At the recent annual meeting of the American College of Obstetricians and Gynecologists (ACOG), Dr. Haywood Brown ended his term as president with an address that inadvertently began a social media firestorm.
In his April 27 conference opening remarks, Brown used a slide that showed a cartoon condom with the words “primary prevention of maternal mortality.” ACOG’s official conference Twitter account tweeted an image of the slide and the caption: “#ACOG2018: The primary prevention of maternal mortality is birth control.”
As health-care providers and ACOG members, we were shocked by this spectacularly unnuanced message. With no other information, readers would be left thinking that avoiding pregnancy is the best way to avoid death, disability, or serious illness during childbirth and pregnancy. That’s certainly what scores of Twitter users thought, ACOG members among them, and many responded with outrage and calls for clarification.
ACOG responded on Twitter, saying that “we hear you and we sincerely apologize for the misrepresentation of ACOG’s commitment to addressing racial disparities in maternal mortality and improving women’s health care overall.” The organization also reiterated its commitment to reducing maternal deaths in a written statement for Rewire.News.
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In that statement, Brown and new president Lisa Hollier said:
… it has been extremely disappointing for our dedication to this cause to be called into question with an image that has, unfortunately, been taken out of context. As ob-gyns, we understand the full complexity of healthy motherhood and safe delivery. In no way did we mean to imply that women should avoid pregnancy. Access to all forms of contraception is important for all women so that they can choose if and when they want to become pregnant. Bringing a child into this world, normally a joyful occasion, can be a high-risk endeavor given all the acute and chronic conditions a woman can develop, especially if she’s not in the best of health to begin with due to an unplanned pregnancy. It was also meant to show that men are not exempt from taking on part of this responsibility, which is why the male form of contraception was shown.
Was the Tweet in question a social media misstep or a reflection of a medical specialty that has been slow to change but quick to see maternal death as a matter of individual risk and not structural bias?
We think it’s both—and it’s time for a wakeup call.
There is the reality that some women with serious illnesses may want to avoid pregnancy. But essentially telling women at higher risk for pregnancy-related complications to simply “wrap it up and don’t get pregnant” is woefully incomplete (even when you take into account the brevity of social media messages) and unacceptable. Because it’s our jobs as medical professionals to help women reach their reproductive life goals, whatever they are, and to help them manage and lessen risk.
The emphasis on contraception reinforces several false narratives that ACOG should be combating, not promoting. Contraception is not a panacea. Furthermore, all pregnancies don’t end in birth, and this framing erases abortion as a legitimate reproductive choice and an equally legitimate intervention to reduce maternal deaths.
While Brown’s comments were not specifically about Black women, this idea of contraception as mortality prevention rings particularly hollow for Black women—who are more likely to die from pregnancy complications than white women—and those typically thought to be at higher risk. The notion that not having babies is the primary way to mitigate Black women’s death and injury conveniently ignores the racist structures of health-care systems that endanger people throughout the reproductive spectrum. And the emphasis on contraception suggests that individual Black women—not their health-care systems or providers—bear the most responsibility to save their own lives.
What is happening to Black mothers in this country is not an accident. We have developed health disparities precisely due to historical and ongoing segregation and bias in medicine and society. The American Medical Association (AMA) actively fought against desegregation in medical facilities and was slow to join the movement for Black civil rights. The racial disparity in maternal mortality and morbidity is the direct result of behaviors and attitudes adopted and enforced by the forefathers of U.S. medicine through the AMA, ACOG, and other national organizations.
ACOG is trying with initiatives like its multi-state alliance for maternal health innovation—but that’s not enough. In late 2017, ACOG co-released with the Council on Patient Safety in Women’s Health Care a maternity safety bundle designed to decrease racial and ethnic disparities before, during, and immediately after childbirth. (A “bundle” describes a set of best practices developed and endorsed by national multidisciplinary organizations for the purpose of improving health-care processes and service delivery.) Despite the extent of the maternal health crisis, this group of recommended practices covers less territory than previous bundles for other issues such as obstetrical hemorrhage and severe hypertension/preeclampsia. When ACOG and its partner should have gone the extra mile, they instead issued what’s basically a concept paper with few accompanying toolkits to help individuals and institutions implement changes.
Nor are its recommendations comprehensive or, in some cases, even practical. While ACOG is starting to branch out to collaborate with other birth workers, the bundle fails to discuss how team-based care and having diverse providers—including doulas, nurses, midwives and others in partnership with prenatal care and home visiting programs—can be successful at improving maternal health outcomes. And while the bundle recommends creating mechanisms for patients and families to report inequitable care or disrespect, the idea that people experiencing discrimination can always speak up and flag the issues—much less be listened to—is unrealistic. There are countless reports of Black women’s reproductive choices or knowledge about their own health being disregarded by their health-care providers, among them the recently publicized case of tennis star Serena Williams.
Even more disturbing is the idea that racial and ethnic disparities can be solved with checklists, bundles, and other tools without addressing the underlying problem: racism in our health systems and society. These modest tweaks will not result in the systemic changes needed to improve reproductive health outcomes. Health-care institutions and organizations are not investing enough in examining the impact of provider bias, nonempathetic care, and structural deficiencies in health facilities. It’s predictable that they don’t want to look inward. But it’s problematic that they aren’t careful when they recommend regulating and reducing birth.
Our health-care system and its leading organizations won’t lower maternal deaths and complications by telling Black people or those at high-risk not to reproduce. Doing so will only widen the chasm between women and providers by promoting these ideas or not being clear about what we mean when we discuss contraception as part of a holistic, multipronged strategy to make pregnancy and childbirth safer. Elimination of births by high-risk Black mothers to prevent maternal mortality only serves to further pathologize Black sex, reproduction, parenthood, and personhood.
ACOG is signaling that it wants to get it right. But if it can’t talk about how to lower maternal risk without setting off controversy, it’s hard to have faith that it can be a real partner in collaborations to fight the discrimination, disrespect, and disability that many Black people experience while pregnant.