Analysis Maternity and Birthing

Stress Kills: Economic Insecurity and Black Women’s Maternal Health Outcomes

Elizabeth Dawes Gay

When we hear “stress kills,” we often imagine a wealthy business executive dying of a heart attack in their early 50s because they put in too many long nights at the office. But stress also kills pregnant Black women and their babies in a more surreptitious way.

This piece is published in collaboration with Echoing Ida, a Strong Families project.

Fifty years ago, President Lyndon B. Johnson announced the War on Poverty, a set of legislation and programs intended to respond to the needs of people living in poverty. Today, many people still need and benefit from War on Poverty programs such as early childhood education, supplemental nutrition assistance (food stamps), work study opportunities, and federal family planning grants.

To commemorate this anniversary, the last few months have seen a kerfuffle of coverage on poverty and economic inequality, opportunity, and growth. Media coverage has also highlighted the connection between economic opportunity and reproductive health in that women need access to reproductive health services to prevent and delay childbearing so they can get further ahead in life, avoid poverty, or lift themselves out of poverty. This is very important. Indeed, data show that women reap substantial social and economic benefits when they are in control of their childbearing; but, that is only one way that economics and reproductive health outcomes intersect. We also understand that economic inequality and injustice can affect the human body and lead to negative health outcomes.

When we hear “stress kills,” we often imagine a wealthy business executive dying of a heart attack in their early 50s because they put in too many long nights at the office. But stress also kills pregnant Black women and their babies in a more surreptitious way. Economic inequality—simply described as the gap in wealth or income between people—takes a toll on health, even when people have health insurance coverage and access to important health-care services. The chronic stress of living in poverty—of knowing a missed paycheck could leave you in dire straits, of not having enough to make ends meet—is killing Black women who choose to become pregnant and give birth.

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The negative maternal health outcomes many low-income women and women of color experience—including maternal mortality—often result from conditions exacerbated by economic instability. Research shows that chronic stress causes cardiovascular changes that increase blood pressure, which must remain stable during pregnancy and labor. Hypertension, or high blood pressure, is a risk factor for pregnancy complications such as preeclampsia, low birth weight, pre-term birth, and damage to the mother’s internal organs and other adverse conditions. Chronic stress could also lead to unhealthy coping behaviors such as overeating (leading to obesity), smoking, and alcoholism—all of which increase the risk of adverse pregnancy outcomes. Being financially insecure and experiencing financial hardship is stressful, and Black women are more likely to be poor during pregnancy than women of other races.

The reality of the economic hardships of Black women in the United States is a hard pill to swallow. A 2013 report by the Center for American Progress summarizes the concerning statistics:

  • Black women earn, on average, 55 cents to the dollar that white men earn. The statistic of 77 cents to the dollar for American women just doesn’t hold true for communities of color.

  • Black women are more likely to hold low-wage jobs with few benefits and less job security.

  • The poverty rate for Black women is 28.6 percent compared to 10.8 percent for white women.

  • The most telling of this data is that single Black women have a median wealth of $100, compared to a median wealth of $41,500 for single white women. That’s a huge disparity. Low wealth is indicative of financial insecurity. For example, a single woman earning $40,000 a year with no savings, investments, or assets is essentially living paycheck to paycheck and is at risk of going into debt and falling into poverty even though her income is far above the federal poverty level. Based on our median wealth, Black women are extremely financially insecure, and thus subject to the chronic stress that accompanies that insecurity.

It’s clear that if we want to see better maternal health outcomes for Black women, reproductive health and justice advocates must also work to achieve economic justice. Health happens at the intersection of various parts of our lives and is influenced by where we live, work, and play. We must support policies and action that are outside of the traditional scope of reproductive and sexual health in order to achieve the improvements we seek in a range of health outcomes.

