A Historical Analysis of Black Women’s Stratified Reproduction and Experiences of Gendered Racism in Reproductive Healthcare Settings

Introduction

Increasing attention is being paid to the underlying social and structural causes of what is known as the Black maternal health crisis, a phrase used to describe the adverse maternal health outcomes and increased risk of preventable maternal mortality and morbidity among Black birthing people.¹ Social science scholarship related to the Black maternal health crisis tends to focus on racial disparities in biological reproductive outcomes, such as premature birth outcomes, maternal mortality, and higher rates of STIs. Yet there is a shortage of scholarship that acknowledges the relationship between Black birthing people’s adverse reproductive health outcomes, racism, and structural determinants of reproductive injustice, such as unstable housing, barriers to insurance coverage, and access to healthcare.² A similarly scarce scholarship situates Black birthing people’s current reproductive health disparities in the context of slavery and its aftermath. Attending to the biological and structural determinates of Black birthing people’s adverse reproductive health outcomes requires a better understanding of the conditions that, historically and in the present, have allowed structural racism to materialize during medical encounters. At issue is Black birthing people’s embodied experience of racialization while navigating reproductive healthcare settings: what it feels like emotionally, where in the body it is felt, and “the process whereby bodies come to be seen, known and lived as ‘having’ a racial identity.”³

This special issue is curated around the work of Dána-Ain Davis, author of Reproductive Injustice: Racism, Pregnancy, and Premature Birth (NYU Press, 2019), who brilliantly calls attention to how racism manifests structurally and interpersonally in Black birthing people’s reproductive medical encounters and how cycles of reproductive injustice and racism are reproduced in the very technologies and interventions that claim to save Black babies and their birth parents. Through Davis’s work and guidance as an advisor, I have learned the importance of examining how racism is systematically upheld within institutions. I have also learned the importance of research that considers the history of science and medicine and how that history shapes our current conditions. Finally, from Davis I have learned the importance of language: the words we choose to name, define, and analyze have history and consequence. As Davis has shown me, we can use research to reveal how social categories like race, gender, and class are mobilized in language, institutions, and individual practices to justify and perpetuate oppression and injustices under the guise of power, order, or safety, and we can use this research to contribute to change.

In the following essay, I use these lessons to situate contemporary Black birthing people’s experiences of gendered racism within a longer history of reproductive injustices. Contextualizing Black women’s current stratified reproduction within the history of slavery and American gynecology and the relationship between the two will help us, as feminist scholars, better understand the current reproductive injustice Black birthing people face.

This essay begins with an examination of the intrinsic relationship between slavery, the progression of science and medicine, and violations of Black reproductive bodies. I aim to excavate how histories of gendered racism are embedded into the reproductive healthcare systems that exist within the current medical-industrial complex.⁴ Beginning with a historical analysis, I then turn to Black women’s current experiences of gendered racism in their reproductive health encounters and connect these experiences to slavery and its aftermath. Beyond discussing these findings, I also examine the methodologies typically employed in this area of research. This line of inquiry will then lead to a concluding statement on how future research can build on the numerous lessons from Davis and other scholars and provide an ethics of care for Black women and birthing people.

Historical Perspectives on Black Women’s Reproduction

Black birthing people experience reproductive health inequities because of three types of racism: gendered, medical, and obstetric. Looking at the problem using these three types of racism as an analytic framework allows us to clearly name and explain the individual and collective consequences of Black birthing people’s experiences of reproductive, gynecological, and obstetric medical encounters. These conceptual frameworks are rooted in the historical context of how the Black reproductive body was conceptualized during slavery and its aftermath, as well as the violence inflicted on these bodies in the name of science and biomedicine.

During the antebellum era in the United States, the institution of chattel slavery relied on enslaved African people to produce labor. According to Ahmed, Europe’s project of colonization depended on marking all bodies that were different from the white masculine subject as inferior to varying degrees to uphold its power over internal and colonized subjects.⁵ By marking the enslaved African body as Black, not only was race invented, but also white supremacy, providing the ideological basis for the justification of a brutal and dehumanizing economic and political system in the United States. Not only did the institution of slavery mark enslaved Africans as Black to extract their labor, it constructed them as both “person and property, as absolutely subject to the will of another,” and thereby attempted to prevent their existence as political and fully human subjects who could claim rights or overthrow a system.⁶ In other words, the racialization of colonized bodies was used to maintain and uphold white supremacy and the domination of enslaved Black bodies used for free labor.

