black women and girls who are negotiating housing, income, food, sex and safety, as well as victimization and revictimization, and negotiating care for themselves, their children, and other households across communities.”

To continue an intersectional approach to solutions including service provision, evaluation, training, and research, Dr. Scott asks to consider the intersection of people’s personhood. “What would it look like if our language and history-taking recognized the trifecta of Blackness, girlhood, and womanhood in our care?” she asked. “It will look like investing in Black women-led research and improvement and implementation of initiatives that study Black girl’s and women’s perspectives on sexual activity, sexual behavior, and the agency they may lack but also seek to achieve and sustain.”

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Dr. Scott recalled finding and sharing the following quote several years ago after discovering the disparate rates of HIV and mortality risks among Black women and birthing bodies in comparison to the level of care received:

Black women choosing to live is resistance. Black women choosing ourselves is resistance. Black women choosing joy is resistance. Black women loving black women is resistance. Anyone loving black women is resistance. Black women being is resistance. I am resistance simply because I’m here. – Kimberly McCrae (Gaubault)

Today, Dr. Scott adds a new truth to this sentiment: “Black women and people having sex, getting pregnant, ending pregnancy, staying pregnant, birthing a baby, creating a family, and living beyond pregnancy and childbirth together in a thriving parent-child relationship are acts of resistance and resilience.”

Dr. Scott is the CEO of Birthing Cultural Rigor, LLC, which formed as a living act of resistance to disrupt the status quo through knowledge and dissemination of narratives of care, fulfillment, delay or denial during childbirth hospitalization. Their vision is a more humane and just health system that integrates patient experiences and community wisdom into health services design, provision, evaluation, and training.