Edited by: Regina Davis Moss, American Public Health Association, United States
Reviewed by: Stacie Craft DeFreitas, University of Houston–Downtown, United States; Darcell P. Scharff, Saint Louis University, United States
This article was submitted to Public Health Education and Promotion, a section of the journal Frontiers in Public Health
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
It took a white police officer's knee on George Floyd's neck before white people began to reckon with 400 years of slavery and its aftermath, the effects of which Black people have endured for generations. Monuments are being taken down, flags are being redesigned, and institutions that honored those who denied the humanity of Black people are being renamed. Unfortunately for Sandra Bland, Breonna Taylor, Sha-Asia Washington and countless other Black transgender people including those with capacity for pregnancy, there was no justice even prior to the global pandemic of SARS-Cov-2 or coronavirus; namely racism, violence, and the Black Maternal Health crisis that makes it less likely that Black women will survive pregnancy and childbirth. The purpose of this article is to situate the state of Black people with the capacity for pregnancy in the context of these existing crises to illuminate the myths that racism has perpetuated through science, health services provision and policy. The greatest of these is the myth of a default human that can serve as a standard for the rest of the population. This racist ideal underpins education, provision of care, research, policies, and public health praxis. Demolishing the myth starts with acknowledging that Black people are not the architects of their own destruction: the default standard of whiteness is. The article begins with a historical background on how this myth came to be and elucidates the development and perpetuations of the myth of the default human. Next, we present an evidence based scoping review of the literature to summarize current thinking with specific focus on the Black maternal health crisis, we make policy recommendations and retrofits of upstream public health approaches for existing programs toward health equity. We also situate Black maternal health as part of a reproductive justice frame that centers Black women and birthing people's autonomy and agency. In other words, we use the scoping review to end with reimagining public health policy and provide an actionable roadmap to specifically disrupt the myth of the default human and dismantle racism in education, provision of care, research, policies, and public health praxis.
The myth of a default human posits that white people are the natural reference group for all others when designing scientific studies, reporting scientific findings, allocating human, money and time resources, and that the health outcomes of white people in the United States (U.S.) are the best that can be attained. Demolishing this myth starts with acknowledging that Black people are not the architects of their own destruction: the default standard of whiteness is.
The article begins with a historical background on how this myth came to be and essential definitions. The historical background also elucidates the development and perpetuations of the myth of the default human in published scientific and public health literature. Next, we present an evidence based scoping review of the literature to summarize current thinking with specific focus on the Black maternal health crisis. We seek to clarify key concepts and to identify and analyze knowledge gaps. Finally, we make policy recommendations and retrofits of upstream public health approaches for existing programs toward health equity. We also situate Black maternal health as part of a reproductive justice frame that centers Black women and birthing people's autonomy and agency to illuminate how the myth plays out across the reproductive health spectrum. In other words, we use the scoping review to end with reimagining public health policy grounded in reproductive justice and provide an actionable roadmap to specifically disrupt the myth of the default human and dismantle racism in education, provision of care, research, policies, and public health praxis.
This article is unapologetically specific to understanding the experiences of Black people and how scientific racism is manifest in the conduct of clinical and public health research. We begin with some essential definitions to provide readers with clear meanings as they are used in this article. First, where relevant and appropriate we acknowledge that all pregnant capable people do not identify as women, thus we use gender neutral language to foster inclusivity. Second, when citing historical sources and research literature, we retain the language used by the authors. Third, when using the term Black, we make no distinction across diasporas unless specifically noted. In other words, we do not use African Americans to encompass the range of Black people who originate from other geographies, nor do we use Black and African Americans interchangeably. Fourth, we define Black maternal health as the full spectrum of reproductive health experiences that include the perinatal period of pregnancy, labor, birth, and post-partum; when discussing other pregnancy outcomes (i.e., abortion, family planning, miscarriage, surrogacy) we use the more accurate terminology. When discussing people with capacity for pregnancy or pregnant capable people, who are not currently pregnant, we purposively use these terms as opposed to pre-conception. Finally, we include the word mother in our title out of respect to the family members who intentionally use this term in the context of maternal mortality.
The Black maternal health crisis as we know it today devolved from a system that once deemed Black women the most valuable of all commodities. In 1619, the United States of America was as nascent as its capitalist system, the foundations of which were built on the backs of Africans brought to the Americas as chattel (
The U.S. Congress abolished the transatlantic slave trade in 1807 (
“Although enslaved midwives and nurses supplied much of the daily plantation health care, slaveowners called upon White physicians for cases such as assisting difficult births with forceps, examining the causes of an enslaved woman's infertility, or investigating cases of infant mortality” (
Such surveillance ensured that enslaved Black women continued to reproduce: Between 1807 and 1860, the number of enslaved Black people in the U.S. increased from just over 1 million to over 3.9 million (
Trajectory of the Slave Population in the United States (U.S.) from 1790 until 1860. This figure used with permission from (copyleft 2007) Chad David Cover. Data derived from “Series A 119–134. Population by Age, Sex, Race, and Nativity: 1790–1970.” U.S. Bureau of the Census, Historical Statistics of the United States, Colonial Times to 1970. Bicentennial Edition, Part 2. Washington, D.C., 1975.