Under this political and economic system, enslaved and colonized bodies were only valuable in terms of the labor they were able to produce. Therefore, the Black birthing body was essential to the maintenance of chattel slavery because Black birthing people’s reproductive labor was necessary for the creation of slaves. Even though Europe and the United States ended the transatlantic slave trade around 1807, slavery as an institution remained intact because of its economic importance, creating conditions under which “slavery and the southern way of life could continue only if children were born in bondage.”⁷ As a result, the end of the transatlantic slave trade increased the value of the enslaved Black reproductive body drastically.⁸ Furthermore, since enslaved Black birthing people were denied rights to their personhood, their reproductive bodies were deemed property, and their ability to consent to sex and reproduction, the institution of slavery gave slave owners, doctors, and scientists license to violently exploit their sexual and reproductive bodies.⁹ The institution of slavery depended upon reproductive exploitation, and reproductive exploitation, in turn, maintained the institution of slavery.

American Gynecology’s Roots in Slavery

The law’s construction of enslaved Black birthing people as both a dehumanized person and property led to their reproductive exploitation and catalyzed their use as subjects of medical experimentation. The progression of medical science and the development of reproductive medicine coincided with the legal end to the transatlantic slave trade and, consequently, an increased investment in Black women’s reproductive labor to sustain slavery in the US. Since the US was becoming an “increasingly profitable slave-based nation,” and the institution of slavery was dependent on viable slave labor, slaveowners also became increasingly invested in maintaining a healthy slave population and providing medical care to enslaved Black bodies.¹⁰ Thus developed a partnership between slave owners and medical doctors to protect and maintain the (re)production of slave labor.¹¹ As Evans and Lee write, medical knowledge now played a crucial role in the regulation of individual bodies and whole populations. It produced a set of “apparently verifiable truths,” giving it a central role in the production of “the disciplinary society.”¹² To put it differently, slaveowners needed enslaved Black women to (re)produce a healthy slave-nation and so they needed a medical system that could discipline and subjugate those bodies. Thus, a complex and complicated relationship between slave owners, reproductive medicine, and the Black reproductive body was born.

In the antebellum South, medical schools and doctors often partnered with slave owners to attend to the reproductive health of enslaved Black birthing people and this transformed the field of modern American gynecology in the nineteenth century.¹² Medical doctors, students, and entire medical schools exploited the denial of consent given to enslaved Black birthing people and used them to conduct various experimental surgeries. Most infamously, Dr. James Marion Sims, known as the father of gynecology, relied exclusively on enslaved Black bodies for reproductive surgical experimentation, which he often performed without anesthesia, to develop treatments for his white patients.¹³ What are now routine gynecological treatments and procedures, such as the cesarean section and the removal of infected ovaries, were then developed and perfected through the nonconsensual exploitation of enslaved Black birthing people.¹⁴ Thus, as Ahmed writes, the Black female body became “the means by which science accumulate[d] knowledge.”¹⁵

American gynecology in the antebellum era also sustained ideologies of racial difference. Medical knowledge and representation were used to “prove” the belief in the inherent biological difference between the superior white and the inferior yet super Black body. Qualities that were seen as natural for white women were rarely attributed to Black women, and vice versa, including extremely damaging beliefs about Black women’s tolerance for pain.¹⁶ Like much of white supremacy, the belief that Black bodies are superhuman and thus can withstand dehumanizing pain persists in today’s mainstream medicine.¹⁷

Far beyond the antebellum era and the formal abolition of slavery, Black women’s bodies continued to be exploited for the gain of medical knowledge, and Black birthing people were not alone. Other global majority birthing people such as Indigenous, Arab, Asian, and Latinx people also faced medical violence through forced and nonconsensual sterilization and use for experimentations like tubal ligations and hysterectomies, but the targeting of Black bodies has specific significance. In the last one hundred years alone, Black people have been subjected to myriad forms of state-sponsored medical violence and control: in the 1930s, the US government funded birth control clinics to forcibly limit the reproduction of Black people, and in the 1980s and 1990s doctors and public assistance officials forced low-income Black women into sterilization by threatening to withhold government assistance and welfare benefits unless they complied.¹⁸ This legacy has led to Black birthing people’s distrust of the medical institution and has contributed to the Black maternal health crisis and general reproductive health inequities for Black birthing people.