In particular, we must take action and support policies that improve economic security, increase pay, and promote the accumulation of wealth in the Black community. The rhetoric of the War on Poverty may be antiquated but the underlying theme of greater economic security and opportunity is still relevant. In fact, the War on Poverty set a precedent of economic policies that improve pregnancy outcomes. A 2011 analysis concludes that the food stamp program helped to increase infant birth weight, particularly among Black mothers living in high-poverty areas, by increasing the financial resources available to families. If supplemental nutrition programs can help increase birth weight, imagine what strategic and concerted efforts to reduce financial hardship can accomplish.

Researchers and advocates have pointed to a few key opportunities to improve the economic experience, and health outcomes, of people living in the United States over the next 50 years:

Education That Leads to Economic Opportunity

Black people must be better prepared to compete for well-paying jobs that ultimately increase economic and social equity. Specifically, reforming public school funding to more equitably distribute financial resources could go a long way. Currently, public K-12 schools may be funded by the state or local government and property taxes from the school’s surrounding area. What we have seen as a result is under-funded schools in lower-income areas and disparities in quality of education from neighborhood to neighborhood and state to state. As you might have guessed, underfunding is more likely to impact students of color. And school funding has been directly linked to the quality of education and student outcomes.

It is imperative that all children receive a high-quality education that prepares them to enter institutes of higher education or enter the workforce with the skills necessary to compete for higher-paying jobs. Reproductive justice advocates must actively support meaningful attempts to address the way our schools are funded. We know that other issues also plague our schools—the school to prison pipeline, cultural incompetence, and inconsistent instruction and curriculum—but achieving equality in funding is a good place to start.

At Least a Living Wage

Earning a low income and living in impoverished areas not only directly impedes access to health-care services, but indirectly affects health outcomes through the stress of financial insecurity. The Center for American Progress asserts that “the best ticket out of poverty is a job that pays a living wage.” According to the White House, raising the minimum wage to $10.10 would affect 28 million Americans and boost the economy. While a minimum wage of $10.10 an hour would be a good start, it falls far short of a living wage—especially for families with at least one dependent.

Raising the minimum wage is an absolute necessity, but advocates must not be content with that. A living wage must be the new minimum and the work shouldn’t stop there. We should support people in prospering from their work and growing wealth. Wealth can serve as a personal safety net, reducing financial insecurity and increasing health.

Adequate Leave to Enhance Job Security

Finally, people must have sufficient and generous personal leave so that they can take off from work when they are sick, take care of their families and personal responsibilities, and rest and relax without having to worry about losing their jobs. Sufficient leave provides job and financial security. Moreover, adequate maternal, paternal, and family leave policies not only have an immediate benefit, but help create a culture that respects the reproductive decision-making of individuals rather than punishing them for creating the families they want. Reproductive health and justice advocates’ participation in pushing for better leave policies is essential.

So, where do we begin? Forming partnerships between reproductive justice and economic justice advocates is a good place to start. Coalitions that cross traditional lines to begin thinking and working across issues will be important for any forward momentum. Strong Families is an example of a network of activists and advocates across movements who collaborate and amplify each other’s work to create meaningful policy and culture change. But, this intersectional collaboration requires the participation of actors at all levels and in various fields, importantly policymakers. For example, the American Public Health Association published guidance to encourage state and local governments to incorporate health into all policies. Incorporating health into all policies is an approach to provide real opportunities for people to achieve and maintain their best health and improve the health of our nation.

Economic inequality produces the stress that manifests as illness in our communities. Advocates, policymakers, scholars, and community representatives must combine forces to address the inequality that hurts Black women and their families, and ultimately our society. Economic injustice makes it nearly impossible to survive and there’s nothing more stressful than that.

Commentary Sexuality

Auntie Conversations: Black Women Talk Sex, Self-Care, and Illness

Charmaine Lang

These auntie conversations were just as much about me as they were about my aunts and mama. I really want to know what to expect, what to anticipate, and perhaps, even, what not to do as I age and grow in relationships so that I, too, can have a fulfilling and healthy partnership.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

“You’re just being nosy,” one of my aunts said, after I asked her if she enjoyed having sex with her husband. I assured her this was all part of a research project on the intimate lives of Black women. She relented a bit, but still gave me the side-eye.