A lesser-known fact is that while enslaved Black women did not have control over their sexuality or ownership of their bodies, they found ways to manage their fertility (
Instances of abortion and infanticide are mere mentions in the historical record. According to Deborah Gray White, how enslaved Black women managed their fertility remained a subject discussed only amongst themselves (
The abolition of slavery and the failure of Reconstruction demanded that a hierarchy of humanity be reasserted. While chattel slavery was no longer part of the capitalist system, Jim Crow laws became its proxy, denying freed slaves the rights secured by whites. Laws that mandated segregation based on race gave rise to the development of new systems and structures that excluded Black people. The 1856 ruling in Scott v. Sandford (
If Scott v. Sanford built the table, Plessy v. Ferguson (
Limited access to quality public education has had the most profound effect on Black people's health outcomes. After emancipation, the sharecropping system kept Black families in poverty and truncated secondary education. While land grant institutions were founded to educate freedmen, there were many barriers to medical education for Black people, including affordability and access. Racial segregation and structural racism also limited access to residency and specialty fellowship programs. In response to these barriers, a movement to train more Black physicians resulted in the founding of 14 medical schools between the late nineteenth century and early twentieth century. While it has been argued that a few of those schools may have been established as diploma mills that did nothing to advance the cause of medical education for Black people, it is also important to note that most of them were underfunded, lacked adequate facilities, and had limited access to patients (
Abraham Flexner in his report (
Flexner's goal, to improve the quality of medical education, came with a consequence that the healthcare enterprise continues to reckon with. The closure of medical schools founded to educate Black people who were refused admission to majority-white institutions, coupled with the closure of majority institutions that also did not meet the standards that Flexner set, placed medical education further out of reach, especially for Black students. There have been just two Black medical schools founded in the last 100 years: Charles Drew Medical School and Meharry Medical School and <4% of physicians in the U.S. are Black, while Black people make up 13% of the population (
Dr. Charles H. Epps, renowned orthopedist, put a finer point on the impact of Flexner's work. In his article, Perspectives From the Historic African American Medical Institutions (
For Black people, “The opportunity to train to be a physician is still not where it should be,” Dr. Ed Harley told
On the heels of Flexner's report came another set of standards developed without regard for, or understanding of, the historically and culturally relevant experiences of Black women. The Sheppard-Towner Act (
In her ground-breaking work,
“Explicit segregation in the realm of health care remained completely intact until the mid-1960s. In 1964, Congress passed the Civil Rights Act, which prohibited federally funded programs and institutions from discriminating on the basis of race. The following year, Congress created the Medicare Program, which made almost all hospitals the recipients of federal funding. As a consequence of their participation in the Medicare Program, almost every hospital in the U.S. was forced to abide by the provisions of the Civil Rights Act of 1964. Despite attempts to prevent racial integration, medical facilities eventually came to treat patients and hire doctors of all races” (
While the Civil Rights Act ended de facto segregation, it did not change the fact that Black people were at the bottom of the hierarchy of humanity. As such, they continue to experience seemingly intractable health disparities. In examining the clinical, research and education enterprises within healthcare, these disparities are the result of systematic and intentional adherence to standards built with and toward the exclusion of Black people. Paradoxically, the default standard of whiteness used as the exemplar in the healthcare is also a damnable one: One of the most profound disparities- the high rate of Black women dying during or soon after childbirth- threatens the very ability for Black people to reproduce.
The process of naming, defining, and documenting a longstanding myth of a default human—that white people are the natural reference group for all others when designing scientific studies, reporting scientific findings, allocating human, money and time resources and that the health outcomes of white people in the U.S. are the best that can be attained—requires rigorous methods. The study of race and racism crosses multiple domains including the arts and humanities, clinical health services provision, healthcare, history, psychology, public health, and sociology. Despite recent attention to health disparities (
The purpose of scoping reviews has been described as the following: (1) To identify the types of available evidence in a given field; (2) To clarify key concepts/definitions in the literature; (3) To examine how research is conducted on a certain topic or field; (4) To identify key characteristics or factors related to a concept; (5) As a precursor to a systematic review; and (6) To identify and analyze knowledge gaps (
The purpose of the scoping review was two-fold. The first was to clarify key concepts, which requires articles that report data comparing either among Black people and/or between Black people and people of other races to meet inclusion criteria. The second was to achieve our goal of identifying and analyzing knowledge gaps, therefore articles needed to either include interventions in their research methods, report evaluation of interventions, or discuss interventions or mitigation of harm in the section Discussion. Maternal mortality was used as the primary Medical Subject Headings (MeSH) search term including sub-headings of morbidity. The authors conducted the scoping review between December 2020 and February 2021.
