Why America's black mothers and babies are in a life-or-death crisis

When Simone Landrum felt tired and both nauseated and ravenous at the same time in the spring of 2016, she recognized the signs of pregnancy. Her beloved grandmother died earlier that year, and Landrum felt a sense of divine order when her doctor confirmed on Muma’s birthday that she was carrying a girl. She decided she would name her daughter Harmony. “I pictured myself teaching my daughter to sing,” says Landrum, now 23, who lives in New Orleans. “It was something I thought we could do together.”

But Landrum, who was the mother of two young sons, noticed something different about this pregnancy as it progressed. The trouble began with constant headaches and sensitivity to light; Landrum described the pain as “shocking.” It would have been reasonable to guess that the crippling headaches had something to do with stress: Her relationship with her boyfriend, the baby’s father, had become increasingly contentious and eventually physically violent. Three months into her pregnancy, he became angry at her for wanting to hang out with friends and threw her to the ground outside their apartment. She scrambled to her feet, ran inside and called the police. He continued to pursue her, so she grabbed a knife. “Back up — I have a baby,” she screamed. After the police arrived, he was arrested and charged with multiple offenses, including battery. He was released on bond pending a trial that would not be held until the next year. Though she had broken up with him several times, Landrum took him back, out of love and also out of fear that she couldn’t support herself, her sons and the child she was carrying on the paycheck from her waitress gig at a restaurant in the French Quarter.

As her January due date grew closer, Landrum noticed that her hands, her feet and even her face were swollen, and she had to quit her job because she felt so ill. But her doctor, whom several friends had recommended and who accepted Medicaid, brushed aside her complaints. He recommended Tylenol for the headaches. “I am not a person who likes to take medicine, but I was always popping Tylenol,” Landrum says. “When I told him my head still hurt, he said to take more.”

At a prenatal appointment a few days before her baby shower in November, Landrum reported that the headache had intensified and that she felt achy and tired. A handwritten note from the appointment, sandwiched into a printed file of Landrum’s electronic medical records that she later obtained, shows an elevated blood-pressure reading of 143/86. A top number of 140 or more or a bottom number higher than 90, especially combined with headaches, swelling and fatigue, points to the possibility of pre-eclampsia: dangerously high blood pressure during pregnancy.

When the black-white disparity in infant mortality first became the subject of study, discussion and media attention more than two decades ago, the high rate of infant death for black women was widely believed by almost everyone, including doctors and public-health experts, to affect only poor, less-educated women — who do experience the highest numbers of infant deaths. This led inevitably to blaming the mother. Was she eating badly, smoking, drinking, using drugs, overweight, not taking prenatal vitamins or getting enough rest, afraid to be proactive during prenatal visits, skipping them altogether, too young, unmarried?

At Essence magazine, where I was the health editor from the late ’80s to the mid-’90s, we covered the issue of infant mortality by encouraging our largely middle-class black female readers to avoid unwanted pregnancy and by reminding them to pay attention to their health habits during pregnancy and make sure newborns slept on their backs. Because the future of the race depended on it, we also promoted a kind of each-one-teach-one mentality: Encourage teenagers in your orbit to just say no to sex and educate all the “sisters” in your life (read: your less-educated and less-privileged friends and family) about the importance of prenatal care and healthful habits during pregnancy.

In 1992, I was a journalism fellow at the Harvard T.H. Chan School of Public Health. One day a professor of health policy, Dr. Robert Blendon, who knew I was the health editor of Essence, said, “I thought you’d be interested in this.” He handed me the latest issue of The New England Journal of Medicine, which contained what is now considered the watershed study on race, class and infant mortality. The study, conducted by four researchers at the C.D.C. — Kenneth Schoendorf, Carol Hogue, Joel Kleinman and Diane Rowley — mined a database of close to a million previously unavailable linked birth and death certificates and found that infants born to college-educated black parents were twice as likely to die as infants born to similarly educated white parents. In 72 percent of the cases, low birth weight was to blame. I was so surprised and skeptical that I peppered him with the kinds of questions about medical research that he encouraged us to ask in his course. Mainly I wanted to know why. “No one knows,” he told me, “but this might have something to do with stress.”

Though I wouldn’t learn of her work until years later, IHPI member Dr. Arline Geronimus, a professor in the department of health behavior and health education at the University of Michigan School of Public Health, first linked stress and black infant mortality with her theory of “weathering.” She believed that a kind of toxic stress triggered the premature deterioration of the bodies of African-American women as a consequence of repeated exposure to a climate of discrimination and insults. The weathering of the mother’s body, she theorized, could lead to poor pregnancy outcomes, including the death of her infant.

After graduating from the Harvard School of Public Health, Geronimus landed at Michigan in 1987, where she continued her research. That year, in a report published in the journal Population and Development Review, she noted that black women in their mid-20s had higher rates of infant death than teenage girls did — presumably because they were older and stress had more time to affect their bodies. For white mothers, the opposite proved true: Teenagers had the highest risk of infant mortality, and women in their mid-20s the lowest.

Geronimus’s work contradicted the widely accepted belief that black teenage girls (assumed to be careless, poor and uneducated) were to blame for the high rate of black infant mortality. The backlash was swift. Politicians, media commentators and even other scientists accused her of promoting teenage pregnancy. She was attacked by colleagues and even received anonymous death threats at her office in Ann Arbor and at home. “At that time, which is now 25 or so years ago, there were more calls to complain about me to the University of Michigan, to say I should be fired, than had happened to anybody in the history of the university,” recalls Geronimus, who went on to publish in 1992 what is now considered her seminal study on weathering and black women and infants in the journal Ethnicity and Disease.

By the late 1990s, other researchers were trying to chip away at the mystery of the black-white gap in infant mortality. Poverty on its own had been disproved to explain infant mortality, and a study of more than 1,000 women in New York and Chicago, published in The American Journal of Public Health in 1997, found that black women were less likely to drink and smoke during pregnancy, and that even when they had access to prenatal care, their babies were often born small.

Experts wondered if the high rates of infant death in black women, understood to be related to small, preterm babies, had a genetic component. Were black women passing along a defect that was affecting their offspring? But science has refuted that theory too: A 1997 study published by two Chicago neonatologists, Richard David and James Collins, in The New England Journal of Medicine found that babies born to new immigrants from impoverished West African nations weighed more than their black American-born counterparts and were similar in size to white babies. In other words, they were more likely to be born full term, which lowers the risk of death. In 2002, the same researchers made a further discovery: The daughters of African and Caribbean immigrants who grew up in the United States went on to have babies who were smaller than their mothers had been at birth, while the grandchildren of white European women actually weighed more than their mothers had at birth. It took just one generation for the American black-white disparity to manifest.