I am so grateful to each of you for engaging with Reproductive Injustice: Racism, Pregnancy and Premature Birth for this forum and I thank you for your careful reading of my book and your respective interpretations. I also appreciate everyone at Somatosphere for holding space for such productive dialogue.
When I wrote this book, I had hoped that it would disrupt on several scales. I wanted to disturb the idea that birth outcomes are linked to race, rather than racism. I wrote to unsettle the dominant discourse that those outcomes were overwhelmingly a problem of low-income or poor Black women to the exclusion of Black women across class. I tried to disentangle the tendency to position race as social construction without taking into account what racism feels like—how not only Black women specifically, but Black people in general, interpret various interactions as racist. Importantly, mapping some of those feelings and interpretations allow readers to understand the subtle and obtuse experiences of racism that are relational in the context of medical encounters. Generally, people do not think that medical encounters cast a pall over assisted reproduction, pregnancy, labor, birth, and during post-partum, nor do many take into account how that shroud accrues into various degrees of mistrust among Black people of medical professionals and institutions.
Considering that neonatal intensive care units (NICUs) are forms of technology that play a role in assisting in reproduction in that they can facilitate completion of fetal development among premature infants, I also wanted to disturb the reification of saving technology. Many people believe that technology will save lives, including reproductive health practitioners and consumers; however, “saving” itself has consequences and comes with some level of apprehension.
There are, of course, other issues that I attempt to trouble, not least among them the desire to produce an account of racism and reproduction that holds history and the present in ethnographic tension. My theoretical and methodological choice to think through Saidiya Hartman’s afterlife of slavery (2007) was an intentional move to bring together insights from Black humanist approaches and feminist anthropology. These fields and approaches illuminate racism and reproduction across the medical system and the individual practice of medicine.
The commentators offer eloquent opinions of the book and I want to come at their generous and thought-provoking considerations by discussing three themes that surfaced as I embarked on a slow-reading (to take up Jacqueline Woodson’s mandate) of their comments. The three themes are landscapes of inequality, risk, and technologies of reproduction.
LANDSCAPES OF INEQUALITY
Sameena (Mulla) begins her comments by scrutinizing my work through the lens of her brilliant attention to how care is violent, noting that medical practices are “always implicated in the past and present landscape of inequality.” In thinking about this sort of spatiality of racism, as a landscape, it was my intention to show the location, or geography, where racism, saving, and Black reproduction were refracted through the afterlife of enslavement. The geographies of racism, one might argue, sit in relational proximity to racial capitalism, the “productive” material spaces that Black bodies inhabit, and are entangled in systems and projects orchestrating (and killing) Black life.
Both Annie (Menzel) and Rayna (Rapp) lift up and extrapolate from my deployment of Hartman’s brilliant framing of the afterlife of slavery which scaffolds so much of Black life in the United States. The afterlife of slavery serves as a generative lens through which to analyze Black women’s obstetric and gynecological encounters. Annie locates the legacy of slavery as a “project of mastery” that rests on innocence. Her framing is particularly useful when thinking about how the biomedical technological complex often denies the harms it causes. Following from the logic of the mastery of innocence, denial is revealed when the biomedical complex asserts mastery of intervention and limits its own culpability while at the same offering promises of possible successes through invasive techniques. For example, C-sections were performed on Black enslaved women and have become a typical procedure that often offers assurance of good and necessary outcomes, while limiting the liability associated with the danger or potential danger that C-section surgery poses. Although I had thought to make the links between the past and the present, those particular connections did not quite position the biomedical complex also as a master!
What an incredible move on Annie’s part to think so deeply about processes of reproductive governance and expose how from enslavement to the present there has been little attrition of reproductive mastery. As I consider the idea of mastery, I am reminded that James (Doucet-Battle) opens his book (Doucet-Battle 2021) with an introduction titled, “Sugar’s Racial Project, From Slavery to Diabetes.” That title certainly serves as provocation for my thinking and if I may be so bold, I take this opportunity to transmute his title to accommodate what I hope is being worked through in my book: “Reproduction’s Racial Project: From Slavery to NICUs.” In thinking with James and Annie’s remarks, I would argue that a particular form of gendered racial terror, similar to that of which Sarah Haley (2019) speaks, puts Black women outside the category of gender, subjecting their reproducing bodies to a power that constructs those bodies as unworthy, as incarcerable and as exploitable. I argue in different ways that Black bodies are absent the kind of vulnerability one might expect be bestowed upon pregnant and birthing people. The absence of vulnerability, then, subtends the possibility of transformative change from within the biomedical complex.
