Maternal Mortality, Abortion, and Race: A Dangerous Trifecta

Much has been written in the literature of public health about America’s shocking maternal mortality rate. Occasionally media reports the alarming rate when there is a hook. Advocates concerned with women and health illuminate the problem in reports and at conferences. But in light of the SCOTUS Dobbs decision on abortion, new urgency arose in addressing U.S. maternal mortality and its causes because of the link between reproductive rights and the persistence of inherent racial issues in women’s healthcare.

It is disturbing and illuminating to note the World Health Organization's maternal mortality rate rankings.  The U.S. is 55th in the list of industrialized nations at nearly 24 deaths per 100,000 live births. A 2022 study found that women in this country face the highest rates of preventable problems and mortality when compared with women in 10 other wealthy nations, and that rate continues to go up. The race disparity in maternal mortality is additionally alarming. Black women die at a rate of 55.3 deaths per 100,000 live births, more than 50 percent higher than white women.

That’s one reason Rep. Alma Adams (D-NC) and several colleagues in the House introduced a bill earlier this year to specifically address the high rate of stillbirths, which Black women and other women of color are twice as likely to experience as white women. Targeted legislative like that is critical to changing the public health landscape when it comes to pregnancy outcomes and the health of women and children.

So are campaigns like the “Hear Her” initiative at the Centers for Disease Prevention and Control (CDC), designed to address the fact that women are often not heard, believed, or viewed as reliable when they present relevant histories or symptoms. That problem is worse for Black women too. Research shows that women of color are more likely to be described negatively in notes and reports and recent studies reveal that doctors are most likely to use “stigmatizing language” in their notes about patients of color, referring to them as “noncompliant, challenging or resisting,” as research at the University of  Chicago revealed.

That’s why the all-out attempt to end abortion nationally, ignoring 50 years of precedent regarding a woman’s right to privacy, reproductive healthcare and choice was such a travesty, exacerbating the already shameful maternal morbidity and mortality data which serves as an indicator of continuing racism in this country.   

Black women and their sisters of color are likely to suffer enormously from the consequences of state-ordered pregnancy in the states that cling to misogynistic, racist policies, and not only in terms of their health or possible survival. They will also be affected economically in dramatic ways. A Forbes report suggests they will be deprived of education that can lift them out of poverty, and they will be targets of aggressive invasions of privacy through data searches that enable the over-policing of their reproductive habits and practices. Depending on where they live, they may be subject to fertility and period-tracking apps used by police according to their zip code because they are deemed to reside in high .abortion areas.

In her monumental work resulting in the 1619 Project documenting the history of broad-reaching racism in this country, Nicole Hannah-Jones provides a historical perspective essential to understanding the confluence of maternal mortality, the abortion crisis we now face, and unrelenting racism. Her book provides vital context regarding the connection between those three issues.

The title of both the project and book derives from the origins of slavery in America, dating back to 1619 with much of the book’s relevance focusing on the period of Reconstruction following the Civil War, when a key question arose. What would white America do with black people post slavery? Where would formerly enslaved people fit in a paid workforce? How would former slaves be treated if they were free Americans? What would be done about their education or healthcare?

Southern Democrats resisted these considerations mightily, especially when reformers like Rebecca Lee Crumpler, the first black woman doctor in America, laid bare the burdens of being black in a country unwilling to facilitate freedom for former slaves.

Because of that resistance, the National Medical Association formed by black doctors in 1895 called for a national health care system - which went nowhere until the idea became a states’ rights issue during WWII when President Truman called for an expanded hospital system that predictably led to segregation and the denial of healthcare for black people. Later, insurance-based healthcare presented a further hurdle, while medical schools excluded black physicians and medicine became a for-profit, unregulated system. All of this has led to present-day lack of equitable, affordable, accessible healthcare if you are black or poor.

In the midterm election, five states had abortion on the ballot and in all five, voters supported the right to choose. Three of them guaranteed the right to abortion in their constitutions.   That is a huge relief to women in the five states, but it remains to be seen how women of color will fare. 

In Nicole Hannah-Jones’ words, “…arguments about socialized medicine, equity and human rights…echo down to the present day.”  Her book reveals the connections that make women of color exceptionally vulnerable even in this moment, and reminds us that there is still work to be done.