I’ve been engaged in archival research for the last year. While the personal letters of Black women writer-activists and the newspapers of the Third World Women’s Alliance are remarkable and informative, they provide little insight into the intimate lives and sexual desires of Black women. After all, sex improves our mood and alleviates stress: That immediate gratification of pleasure and release is a way to practice self-care.

So on a recent trip home to Los Angeles, I asked my aunties to share their stories with me at a little gathering they threw in my honor.

And they did.

I asked them: “What’s your sex life like?” “Do you want to have sex?” “Are you and your husband intimate?” “You know … does he kiss you and hold your hand?” And I learned that contrary to tropes that present us as either asexual mammies or hypersexual jezebels, the Black women in my life are vulnerable and wanting love and loving partners, at all stages of life.

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Between 1952 and 1969, my maternal grandmother had six daughters and one son. All of them grew up in South Central Los Angeles, witnessing white flight, the Watts riot of 1965, and the crack epidemic. At the same time, the women have kept the family intact. They are the ones who always plan big dinners for the holidays and organize food drives for their churches. And they arranged care of their mother toward the end of her life. I’ve always wondered how they were able to prioritize family and their own desires for intimacy.

So I asked.

My 57-year-old aunt who is a retired customer service representative living in Pomona, California, told me: “My lifetime of sex consisted of first starting off with getting to know the person, communicating, establishing companionship. Once that was done, the sex and intimacy followed. When you’re younger, you have no frets. You experiment all the time.”

I wanted to know more.

“You’re not just trying to get in our business? You’re actually going to write something, right?” was my mother’s response.

When asked about the state of her sex life, my 59-year-old aunt, a social worker, said: “I am a married woman without a physical sex life with my husband. His illness has a lot to do with this, along with the aging process.”

My Pomona aunt went into more detail about how as we get older our ability and desire changes.

“You try to keep pace with pleasing your partner, and he tries to please you. But it is hard when you are a full-time worker, wife, and mother, and you commute to work. You’re tired. Hear me: You’re tired; they are not. You grow older, gain weight, and get sicker. You start to take medicine, and all that affects your ability and desire to perform.”

“For me, in a nutshell, [sexual activity] feels like work: I don’t feel excited. When it happens, it happens,” she said.

I learned the combination of energy spent on wage work, domestic labor, and mothering is draining, dissipating the mood for sex or intimacy. A husband who does not have the same domestic responsibilities has more energy for sex. The unbalanced load equates to differences in desire.

I wondered: Did my aunts talk to their partners about this?

Illnesses, such as diabetes and cancer, can cause anxiety, depression, and fatigue, which interrupt lovemaking. Talking to a partner can help to create a new normal in the relationship.

However, as my social worker aunt made clear, “It takes two to talk openly and honestly, which I find very difficult most of the time.”

“To be vulnerable is hard because I do not want to get hurt emotionally, so I protect my heart from harm,” she explained. “[My husband and I] can be harsh and curt to each other at times, which leads to me shutting down and not expressing my true feelings. My husband can be prideful and unwilling to admit there are issues within the relationship.”

Aunt April, a 47-year-old Los Angeles teacher, had some things to share too. “My love life is complicated. After suffering an overwhelming and devastating loss in 2011 of my husband and mate of nearly 20 years, I’m very hesitant to fully try again.”

She hasn’t dated since 1991. After much counseling, grieving, and encouragement from her 12-year-old daughter, she decided to give it a try.

“I have been seeing someone, but I have a lot of fear that if I relinquish my heart to him, he will die. So, I think about sabotaging the relationship so that I don’t have to get to know him and start worrying about his well-being and wondering if he feels the same way I do. In my mind, it’s easier to be casual and not give too much of my heart,” she said.