Enslaved Black Women’s Resistance Against Reproductive Injustice

Despite the egregious truth of violent experimentation on enslaved Black reproductive bodies, enslaved people with the capacity for pregnancy found ways to resist their exploitation and find agency to “resist the wholesale control that slave owners and medical doctors had over their bodies.”¹⁷ For example, during auctions, enslaved birthing people would present themselves as healthy “even when they knew they had reproductive illnesses and sexually transmitted diseases that affected their fertility” to potentially escape abuse and prevent their new slaveowner from capitalizing off their reproduction.¹⁹ These birthing people would also weaponize their sexuality to threaten the health of other enslaved individuals, as well as their masters, by, for example, not disclosing known cases of STIs and other venereal diseases.²⁰ Some enslaved Black birthing people, sometimes referred to as bondwomen, held knowledge of the medicinal value of certain herbs. They would use this knowledge to treat and heal other members of their community. They served as midwives who provided holistic methods of healing.²¹ Research and oral histories also suggested that enslaved African birthing people would ingest various plant materials and other non-edible items as contraceptives or abortifacients.²² The holistic medical practices of bondwomen and enslaved midwives provided healing to enslaved birthing people and helped prevent them from going to hospitals where they would be exposed to invasive reproductive medical experimentations. The medical practices rooted in folk knowledge allowed enslaved birthing people to resist their reproductive exploitation and reclaim some agency in reproduction.

It is essential to comprehend these stories of resistance alongside the egregious violations and atrocities performed on enslaved Black reproductive bodies. We must portray enslaved Black birthing people in the wholeness of their lives and capture the power dynamics that result in the everyday imposition of exploitation on the seemingly powerless.²³ By holding these two historical threads together, we can, as Tuana writes, prevent an epistemology of ignorance and promote an epistemology of resistance.²⁴

Contemporary Implications of American Gynecology’s Historical Injustices

As mentioned above, the history of the medical mistreatment of Black reproductive bodies continued well past the antebellum era and persists in Black birthing people’s current experiences of reproductive healthcare. As I discussed in a recent qualitative study on middle-class Black birthing people’s experiences navigating reproductive healthcare systems, history has contemporary impacts.²⁵

I found that most participants had an awareness of the current reproductive injustices and inequities that many Black birthing people face. They were also aware that their experience of what I call gynecological trauma is connected to history.²⁰ Additionally, they all described various experiences of being fetishized by their gynecologist, having doctors talk down to them, having their bodily autonomy ignored, and having their pain dismissed.²⁰ These narratives of being violated, disrespected, and ultimately treated inhumanely are examples of the types of medical racism that Davis aptly labels obstetric racism in the aftermath of slavery.²⁶ Moreover, these retellings demonstrate how gendered racism is embedded in the structures of obstetric, gynecological, and reproductive medicine as a direct consequence of the interdependence between American gynecology and the American institution of slavery.

As Davis has taught me, carefully examining the existing literature on racism and reproduction allows us to see patterns of injustice throughout the history of medicine. As I mentioned above, Black birthing people’s experiences of dismissals and violations are grounded in the persistence of the racist belief in the Black super body, a body with extraordinary, abnormal strength and ability to withstand pain, and thus without need for the kind of baseline care presumed normal for white women.²⁷ Indeed, a recent study on racial bias in pain assessment and management demonstrated that, despite evidence, white medical students and residents still tend to believe that Blacks and whites are biologically different, upholding a racially biased perception of differential pain tolerance.²⁸

Despite these painful experiences, Black birthing people don’t passively accept mistreatment and racism in reproductive healthcare.²⁹

Instead, they employ what I refer to as “strategies of protection and resistance against gendered racism” to fight against Black birthing people’s interlocking oppressions.³⁰ When Black birthing people share these experiences with one another, they do so, to borrow Collins’ words, “not merely [to] survive or fit in or to cope; rather it becomes a place where we feel ownership and accountability” over our reproductive health.³¹ However, these stories are also indicators of the burden that Black birthing people carry as they experience the legacy of gendered racism in everyday, transactional reproductive health encounters.