On the topic of risk, I must stay I have learned so much from James’ brilliant intervention in his book Sweetness in the Blood: Race, Risk, and Type 2 Diabetes (2021) and from Sameena’s generative observations on the subject of risk. Delving into how the medical complex imposes risk on Black bodies, one can see that Black bodies are systematically in conversation with dialectical forces of compulsion. James clarifies this point so stunningly in his work by noting that the inhabitation of racial risk leads to a risk-managing subject. As Sameena points out, “the Black maternal body is signified and reinforced as a site of risk through the commonly-held beliefs about prematurity and low birth weight that characterize the prenatal health world,” referring is the CDC infographic (Davis 2019:42), that reports “Black race” as a primary risk factor for premature birth. The Black body becomes chaotically magical in its incantation of risk and the representation of that body ultimately fulfills the prophecy for medical interventionists.
The subject of Black reproducing bodies being positioned as ‘at-risk’ is at once a play of affirmation and negation. On one hand, risk can be affirmed through data collection but risk can also cement a body in a sphere of negation intensifying that body’s likelihood of being intervened upon. Black bodies, when consistently viewed as being ‘at-risk’ become subject to attempts to control the “regime of crisis” (Berlant 2011) that they pose. The crisis portends the Black body as a site where humanity is eroded. In thinking about the risk that both James and Sameena discuss, I am struck by the ideological, theoretical and practical quicksand into which Black bodies fall. Sometimes those bodies, in the medical context, are seen as immune to risk, and other times they are viewed as susceptible to risk. Black bodies are subjected to an expansive contrariness, by history, society, and medicine, which results in positing our ability to both inhabit risk—which leads to intervention; or be immune to risk –which leads to neglect or dismissal.
I do not want conclude this discussion of risk without making some mention about reproduction and the logics of capitalism. I admit that in the book I wanted to delve more deeply into the ways that the reproducing Black body helps capitalize the medical complex. Although I mention Makena, a drug used to ostensibly reduce the likelihood of premature birth, a more comprehensive discussion would have served as a cogent example of how Black and brown bodies are entangled in racialized economies of pharmaceutical development. The drug was used to decrease the risk of premature birth and received accelerated approval in 2011 after a trial in which 60% of the enrollees were Black women. Approval was followed by a proposal to withdraw approval by the FDA’s Center for Drug Evaluation and Research (FDA 2021). Initially the cost was $30,000 per pregnancy, then reduced to $15,000 per pregnancy, which was about 50 times more than the compound version. Another example of reproduction and the logic of capitalism centers on how much NICUs generate income for hospitals.
Upon further reflection, a discussion of each example could untangle the intersections of risk, race, reproduction, and capital. Clearly a system that sees Black birthing people’s bodies as sites of risk should be subject to deeper analyses of economies of power, control, and the forms that (ir)rationalities of intervention or retrenchment take. There is so much more to say about how research and funding foregoes investing in preventive measures to address prematurity and instead ranks the Black body as a risk: readying it for commodification. By commodification I do not mean that Black bodies are only inserted into a commodity circuit, but more that they become an object upon which other commodities of intervention act (such as inductions, C-sections, etc.).
