In late 2019, I had the chance to sit down with doula and community organizer Tamara Thompson, founding member of the Milwaukee-based Black radical doula collective Maroon Calabash.[i] We were meeting to think about possible speakers to invite to a convening around reproductive justice. Thompson said that she was reading an amazing new book that I might have heard of: Reproductive Injustice, by Dána-Ain Davis, and that she wanted to invite that author, herself both a profound analyst and doula, to speak. As an activist, Thompson’s endorsement of this leading change-maker speaks volumes—and exemplifies the widespread acclaim that Davis’s book is receiving from scholars and on-the-ground reproductive justice advocates and practitioners alike. The book talks Davis gave for Reproductive Injustice following its July 2019 publication testify to the power of the text as both an action-oriented analysis and rich scholarly contribution: University of Minnesota’s Institute for Advanced Study and Baltimore’s Bloom Collective, a health equity organization; Barnard’s Center for Research on Women and Gender and Kansas City, MO’s Uzazi Village, a site that uses innovative models, including community-based doulas, to foster maternal and infant health in Black and Brown families.
Grounded in Black women’s own stories, Davis’ book analyzes the anti-Black racism that pervades obstetrical and neonatal medicine as a direct manifestation of the ongoing legacies of slavery. The first chapter situates the numerous, yet little-noted, examples of premature birth among enslaved women in Harriet Jacobs’ autobiographical Incidents in the Life of a Slave Girl in relation to Black women’s experiences of premature birth in recent decades. The firstborn baby of Linda Brent, Incidents’ narrator, is born early and sickly amid constant threats and abuse from Brent’s sadistic physician master, Dr. Flint; in a long passage that serves as the chapter’s epigraph, Brent expresses aching ambivalence as her babe hovers between enslaved life and premature death. But Davis also highlights the reproductive violence suffered by the narrator’s Aunt Nancy. Aunt Nancy performs literally ceaseless labor at the beck and call of her mistress, as housekeeper, waiting-maid, and night-nurse to the children, sleeping on the floor at the doorway of Mrs. Flint’s bedroom while herself pregnant and postpartum. Under these conditions, Aunt Nancy gives birth prematurely at least six times, and each of those babies dies. While, as Davis notes, the Flints’ children thrived on Aunt Nancy’s stolen maternal labors, Aunt Nancy herself was “unable to tend to her own health needs or those of her children.”[ii] It should not escape our notice that Dr. Flint was at once physician to Brent and Aunt Nancy, and their owner. As Davis writes, Jacobs’ narrative “haunts the more contemporary stories told in this book,” as Black infants’ persistent vulnerability to premature birth remains linked to a medical system founded on Black suffering and loss, and which still dismisses Black mothers’ needs and concerns, disavows its own implication in violence, and rejects Black women’s capacities to know, to feel, and to parent.
Davis shows how Black women’s experiences of maternal and neonatal care are shaped not only by the history of commoditized human reproduction and care but by the prevailing expert logics of that care itself. Davis concretizes these continuities within obstetrical medicine, offering a highly useful diagnostic schema to name four precise components of obstetrical racism. These comprise the potentially fatal diagnostic lapse: the rampant tendency to misdiagnose and/or ignore Black women’s symptoms, wherein providers refuse to hear Black women’s own insistence that something is wrong, as in Serena Williams’ highly publicized postpartum brush with death from a blood clot. Davis’s interlocutors make clear that Williams’ case was, if anything, typical, as they describe providers grossly ignoring Black mothers’ symptoms and concerns again and again. This diagnostic lapse is linked to the governing tropes of obstetrical hardiness and its derivative, hardy babies — remnants of 19th century obstetrical medicine’s founding mythologies of painless birth and fecundity among “primitive” peoples and related to the still-pervasive medical myth that Black people feel pain less acutely than white people. The persistence of these tropes in view of the staggeringly disproportionate death rates of Black mothers and infants is not only cruelly ironic, but centers the (typically-abled, cisgender) white woman’s body as the obstetrical norm. Finally, the component of menacing mothers denotes a maternity cast as categorically deviant, threatening, and deserving of punishment for any and all reasons, from not being present enough — “neglectful,” no matter what the circumstances — to being too present and thus “demanding.”