Methodology Matters

American gynecology’s originating enactment of violence on Black birthing people’s bodies resulted in the institutionalization of medical and obstetric racism. However, the methodological focus of research on reproductive health disparities rarely focuses on the ways that Black birthing people’s experience of reproductive injustices result from the aftermath of slavery. By obscuring the legacy of slavery, this research unwittingly asserts that race and not institutional racism is the cause of Black birthing people’s adverse reproductive health outcomes. In a recent report, the Black Women Scholars and the Research Working Group of the Black Mammas Matter Alliance asserts that there tends to be a methodological focus on “the notion that the ‘Black race’ is a risk factor that is associated with many poor health outcomes across the reproductive spectrum.”³² On the contrary, they write,

Race is not the risk factor—racism is. Black race is an exposure variable—in other words, it is a characteristic of a population; however, it has been used in statistical models as an independent variable; meaning it can be manipulated in a scientific experiment like temperature or feedings. There is nothing inherent about Black skin that is physiologically different from any other type of skin except its capacity to overexpose those who have it to racism. This is a methodological problem—driven by research methods.²⁰

Although research on Black birthing people’s poor reproductive health outcomes considers race and class stratification, class is often treated as a mediating variable of racialized reproductive health disparities. Race and class are often treated as mutually inclusive since, in the US, race often influences class position.³³ However, poor reproductive health outcomes among Black birthing people exist across income levels and socioeconomic status.³⁴ Sacks demonstrated that middle-class Black birthing people, despite having access to resources like a college education, gainful employment, and insurance coverage, as well as healthcare providers attuned to person-centered care, also report feeling dismissed or condescended to by their healthcare providers.³⁵ In another study, Sacks found that Black birthing people reported feeling negatively evaluated by their providers based on negative stereotypic images of Black birthing people and felt they had experienced differential treatment based on their race and gender.³⁶

Research that treats race instead of racism as a risk factor and treats class as a proxy for race undermines an adequate analysis of the real history of slavery and American gynecology and its consequences.³⁷ By excavating the egregious legacies of slavery and American gynecology, we can begin to understand the conditions in which Black birthing people experience gendered racism in their medical encounters today. Social scientists who utilize critical feminist and race theory can start to uncover the institutional racism embedded in reproductive healthcare systems and potentially lessen the burden imposed on Black birthing people. Researchers who expand on Davis’s analytic and interpretative frameworks of obstetric racism can help break the cycles of reproductive injustices enacted on Black reproductive bodies.

Such methodological expansion can also generate new ways of producing knowledge. As an emerging scholar and student of Dr. Davis, I hope to conduct research that integrates an ethics of care and love for Black birthing people into my theoretical and methodological frameworks. In my dissertation, I am applying this integrated method and my Black feminist politics to create a new methodology that draws on the long history of crafting, specifically quilt making, in Black communities. Crafts such as weaving, sewing, knitting, pottery, quilting, and other textile arts have long histories in various cultures across the globe. Crafting has often been recognized as a gendered, feminine, domestic hobby, while there have also been recognitions of its more complex history. Now there is a resurgence of craft arts. Artists, activists, and cultural workers are reclaiming craft arts as feminist action, resistance, and healing. In fact, art therapists have started to merge feminist models of social change and community with crafting practices as a new critical healing methodology focused on embodied change.³⁸ I take this innovation into my own scholarly work: crafting can promote creative agency of mind and body for those who practice it.

I turned to quilting during the first pandemic summer of 2020. I felt called, perhaps by my ancestors who taught me how to sew, to return to my own background in fashion design and crafting. I signed up for a Zoom quilting class called “A Quilt is Something Human.” During this class I learned about the Gee’s Bend quilters, an intergenerational collective of African American women quilters who live in a secluded town called Gee’s Bend in Alabama. This community of quilters used their craft to help provide income for their community, and the practice of quilting generated a source of feminist empowerment for themselves. I became obsessed with the Gee’s Bend quilters, and this led me to research broader African American quilting traditions that, like the Gee’s Bend quilters, have dated back centuries, to the antebellum period. 