Intimacy, then, is also about being vulnerable in communicating how one feels—and open to all possibilities, even hurt.

As a 34-year-old queer Black woman figuring out my dating life, my aunt’s words about communication struck me. At times I can be guarded, too, fearful of letting someone get close. I started to ask myself: “What’s my sex life like?” and “What role does intimacy play in my life as I juggle a job and doctoral studies?”

These auntie conversations were just as much about me as they were about my aunts and mama. I really want to know what to expect, what to anticipate, and perhaps, even, what not to do as I age and grow in relationships so that I, too, can have a fulfilling and healthy partnership.

“I enjoy sex more now then I did before,” my mama, Jackie, said. Now 55, she remarried in 2013. She lives in Gilbert, Arizona, and works in the accounting and human resource field. “My husband loves me unconditionally; with him, I’m more comfortable. It’s more relaxing.”

My mama expressed her ability to enjoy herself with her husband because of the work she put into loving herself and prioritizing her needs.

I always talk to my mama about my dating life: heartbreaks and goals. She always says, “Learn to love yourself first.” It really isn’t what I want to hear, but it’s the truth. Self-love is important and central to the success of any relationship, especially the one with ourselves. My social worker aunt often takes trips to the spa and movies, and my aunt April is an avid concertgoer. They have found ways to have intimacy in their lives that is not informed by their relationship status.

The journey to self-love can be arduous at times as we discover parts of ourselves that we don’t like and want to transform. But with much compassion and patience, we can learn to be generous with the deepest parts of ourselves and each other. And isn’t that a necessary part of intimacy and sex?

The stories shared by my womenfolk reveal a side of Black women not often seen in pop culture. That is, Black women older than 45 learning how to date after the loss of a partner, and finding love and being intimate after 50. Neither mammies nor jezebels, these Black women, much like the Black women activists of the 1960s and 1970s I study, desire full lives, tenderness, and love. My aunts’ stories reassure me that Black women activists from decades past and present have intimate relationships, even if not explicit in the body of literature about them.

The stories of everyday Black women are essential in disrupting dehumanizing stereotypes so that we can begin to see representations of Black women that truly reflect our experiences and dynamic being.

Commentary Abortion

It’s Time for an Abortion Renaissance

Charlotte Taft

We’ve been under attack and hanging by a thread for so long, it’s been almost impossible to create and carry out our highest vision of abortion care.

My life’s work has been to transform the conversation about abortion, so I am overcome with joy at the Supreme Court ruling in Whole Woman’s Health v. Hellerstedt. Abortion providers have been living under a very dark cloud since the 2010 elections, and this ruling represents a new day.

Abortion providers can finally begin to turn our attention from the idiocy and frustration of dealing with legislation whose only intention is to prevent all legal abortion. We can apply our energy and creativity fully to the work we love and the people we serve.

My work has been with independent providers who have always proudly delivered most of the abortion care in our country. It is thrilling that the Court recognized their unique contribution. In his opinion, after taking note of the $26 million facility that Planned Parenthood built in Houston, Justice Stephen Breyer wrote:

More fundamentally, in the face of no threat to women’s health, Texas seeks to force women to travel long distances to get abortions in crammed-to-capacity superfacilities. Patients seeking these services are less likely to get the kind of individualized attention, serious conversation, and emotional support that doctors at less taxed facilities may have offered.

This is a critical time to build on the burgeoning recognition that independent clinics are essential and, at their best, create a sanctuary for women. And it’s also a critical time for independent providers as a field to share, learn from, and adopt each other’s best practices while inventing bold new strategies to meet these new times. New generations expect and demand a more open and just society. Access to all kinds of health care for all people, including excellent, affordable, and state-of-the-art abortion care is an essential part of this.

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We’ve been under attack and hanging by a thread for so long—with our financial, emotional, and psychic energies drained by relentless, unconstitutional anti-abortion legislation—it’s been almost impossible to create and carry out our highest vision of abortion care.