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Elayne Clift writes about women, health, and social issues from Brattelboro, Vt.

The Urgency of Saving Roe v. Wade

She is sixteen years old and pregnant. Still in school and devoid of job skills, she would not qualify to adopt a child, yet she could be forced to carry the fetus to term.

 She is a mother who wants another child, but in the third term of her pregnancy she learns her fetus has severe organ anomalies and will die soon after birth, but she is denied a late term abortion.

 She is a victim of rape who suffers post-traumatic stress that renders her unable to work, but she will be forced to give birth.

 She has been sexually abused by her uncle for years and is now pregnant by him, but she cannot have an abortion.

 Each of these women represent many others. They are the elephant in the room that no one wants to talk about as the United States moves ever closer to draconian restrictions on abortion, and ultimately the death of Roe v. Wade, the landmark 1973 decision in which the Supreme Court ruled that the Constitution protects a woman's liberty to choose to have an abortion without excessive government restriction. 

 Ever since the Supreme Court’s decision a growing number of states have worked hard to promulgate laws and regulations that limit whether and when a woman can obtain an abortion. Restrictions aimed at reducing abortions are designed to challenge to Roe v. Wade in the hope it will be reversed.  They include such measures as mandating unnecessary physician and hospital requirements, setting gestational limits, preventing so-called “partial birth” (late term) abortion, promulgating funding restrictions, and insisting on state-mandated counseling, waiting periods, and parental involvement.

 But never have we seen abortion restrictions like those that now exist in 45 states, making 2021 a “year that is well on its way to being defined as the worst one in abortion rights history,” as the Guttmacher Institute notes.

 Various state laws from Arizona to Arkansas are a Handmaid’s Tale nightmare, but none are as staggering as the laws in Texas. Beginning in January this year, patients are required to receive state-directed counseling including information designed to discourage abortion, coupled with mandated wait times. There are constraints on various insurance policies including those included in the Affordable Care Act. Parental consent is required, and patients must undergo an ultrasound at least 24 hours before obtaining an abortion while the provide shows and describes the fetal image to the patient.  

 Further, in May, Texas governor Greg Abbott signed a fetal heartbeat abortion bill that bans abortion as early as six weeks, well before most women know they’re pregnant. That bill is scheduled to go into effect in September, although it and many other proposed laws are being challenged in the courts.

 No wonder Texan Paxton Smith, graduating valedictorian of her high school class, found her graduation speech going viral.  With enormous courage, she ‘aborted’ her approved speech and spoke eloquently, noting at the start that the six-week “Heartbeat Act” had just been introduced.

 “I cannot give up this platform to promote complacency and peace when there is a war on my body and on my rights. A war on the rights of your mothers, a war on the rights of your sisters, a war on the rights of your daughters. We cannot stay silent,” she told the crowd, noting that medical authorities have said the fetal heartbeat argument is misleading.

 Shortly after Smith gave her speech, a Spokane, WA newspaper revealed that several months earlier a woman who suffered a miscarriage in a Spokane hotel had been investigated by police who found it suspicious that she did not meet them at the hospital as they had instructed. A search warrant followed because the cops thought she might be guilty of criminal mistreatment of a child. Ultimately the investigation was closed.  But women are actually in jail here and in other countries, charged with feticide following a miscarriage. 

 It doesn’t have to be this way.  There are many models we can look to in which women’s right to exercise control over their bodies is not in the hands of the state. The Netherlands is one such country. Abortion is free on demand there and yet they have the lowest abortion rate in the world, while complications and deaths from abortion are rare. Contraception is widely available and free, and abortion is covered by the national health insurance plan. Sex education starts early, and Dutch teenagers have less frequent sex starting at an older age than American teens; their pregnancy rate is six times lower than ours.

 Why, then, but for Paxton Smith, do we never hear media reports about the critical issue of abortion, which male powerbrokers embrace with the force of institutionalized misogyny? Why does the current administration remain silent on an issue of this import when three quarters of Americans want Roe v. Wade to remain in place, citing it as a key issue affecting who will get their vote? Why is the American public so ready to give up on a fundamental human right that can touch all of us?

 Why, Ms. Smith might well ask, do we stay silent?