While learning and researching more about African American quilting traditions, I was reminded of critical methodologies. I thought about the work that Segalo did using embroideries as a decolonizing technique.³⁹ Segalo looks at how Black South African women used embroidery to visually narrate their individual and collective life stories of living in apartheid South Africa. Similarly, I wanted to use quilting as a way for Black birthing people to narrate the stories embedded in their reproductive bodies. Like Segalo’s interpretation of embroidery as a decolonial tool, I want to use quilting as a feminist arts-based methodology rooted in social justice.

Quilting alongside other Black birthing people while they tell me their reproductive narratives is also a method that mirrors feminist ethnography practices established by Davis and Craven and serves as a “methodological release point” for research topics that are centered around vulnerability and are often difficult to talk about.⁴⁰ I am still in the process of conceptualizing this method and hope that it will become a new methodology used by feminists to disrupt our dependence on the master’s research tools, to riff Audre Lorde. My hope is to go beyond simply documenting racism and inequalities and to use research as social justice activism and intervention.⁴¹ This new method centers Black birthing people’s narratives and is engrained with care. It also captures the lessons that I’ve learned from Davis on how to be an ethical researcher committed to my Black feminist politics. Finally, I plan to have an exhibit, open to the public, where the final quilts are displayed and possibly raffled off to raise money for reproductive justice organizations, build community, and offer fulfilling personal experience for people who participate.

Conclusion

Gynecologists and other reproductive healthcare providers are trained within an institution that developed from nonconsensual sexual and reproductive medical exploitation of enslaved Black bodies. Until reproductive healthcare systems begin to acknowledge their past, the poor reproductive health outcomes and systemic injustices that Black birthing people experience will continue to be perpetuated. As researchers work to uncover this history, models of holistic care, like the medical practices of bondwomen and enslaved midwives, as well as epistemological and conceptual frameworks of birth justice, reproductive justice, and Black feminism, must be integrated into the methodological practices of conducting ethical research on Black birthing people’s reproductive health disparities.

Future research should highlight enslaved Black birthing people’s resistance to exploitation and subjugation along with their attempts at reclaiming agency over their bodies. It should also focus on how Black birthing people cope with their experiences of gendered racism in their medical encounters. By centering the voices of Black birthing people and uplifting their narratives, researchers can avoid the reliance on methodologies that only portray Black suffering and oppression in reproductive health research. Using Black feminist theory, critical feminist theory, arts-based research methods centering social justice, and centering Black birthing people’s narratives of radical hope can produce a new understanding that humanizes Black birthing people and captures the fullness of Black reproduction in contemporary society.⁴² I hope that, as feminist scholars, we can learn from the multiple lessons in Davis’s scholarship and integrate an ethics of care and love for Black birthing people into our methodological practices and, in doing so, create a body of research that aides in breaking the cycles of medical and obstetric racism perpetuated in reproductive healthcare.