TECHNOLOGIES THAT ASSIST IN REPRODUCTION
I am so pleased that Rayna lifts up one of the more subtle points that the book makes, which is that NICUs are a form of assistive reproductive technology (ART) and indeed should be an integrated part of the ART story. Rayna, by enlarging the optic of my argument about NICUs and how we might explore the ways in which they fit on the continuum of ART, allows me to elaborate here. ART, through a feminist lens, does indeed focus on concerns about conception and we know that ART includes medical procedures used primarily to address infertility. (Of course, the heteronormative presumption of infertility occludes the desire to conceive though one may be fertile and queer, although in need of assistance in the conception process.) Still, I ask, what are we to make of all the technology in NICUs that bring a pre-term fetus to some form of functional maturity? The NICU provides the range of technologies (both high and low) that among other things, circulate oxygen and blood, facilitate lung development, and help in the development of pre-term neonates. Such is the “magic” of technology. But it also begs inclusion into the feminist focus on the machinations of ART because many of the issues that accompany this form of assistance evoke similar concerns about power dynamics as, for example, IVF and surrogacy. There are disparate outcomes by race in terms of infant and maternal mortality relative to prematurity and there are disparate racial outcomes in terms of IVF success rates.
“Traditional” ART forms have been mediated by access to insurance and have been subject to ethical articulations that analyze both life and beyond life. But so too, are forms of reproduction assisted to complete pregnancy. There are similar manifestations of disparity and racism in the NICU environment as in access issues related to ART. Here I want to linger for a bit on what I was thinking with regard to the role of medical treatments that shift the in-utero fetus to an ex-utero environment, such as prenatal steroids, ventilator settings, surfactant replacement therapy, and arterial lines. While such interventions have successfully “saved” infants at 23-weeks’ gestation, anytime earlier than 23 weeks causes greater pause. Indeed, based on my interviews with medical staff, some felt that intervening to save fetuses at 22 and 23 weeks posed ethical and future health concerns.
Neonatology has normalized saving preterm infants, lowering the age of viability over the last twenty years. The optimization of saving more newborns has depended on using technology that is both invasive and non-invasive. Premature infants are not simply little versions of full-term babies, they have underdeveloped organs, possible fused eyelids, and skin that is unable to retain heat. Their breathing is inefficient and they require a range of interventions that “mimic” intrauterine environments. My point is that the constellation of technologies that facilitate conception although differ drastically from the constellation of technologies that save, there are elements of saving premature infants that have a similar theater of performance and “making.”
I would suggest that an analysis of the NICU overlaps with Monica Casper’s brilliant book The Making of the Unborn Patient: A Social Anatomy of Fetal Surgery (1998), which explores fetal surgery with the placement of biomedicine as heroic. The NICU as a space where saving takes places, intersects with similar questions of ethics along the same line as fetal surgery, the ethics of making babies in test-tubes, and making babies outside of heteronormative patriarchal lineages. Like fetal surgery, the existence of the NICU is justified because it speaks to a particular ethic of personhood, while at the same time demonstrating conflict with birthing people’s decision-making processes. The idea that a preterm patient can be saved speaks to all the political angst that holds up right to lifers’ anti-abortion stance and concerns about saving at all costs. Like Casper’s fine-grained analysis of saving through fetal surgery, NICUs converge on the same ethical plane. Fetal surgery and NICUs also intersect with regard to how both make wombs somewhat parenthetical to the technologies that privilege fetal health over maternal health. Both also sometimes prevail as objects of interest over the birthing person and it is the presumptive fetus or neonate whose viability is fortified through technology that can take precedence.
Much in the way that reproduction is a site of social control over agency, which as Casper notes, differs by race, class, sexuality, and ethnicity, the birth of premature infants is also stratified and involves dynamics around power, access, care, determining who is successfully saved, and the kinds of lives people live in the afterlife of being saved. Technology that saves fetuses and neonates is insinuated with moralities shaped by various ethical, legal, political, and economic interests.
After the publication of Reproductive Injustice, I developed the framework, obstetric racism in the special issue on race, racism, and reproduction across medicine, science, and technology co-edited by Valdez and Deomampo (2019). Obstetric racism explains what some Black women encounter and are subjected to at medical institutions. Constituent elements of the book coalesce into this framework and to suggest that reproductive, gynecological, and obstetric services are woven together with the thread of histories that value Black women and our bodies for their experimental and capitalist purchase. Simultaneously, Black women and our bodies are derided, racial stratification is exported in such a manner that threatens maternal life. Obstetric racism highlights the forms of violence and abuse, that medical institutions routinely perpetrate against Black women and is composed of beliefs and practices that harm reproducing Black bodies (Davis 2019). The degree to which health-care infrastructure is built on institutional relations of power and violence is uncovered when one explores the “logics of racial domination on Black women at any point in their reproductive lives…Obstetric racism rests on the fact that racial hierarchies have led to differential practices, tasks and clinical decisions” (Scott and Davis, 2021:2).