Now that the Supreme Court has made it clear that abortion regulations must be supported by medical proof that they improve health, and that even with proof, the burdens can’t outweigh the benefits, it is time to say goodbye to the many politically motivated regulations that have been passed. These include waiting periods, medically inaccurate state-mandated counseling, bans on telemedicine, and mandated ultrasounds, along with the admitting privileges and ambulatory surgical center requirements declared unconstitutional by the Court.

Clearly 20-week bans don’t pass the undue burden test, imposed by the Court under Planned Parenthood v. Casey, because they take place before viability and abortion at 20 weeks is safer than childbirth. The federal Hyde Amendment, a restriction on Medicaid coverage of abortion, obviously represents an undue burden because it places additional risk on poor women who can’t access care as early as women with resources. Whatever the benefit was to late Rep. Henry Hyde (R-IL) it can’t possibly outweigh that burden.

Some of these have already been rejected by the Court and, in Alabama’s case, an attorney general, in the wake of the Whole Woman’s Health ruling. Others will require the kind of bold action already planned by the Center for Reproductive Rights and other organizations. The Renaissance involves raising an even more powerful voice against these regulations, and being firm in our unwillingness to spend taxpayer dollars harming women.

I’d like to entertain the idea that we simply ignore regulations like these that impose burdens and do not improve health and safety. Of course I know that this wouldn’t be possible in many places because abortion providers don’t have much political leverage. This may just be the part of me that wants reproductive rights to warrant the many risks of civil disobedience. In my mind is the man who stood in front of moving tanks in Tiananmen Square. I am yearning for all the ways to stand in front of those tanks, both legal and extralegal.

Early abortion is a community public health service, and a Renaissance goal could be to have early abortion care accessible within one hour of every woman in the country. There are more than 3,000 fake clinics in this country, many of them supported by tax dollars. Surely we can find a way to make actual services as widely available to people who need them. Of course many areas couldn’t support a clinic, but we can find ways to create satellite or even mobile clinics using telemedicine to serve women in rural areas. We can use technology to check in with patients during medication abortions, and we can provide ways to simplify after-care and empower women to be partners with us in their care. Later abortion would be available in larger cities, just as more complex medical procedures are.

In this brave new world, we can invent new ways to involve the families and partners of our patients in abortion care when it is appropriate. This is likely to improve health outcomes and also general satisfaction. And it can increase the number of people who are grateful for and support independent abortion care providers and who are able to talk openly about abortion.

We can tailor our services to learn which women may benefit from additional time or counseling and give them what they need. And we can provide abortion services for women who own their choices. When a woman tells us that she doesn’t believe in abortion, or that it is “murder” but she has to have one, we can see that as a need for deeper counseling. If the conflict is not resolved, we may decide that it doesn’t benefit the patient, the clinic, or our society to perform an abortion on a woman who is asking the clinic to do something she doesn’t believe in.

I am aware that this last idea may be controversial. But I have spent 40 years counseling with representatives of the very small, but real, percentage of women who are in emotional turmoil after their abortions. My experience with these women and reading online “testimonies” from women who say they regret their abortions and see themselves as victimized, including the ones cited by Justice Kennedy in the Casey decision, have reinforced my belief that when a woman doesn’t own her abortion decision she will suffer and find someone to blame for it.

We can transform the conversation about abortion. As an abortion counselor I know that love is at the base of women’s choices—love for the children they already have; love for their partners; love for the potential child; and even sometimes love for themselves. It is this that the anti-abortion movement will never understand because they believe women are essentially irresponsible whores. These are the accusations protesters scream at women day after day outside abortion clinics.

Of course there are obstacles to our brave new world.