Davis offers horrific examples of each of these components from the casebooks of antebellum medicine, and then focalizes them through the relatively recent birth story of Yvette Santana. Santana, a 40-year-old IVF patient carrying twins, was clearly in need of particularly watchful care, yet because she did not embody what her OB saw as “typical Black” pathologies of high blood pressure or gestational diabetes, the provider failed to classify her pregnancy as higher risk (itself an admittedly problematic term that, as Khiara Bridges has shown, carries racialized baggage in its application, as it does here in its omission).[iii] Thus, assuming Santana’s obstetrical hardiness, this provider also dismissed the IVF patient’s expressed feelings of ill health during the pregnancy. Due at least in part to these diagnostic lapses, replicated in an ER visit, Santana gave birth to her twins, a boy and a girl, at 26 weeks. While all babies born so prematurely are profoundly fragile, NICU staff reassured Santana that she need not worry, as Black babies are hardy babies: “so strong and fit.” Tragically, her infant son died in the NICU while she briefly visited home; on her return to the hospital a security guard was stationed in front of her son’s room, highlighting Santana’s construction by the medical establishment as a menacing mother — not a grieving mother, as a white parent in her position would almost certainly have been configured. Each of these accounts demonstrates how the reproductive health experiences of these Black mothers were shaped by one or more of these components. Davis’s lucid schematization of the precise dynamics of medical racism thus brings into focus contemporary obstetrical medicine’s pervasive failures to care for Black women and birthing people as unspoken institutional protocols.
One reason this is so important is that the recent turn to epigenetic impacts of racism as stress across the life course, while crucial, highlights a toxic societal environment but without particular agents (this can also be true of the social determinants of health framework). While this approach importantly points to structural factors, intergenerational impacts of racism, and collective societal responsibility, it also risks letting medical providers and institutions off the hook for practices and protocols in their control. Davis’s text makes this move impossible. She shows that, far from offering shelter from what Christina Sharpe terms the weather of pervasive societal anti-Blackness — resonant with Naa Oyo Kwate and Shatema Threadcraft’s deployment of Arlene Geronimus’ term weathering, or the cumulative lifelong physiological harm of racism /sexism, to describe anti-Blackness as political environment — providers both compound and disavow this everyday violence.[iv] Drawing on interviews with seventeen parents, mostly Black mothers, as well as with providers, Davis reveals obstetrical and neonatal care practices that force the imprint of medical racism onto what are already some of the most vulnerable moments of human life.
In so doing, Davis’s book reveals not only the ongoing reproductive legacies of slavery, but the afterlife of reproductive mastery as well. In a recent lecture, historian Jennifer Morgan spoke about the early modern development of Europeans into slaveowners whose claims to enslaved women’s reproductive capacities were at the heart of the new system of racial capitalism in the 16th and 17th centuries. She identifies a number of interlinked fantasies on which this transformation relied. On one hand, this comprised what a lineage of Black feminist analyses have illuminated as central enabling mythologies about enslaved people, including the fertile and fecund enslaved woman and a denial of maternal and family ties and feelings, such that enslaved procreation could be justifiably commodified. We see resonances of this still in the experiences of Black women in Davis’ book, whose motherhood is constantly called into question by providers. Alongside these fantasies about African women, however, Morgan also places a fantasy about Europeans themselves, that of “slaveownership without entanglement or culpability.”[v]
Just as the fantasies projected onto captive African women still circulate, with punishing effects for Black mothers and families, Davis’s book shows that such dreams of innocent mastery likewise command present attempts at baby-saving. This holds true in hospitals and progressive institutions like the March of Dimes alike, along a kind of spectrum of “deflection,” as Davis describes the move.[vi] In the former, even as the overwhelming majority of their infant patients are Black, four out of the five NICU physicians that Davis interviews (all white) refuse to explicitly name race — let alone racism — as a factor in premature birth, insisting that poverty is the decisive element. Yet they consistently couch their class analyses in the racially loaded idioms of broken families and inner cities.[vii] Reproductive Injustice’s emphasis on middle-class and professional Black women’s experiences of prematurity serves, among other things, as an extended rejoinder to this deflection—for Black women with advanced degrees give birth prematurely at higher rates than white women with the lowest educational status. Physicians’ refusal to countenance the racism that clearly shapes the demographics of their respective units insulates them from consideration of their own interpersonal and/or institutional implications in Black infants’ disproportionate prematurity. In this fantasy of innocence, Davis suggests, providers “spar[e] themselves from having to think about how racial justice might need to be addressed” (87). At the March of Dimes, Davis shows us an institutional environment where race is in fact central to the analysis, but an emphasis on racial disparities statistics, “health equity,” and even “intersectionality” takes the place of an active confrontation with racism. As Davis shows, this deflection also colludes in pre-empting consideration of medical racism as a factor in the outcomes that they so scrupulously chart. Moreover, the organization’s aim of “narrowing the gap” between Black and white birth statistics holds up the white prematurity rate (just over 9%) as the neutral reference point of superior health. This implicitly pathologizes Black prematurity rates (13.8%)—as well as Indigenous pregnancy and birth, for which prematurity is also higher (11.6%)—as deviations from that norm, rather than attending to all of the numbers as functions of a shared history of anti-Black racism, colonization, and white supremacy. “Narrowing the gap” also constrains the vision of reproductive wellness within a (white) national frame, even as prematurity is far lower in places like Japan (5.9%), Antigua/Barbuda (5.8%), and Belarus (4.1%).