Girls and Young Women Will Suffer Most from Anti-abortion Madness

Reading Facebook posts these days has become an exercise in masochism for many of us. Daily horrific posts reveal various forms of violence against the least powerful among us.

Among the victims of such violence are young women and “emerging adult” females. A recent post referenced an eleven-year old girl in Ohio pregnant by rape. Given Ohio’s newly proposed anti-abortion legislation, she could be forced to carry the fetus to term. That’s nothing short of state-sanctioned child abuse. State after state, the same kind of cruelty could be repeated.

We have heard little about the full impact of Draconian measures aimed at overturning Roe v. Wade on women’s mental and physical health, but of this you can be sure: The impact will be more drastic the younger the girl or woman subjected to such measures.

It should be noted that research reveals having a safe, legal abortion does not pose mental health problems for women. According to Lucy Leriche, Vice President of Public Policy, Planned Parenthood of Northern New England, “over 95 percent of women who have had an abortion report feeling relief that outweighs any negative emotion they might have, even years later.”

In contrast, a statement last month by the Activism Caucus of the Association for Women in Psychology (AWP) makes clear the psychological damage that will be inflicted on girls (and women) from restrictions on their reproductive rights, none more so than the hideous laws Alabama and other states want to impose.

“Growing girls learn that in crucial, life-altering ways, the government has more control over their bodies than they do. This is important for many reasons, one of which is that a sense of control has been shown repeatedly in psychological research to be important to mental health and well-being,” write psychologists Paula J. Caplan and Joan Chrisler on behalf of the AWP. “Rape and incest are examples of extreme loss of control, and at least in some cases, making the decision to have an abortion after rape and incest are important parts of healing, which the Alabama law prohibits.”

Like domestic abuse and sexual assault, current proposed and passed laws are about power and control, and men’s fear of losing that power and control. The laws aim to remove any sense of agency from women, over their bodies and their lives. In their worst form, they are a manifestation of terrorism in which a women’s body is owned by the state, as it was in the chilling novel, The Handmaids Tale. Laws that attempt to incarcerate a woman for crossing state lines to have an abortion, laws that can send her or her physician to jail for life, laws that in the extreme could result in executing a woman for having an abortion reveal the pure evil underpinning these laws.

Let’s remember that the same men (and yes, some women) who want to torture girls and women in these ways are the same men (and women) who legislate against ensuring the health, safety, education, and well-being of the babies born of this unspeakable coercion, and who rabidly support capital punishment.

Even if these reactionary attempts to challenge women reproductive and human rights were to fail, “the blaming and shaming of girls and women who choose to use birth control measures or who choose to have abortions causes fear, self-doubt, low self-confidence, feelings of being unsafe, and beliefs that others consider [women and girls] unable to make major, or ethical decisions,” the AWP points out.

The truly heartbreaking thing is that once shamed, fearful, self-doubting, and depressed, it is almost impossible to regain a sense of personhood or control over one’s life. That kind of despair, in which it seems impossible to envision a way out, especially prevalent in the young, can easily lead to self-destructive behavior, including suicide.

Some years ago, when I worked in Romania on reproductive rights, I saw the damage done to girls, women, and children during the time of the dictator Ceausescu. His regime required all girls graduating from high school to undergo a pelvic exam to determine if she was pregnant. Every working woman was also subjected to monthly pelvic exams in their workplaces. These cruel practices were enforced to ensure that all pregnancies were carried to term. I saw the results of that grotesque policy in the Casa Copii – orphanages where unwanted babies were dumped. Many of the children were visibly impaired, physically and mentally. Others suffered in ways that can only be imagined. Very few of them, I’m certain, had any vision of a happy future. It was worse than Dickensian and it broke my heart.

What is happening in this country now is not far removed from the tragedies that have occurred because of pronatalist policies elsewhere. The lack of humanity, morality, and ethics inherent in such policies is stunning. It leaves one speechless. Incredulous. Furious. Grieving.

But it must not leave us silent.

We must march in unity, speak out vociferously, resist mightily, vote, and support the #SexStrike movement together. Most of all, we must refuse to sacrifice our young and our females on the alters of misogyny and in the chambers of violence. Our survival as sentient beings depends upon it.