As we face racism in various realms and as Black women are often subjected to neglect and harm because belief in our vulnerability is suspended, we must also measure the distance of the warrior-advocates, activists, doulas, midwives, legal scholars, birth educators, lactation specialists, scholars, allies, policy analysts, doctors, and organizations, have gone to make justice irresistible. They witness, testify, organize, advocate, challenge, care, carry, and walk alongside Black women. Without them, we would be standing on much shakier ground.
Dána-Ain Davis is Professor of Urban Studies at Queens College and is also on the faculty of the PhD Programs in Anthropology and Critical Psychology at the Graduate Center. Presently, she is serving her second terms as the director of the Center for the Study of Women and Society at the Graduate Center. Davis’ work covers two broad domains: Black feminist ethnography and the dynamics of race and racism. She is the author or co-editor of five books. Her most recent book Reproductive Injustice: Racism, Pregnancy, and Premature Birth (2019) was published by NYU Press. The book received the Eileen Basker Memorial Prize from the Society for Medical Anthropology; The Senior Book Prize from the Association of Feminist Anthropology; and was named a Finalist for the 2020 PROSE Award in the Sociology, Anthropology and Criminology category, given by the Association of American Publishers. The Victor Turner Ethnographic Writing Award Committee of the Society for Humanistic Anthropology awarded the book an Honorable Mention. The book was also listed in New York Magazine‘s “Strategist” column in an article, “Anti-Racist Reading List” and was included in The Black Feminism Book List.
 Jacqueline Woodson discusses the value of reading slowly. You learn new and different things with each re-reading. Spending time with the author’s words and as a reader we should respect the ideas of those who take the time to craft what we are engaged. https://www.youtube.com/watch?v=HzAtOyw6ACw
 Clinical judgement gestures toward saving infants born at 22 weeks-gestation can achieve survival rates of 25% to 50% (Rysavy et al. 2015).
Berlant, Lauren. 2011. Cruel Optimism. Durham, NC: Duke University Press.
Casper, Monica J. 1998. The Making of the Unborn Patient: A Social Anatomy of Fetal Surgery. New Brunswick, NJ: Rutgers University Press.
Davis, Dána-Ain. 2018. Reproductive Injustice: Racism, Pregnancy, and Premature Birth. New York University Press.
_____. 2019. Obstetric Racism: The Racial Politics of Pregnancy, Labor, and Birthing. Medical Anthropology. 38 (7) 560-573.
Doucet-Battle, James. 2021. Sweetness in the Blood: Race, Risk and Type 2 Diabetes. Minneapolis: University of Minnesota Press.
Federal Drug Administration. 2021. Makena Information. CDER Statement. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/makena-hydroxyprogesterone-caproate-injection-information
Haley, Sarah. 2019. No Mercy Here: Gender, Punishment, and the Making of Jim Crow Modernity. Chapel Hill: University of North Carolina
Hartman, Saidiya. 2008. Lose Your Mother: A Journey Along the Slave Route. New York: Farrar, Straus and Giroux.
Rysavy, Matthew A., I Lei Li, Edward F. Bell, Abhik Das, Susan R. Hintz, Barbara Stoll, Betty R. Vohr, Waldemar A. Carlo, Seetha Shankaran, Michele C. Walsh, John E. Tyson, C. Michael Cotton, P. Brian Smith, Jeffrey C. Murray, Tarah T. Colaizy, Jane Brumbaugh, Rosemary D. Higgins. 2015. “Between-hospital variation in treatment and outcomes in extremely preterm infants” New England Journal of Medicine Vol. 372(19): 1081-11.
Scott, Karen A. and Dána-Ain Davis. 2021. Obstetric Racism: Naming and Identifying a Way Out of Black Women’s Adverse Medical Experiences”. American Anthropologist.
Valdez, Natali and Daisy Deomampo. 2019. Centering Race and Racism in Reproduction. Medical Anthropology.