The most obvious obstacles are political. As long as more than 20 states are run by Republican supermajorities, legislatures will continue to find new ways to undermine access to abortion. The Republican Party has become an arm of the militant anti-choice movement. As with any fundamentalist sect, they constantly attack women’s rights and dignity starting with the most intimate aspects of their lives. A society’s view of abortion is closely linked to and mirrors its regard for women, so it is time to boldly assert the full humanity of women.

Anti-choice LifeNews.com contends that there have been approximately 58,586,256 abortions in this country since 1973. That means that 58,586,256 men have been personally involved in abortion, and the friends and family members of at least 58,586,256 people having abortions have been too. So more than 180 million Americans have had a personal experience with abortion. There is no way a small cadre of bitter men with gory signs could stand up to all of them. So they have, very successfully so far, imposed and reinforced shame and stigma to keep many of that 180 million silent. Yet in the time leading up to the Whole Woman’s Health case we have seen a new opening of conversation—with thousands of women telling their personal stories—and the recognition that safe abortion is an essential and normal part of health care. If we can build on that and continue to talk openly and honestly about the most uncomfortable aspects of pregnancy and abortion, we can heal the shame and stigma that have been the most successful weapons of anti-abortion zealots.

A second obstacle is money. There are many extraordinary organizations dedicated to raising funds to assist poor women who have been betrayed by the Hyde Amendment. They can never raise enough to make up for the abandonment of the government, and that has to be fixed. However most people don’t realize that many clinics are themselves in financial distress. Most abortion providers have kept their fees ridiculously and perilously low in order to be within reach of their patients.

Consider this: In 1975 when I had my first job as an abortion counselor, an abortion within the first 12 weeks cost $150. Today an average price for the same abortion is around $550. That is an increase of less than $10 a year! Even in the 15 states that provide funding for abortion, the reimbursement to clinics is so low that providers could go out of business serving those in most need of care.

Over the years a higher percent of the women seeking abortion care are poor women, women of color, and immigrant and undocumented women largely due to the gap in sexual health education and resources. That means that a clinic can’t subsidize care through larger fees for those with more resources. While Hyde must be repealed, perhaps it is also time to invent some new approaches to funding abortion so that the fees can be sustainable.

Women are often very much on their own to find the funds needed for an abortion, and as the time goes by both the costs and the risk to them increases. Since patients bear 100 percent of the medical risk and physical experience of pregnancy, and the lioness’ share of the emotional experience, it makes sense to me that the partner involved be responsible for 100 percent of the cost of an abortion. And why not codify this into law, just as paternal responsibilities have been? Perhaps such laws, coupled with new technology to make DNA testing as quick and inexpensive as pregnancy testing, would shift the balance of responsibility so that men would be responsible for paying abortion fees, and exercise care as to when and where they release their sperm!

In spite of the millions of women who have chosen abortion through the ages, many women still feel alone. I wonder if it could make a difference if women having abortions, including those who received assistance from abortion funds, were asked to “pay it forward”—to give something in the future if they can, to help another woman? What if they also wrote a letter—not a bread-and-butter “thank you” note—but a letter of love and support to a woman connected to them by the web of this individual, intimate, yet universal experience? This certainly wouldn’t solve the economic crisis, but it could help transform some women’s experience of isolation and shame.

One in three women will have an abortion, yet many are still afraid to talk about it. Now that there is safe medication for abortion, more and more women will be accessing abortion through the internet in some DIY fashion. What if we could teach everyone how to be excellent abortion counselors—give them accurate information; teach them to listen with nonjudgmental compassion, and to help women look deeper into their own feelings and beliefs so that they can come to a sense of confidence and resolution about their decision before they have an abortion?

There are so many brilliant, caring, and amazing people who provide abortion care—and room for many more to establish new clinics where they are needed. When we turn our sights to what can be, there is no limit to what we can create.

Being frustrated and helpless is exhausting and can burn us out. So here’s a glass of champagne to being able to dream again, and to dreaming big. From my own past clinic work:

At this clinic we do sacred work
That honors women
And the circle of life and death.