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Elayne Clift writes about women, health and social justice issues from Saxtons River, Vt. www.elayne-clift.com

Let's Be Clear About Third Trimester Abortion

As a longtime women’s health educator and advocate, I was apoplectic when I read a recent commentary in my local newspaper by a “chaplain serving an elderly population” who is also “treasurer of the Republican Party” in my state and a “county party chair.”

The op.ed. proffered so many spurious and false assertions, often stated by others with far-right political views, that my hair was nearly on fire. Given where we are in this country regarding abortion, I felt compelled to address one of the egregiously uninformed views of the author, which I did in a Letter to the Editor.  It seems to me now important to share what I wrote for a wider audience, in the hope of reaching others inclined to make uninformed claims about a vital issue that affects so many lives and the culture in which we live. 

This is the claim that blew me away. It relates to a bill in my state proposing a law like ones in some other states protecting a woman’s right to abortion moving forward. “The bill goes far beyond Roe [v. Wade], guaranteeing unrestricted abortion through all nine months of pregnancy…” the author wrote. It’s a misleading claim that calls for revisiting the facts regarding the inaccurate use of the term “late term abortion.”

The first thing to note here is that abortion after fetal viability is a rare occurrence and usually involves a medical crisis. According to the US Centers for Disease Control and Prevention, abortions after 21 weeks make up less than 1.3% of all abortions in the United States. Abortions that occur beyond 24 weeks make up less than 1% of all procedures. Exceptionally rare cases that happen after 24 weeks are often because a fetus has a condition that cannot be treated and and that renders the fetus unable to survive, regardless of gestational age or trimester.

Secondly, the 14th amendment of the Constitution, which guarantees due process and equal protection under the law, was vital to the 1973 Supreme Court decision in Roe v. Wade. The 14th amendment also protects the right to privacy and the Court held that a woman's right to an abortion fell within that statute. By a 7–2 majority the Court ruled that unduly restrictive state regulation of abortion is unconstitutional. Importantly, the Court also determined the point of fetal viability as the “capability of meaningful life outside the mother's womb,” hence the 24- week marker. The Court’s decision gave women a right to abortion during the entirety of the pregnancy, however, while defining different levels of state interest for regulating abortion in the second and third trimesters.

It’s important to know that, as the Guttmacher Institute points out, if a physician determines that the child is “non-viable” and/or the abortion is necessary for the physical or mental health of the mother, a woman can have an abortion from the moment of conception until the child’s birth. State laws restricting third trimester abortions are unconstitutional under the precedent of Doe v. Bolton, a case in which the Supreme Court overturned a Georgia law. (Numerous states have laws that ban or restrict abortions in the third trimester. Because these statutes remain in place or haven’t been contested in federal court, they may imply that they are allowed by federal law. But because federal law trumps state law, no restrictions can be enacted that do not also allow the doctor to determine if abortion is necessary for the health of the mother.)

Here’s another fact: Overturning Roe and Doe won’t end all third-trimester abortions. When the Supreme Court throws the abortion issue back to individual states, third-trimester abortions will still be protected in states that reiterate prior standards for “viability” or “health.”

But here’s the most important thing for everyone to know. No woman decides to have an abortion after 24 weeks recklessly or without a great deal of anguish. Perhaps she does it because of a serious illness she has, like decompensating heart disease. Maybe her baby has a delayed diagnosis of anencephaly, which means the fetus forms without a complete brain or skull. There are a multitude of medical crises that can precipitate a third trimester abortion. But the decision is never taken lightly. In most cases, there is deep grieving and a profound sense of loss, brought about because of medical necessity and the wish that a much loved and wanted baby not suffer.

That’s why people like the man who wrote the troubling commentary – claiming that he “doesn’t oppose or seek to diminish women’s rights” and that he “supports [women’s] right to their own body and right to choose” -- people who misunderstand not just the right to abortion but the reasons women choose it, at any stage of pregnancy, must move beyond facile arguments, misstatements of fact, and feeble justifications. They must somehow begin to recognize that for many women, the choices they face are devastating and immensely complicated.  

Most urgently, they must find it in themselves to be compassionate and to resist judging those whose experiences and viewpoints differ from theirs. 

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Elayne Clift writes about women, health, politics, and social issues from Saxtons River, Vt. www.elayne-clift.com