The radical Black doulas and birth workers that Davis profiles in her closing chapter—who Thompson and Maroon Calabash also exemplify—thus offer a powerful counterpoint to both the reproductive legacies of slavery and the deflections of mastery, as they “connect the history of Black women’s reproductive exploitation to current medical practices.”[viii] As Davis argues, public health efforts targeting prematurity have largely ignored the work of trailblazers like Kathryn Trujillo-Hall, whose longstanding Birthing Project model is grounded in relationships of mutuality, trust, and affirmation between Black women within the same community—despite the extent and efficacy of her sites, which tend to reduce prematurity and low birthweight among Black infants to rates below their white counterparts, and in some cases eliminate these outcomes entirely. This is perhaps unsurprising, given the Birthing Project’s eschewal of profit-driven models, and what its successes imply about the fundamental failures of mainstream obstetrical care. Davis also offers readers a fine-grained account of community-based doula work like that of Ancient Song Doula Services, founded by Chanel Porchia-Albert, which not only centers deep listening, responsiveness, and empowerment on the birthing person’s own terms, but aims to dismantle the violent systems that have long imperiled Black gestation and birth. As Cara, one of the birth workers that Davis interviews, states, a fundamental part of the practice “centers on mobilizing against the medical-industrial complex, the scientific racist state, and private and corporate practices.”[ix] Health care practitioners and institutions who truly wish to prevent prematurity among Black infants must divest from the deflections of mastery: they must confront the ways that these systems and their histories shape the fatal protocols currently in place, and undertake the work of transformation. As Jennifer Nash cautions, health care institutions cannot simply rely on doulas as a kind of magic bullet. Institutions themselves must devote significant time and resources to shifting these entrenched patterns internally, in order to avoid outsourcing their own responsibilities onto underpaid Black birth workers and replicating racial capitalism’s foundational parasitism on Black women’s caring labors.[x] Yet as Davis shows—and also, by training as a doula over the course of completing this book, herself enacts—radical Black birth workers offer a vision and praxis to follow, fostering reproductive flourishing and justice in birth and beyond.
Annie Menzel is a political theorist and former midwife whose work focuses on understanding how white supremacy, racism, colonization, and gender-based oppression shape human reproductive life, health, and care—as well as theorizations and praxes of reproductive justice and freedom. She is completing revisions on her first book, Fatal Deflection: Black Infant Mortality and the Biopolitics of Racial Innocence, under contract with the University of California Press, and is also at work on a second book project, Birthing Paradox: Race, Colonization, and Radicalism in US Midwifery, which seeks to understand the contradictory politics and practices of the homebirth midwifery movement since 1970. She published in the Du Bois Review, Contemporary Political Theory, Political Research Quarterly, Political Theory, Signs, and The Boston Review.
[i] Maroon Calabash
[ii] RI p. 45
[iv] Christina Sharpe, In the Wake: On Blackness and Being (Durham: Duke University Press, 2016). Naa Oyo Kwate and Shatema Threadcraft, “DYING FAST AND DYING SLOW IN BLACK SPACE: Stop and Frisk’s Public Health Threat and a Comprehensive Necropolitics,” Du Bois Review: Social Science Research on Race 14, no. 2 (2017): 535–56.
[v] Jennifer L. Morgan, “Madwomen on the Slave Ship: Reproduction and Racial Capitalism,” https://history.wisc.edu/event/pgwh-talk-jennifer-morgan/.
[x] Jennifer C. Nash, “Birthing Black Mothers: Birth Work and the Making of Black Maternal Political Subjects,” WSQ: Women’s Studies Quarterly 47, no. 3 (2019): 29–50.