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1. Linda Villarosa, “Why America’s Black Mothers and Babies are in a Life-or-Death Crisis,” The New York Times (April 11, 2018), https://www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html. [↩]
2. Mahrokh Dolatian, Arash Mirabzadeh, Ameneh Setareh Forouzan, Homeira Sajjadi, Hamid Alavimajd, Zohreh Mahmoodi, and Farnoosh Moafi, “Relationship between Structural and Intermediary Determinants of Health and Preterm Delivery,” Journal of Reproduction & Infertility 15, no. 2 (2014): 78–86. [↩]
3. Sara Ahmed, “Racialized Bodies,” in Real Bodies, eds. Mary Evans and Ellie Lee (London: Red Globe Press, 2002), 47. [↩]
4. I use the term “medical-industrial complex” to refer to the capitalist process by which healthcare has been privatized into a for-profit system benefiting corporations rather than patients; see Relman, “The New Medical Industrial Complex,” New England Journal of Medicine no. 303 (October 23, 1980): 963-970. [↩]
5. Ahmed, “Racialized Bodies,” 49. [↩]
6. Saidiya Hartman, Scenes of Subjection: Terror, Slavery, and Self-Making in Nineteenth-Century America (Oxford University Press, 1997), 80. [↩]
7. Marie Jenkins Schwartz, Birthing a Slave: Motherhood and Medicine in the Antebellum South, (Cambridge: Harvard University Press, 2006), 1. [↩]
8. Nicole Ivy, “Bodies of Work: A Meditation on Medical Imaginaries and Enslaved Women.” Souls 18, no. 1 (March 14, 2016): 11–31; Diedre Cooper Owens, Medical Bondage: Race, Gender, and the Origins of American Gynecology (Athens, University of Georgia Press, 2017). [↩]
9. Hartman, Scenes of Subjection. [↩]
10. Owens, Medical Bondage, 15. [↩]
11. Diedre Cooper Owens and Sharla M. Fett, “Black Maternal and Infant Health: Historical Legacies of Slavery,” American Journal of Public Health 109, no. 9 (2019): 1342-45. [↩]
12. Mary Evans and Ellie Lee, “The Pregnant Body,” in Real Bodies, eds. Mary Evans and Ellie Lee (London: Red Globe Press, 2002), 116–17. [↩] [↩]
13. Vernellia R. Randall, “Slavery, Segregation and Racism: Trusting the Health Care System Ain’t Always Easy! An African American Perspective on Bioethics,” Saint Louis University Public Law Review 15, no. 2 (1996): 191–235; Ivy, “Bodies of Work.” [↩]
14. Owens, Medical Bondage. [↩]
15. Ahmed, “Racialized Bodies,” 51. [↩]
16. Leith, Mullings, “Resistance and Resilience: The Sojourner Syndrome and the Social Context of Reproduction in Central Harlem,” Transforming Anthropology 13, no. 2 (October 2005): 79–91; Owens, Medical Bondage. [↩]
17. Owens, Medical Bondage. [↩] [↩]
18. Randall, “Slavery, Segregation and Racism”; Harriet Washington, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present (New York: Doubleday Books, 2006); Dorothy E. Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty, (New York: Vintage Books, 1999). [↩]
19. Ibid., 48. [↩]
20. Ibid. [↩] [↩] [↩] [↩]
21. Keisha Goode and Barbara Katz Rothman, “African-American Midwifery, a History and a Lament,” American Journal of Economics & Sociology 76, no. 1 (January 2017): 65–94; Owens, Medical Bondage. [↩]
22. Angela Davis, Women, Race, and Class (New York: Vintage Books, 1983); Liese M. Perrin, “Resisting Reproduction: Reconsidering Slave Contraception in the Old South,” Journal of American Studies 35, no. 2 (August 2001): 255–74. [↩]
23. Lois Weis and Michelle Fine, “Critical Bifocality and Circuits of Privilege: Expanding Critical Ethnographic Theory and Design,” Harvard Educational Review 82, no. 2 (June 1, 2012): 173–201. [↩]
24. Nancy Tuana, “The Speculum of Ignorance: The Women’s Health Movement and Epistemologies of Ignorance,” Hypatia 21, no. 3 (July 2006): 1–19. [↩]
25. Frances M. Howell, “Resistance and Gendered Racism: Middle-Class Black Women’s Experiences Navigating Reproductive Health Care Systems,” Psychology of Women Quarterly (April 25, 2023). [↩]
26. Davis, Reproductive Injustice. [↩]
27. Mullings, “Resistance and Resilience”; Owens, Medical Bondage. [↩]
28. Kelly M. Hoffman, Sophie Trawalter, Jordan R. Axt, and M. Norman Oliver, “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences between Blacks and Whites,” Proceedings of the National Academy of Sciences 113, no. 16 (April 19, 2016): 4296–4301. [↩]
29. Howell, “Resistance and Gendered Racism.” [↩]
30. Ibid, 10; see also; Patricia Hill Collins, Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment (New York: Routledge, 1991). [↩]
31. Collins, Black Feminist Thought, 563. [↩]
32. Black Women Scholars and the Research Working Group of the Black Mammas Matter Alliance, “Black Maternal Health Research Re-Envisioned: Best Practices for the Conduct of Research with, for, and by Black Mamas,” Harvard Law Policy Review 14, no. 2 (2020): 393. [↩]
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