Inclusion criteria for the scoping review included articles specific to Humans, published in English and any study conducted and published from any time period with data from people aged 13 to 65 years of age. There were no limitations on the types of research methods used by research teams. Studies reporting individual, community, or neighborhood level data were included. Exclusion criteria included animal studies, studies in languages other than English, systematic reviews of pregnancy outcomes, methodology or methods articles, studies without analyses of African American or Black participants. An additional exclusion criterion was any pregnancy mortality that was not the result of an intended birth, specifically studies describing gestational trophoblastic disease and abortion. Gestational trophoblastic disease is managed as malignancies in oncology and abortion related mortality has been known to be rare, particularly after decriminalization codified in Roe vs. Wade in 1973.
Given the specific focus of racism how and how it operates in the U.S., studies including data from international geographies outside of the U.S. were excluded. However, we acknowledge that the myth of the default human grounded in white supremacy and racism are not exclusive to the U.S. Risk categorization was not considered as an inclusion or exclusion criteria since it is already known that education, income, social and marital status do not impact maternal mortality among Black women—risk is equitably shared regardless of these demographic characteristics.
Phase I of the scoping review was conducted to
PRISMA for Scoping Review Phase I—Clarify Concepts.
Phase II of the scoping review was to
PRISMA for Scoping Review - Phase II - Knowledge Gaps.
In lieu of generating summary statistics, we read each article to synthesize the concepts within and across studies. We used procedures included in thematic analysis methods (
A total of 67 published manuscripts combined from Phases I and II were used for this scoping review that includes data that represent both qualitative and quantitative research methods (
Thematic analysis of scoping review by phase.
• Who is measured and when and where measurement occur |
Overreliance on national data sets that are limited. |
The outsourcing of data analyses to university-based researchers |
Mix of morbidity, mortality and conditions that lead to each |
• Attention and focus of research questions |
When facility-based analyses are used, few pay attention to staffing, personnel, skill mix or structural factors that impact the facilities |
Many analyses are atheoretical |
• No community involvement, engagement or oversight |
• Conflation of surveillance statistics and description of disparities |
• Dearth of intervention studies; Policy Studies |
• Blame-based analytics (i.e., crack cocaine, homicide, gun violence) |
• Establishment of outcomes and exposures |
Pregnancy is a condition, and abortion, birth, and miscarriage are outcomes |
Selection of control vs. comparison groups (i.e., few within-Black people analyses) |
Examinations of maternal death out of context (i.e., life expectancy) |
Length of stay analyses |
• Family unit analyses |
White middle-class lens of analytics |
Coupling maternal health and infant outcomes |
Ill-defined geographies and rationale for place-based analyses |
• Public health programs such as Doulas, Home Visiting, Midwifery Model of Care, Healthy Start, Women, Infant, and Children Nutrition Program, Family Planning, Nurse Family Partnership, Group Prenatal Care, Social Support |
• Medicaid expansion—State focus with inequitable distributions, services, policies |
In the Phase I analysis specific to clarifying concepts two themes were identified, data and lack of accountability for generation and perpetuation of blame narratives. Within the data theme were most studies that attempt to define, make sense of, and determine who is measured, when, where, and how. The sub-themes of data are indicative of not having comprehensive national data to understand maternal morbidity and mortality and reflect the limitations of study design when using administrative or publicly available administrative or claims data sets. Specific to lack of accountability, there are several issues that are determined by the fact that Black women and pregnant capable people are not routinely consulted as experts on their own health, nor are their specific research interests reflected in the published literature. Intervention studies are sparce and inadequate because they are focused on leveraging existing structures that are inequitable retrofits (Phase II gap). It is important to note that the bulk of scholarly contributions included in this scoping review have been published within the last 10–20 years (despite no search limits specific to time), reflecting a lack of attention to maternal health more broadly and Black maternal health specifically.
Phase II of the scoping review specific to identifying gaps again focused on data and study design—specifically since the middle-class, white heteronormative gaze is apparent in research questions, the determination of outcomes and exposures without every accounting for the realities of Black life, structural racism, and resilience factors of communities. Additionally, life course approaches were under-utilized in study design. Taken together, one unfortunate conclusion that could be drawn from this scoping review is that the increase in Black maternal death did not draw attention until the data began to indicate an increase in white maternal death. An additional finding from this scoping review suggests the need for a reimagining of education, health services provision, research, and policy specific to the reproductive life courses of Black women and birthing people. Much of the published research treats Blackness as a universal characteristic, with little to no attention to the intersections of class, or income. Despite the fact that it is already known that risk for Black maternal death is equitably shared, interventions have specifically focused on low-income individuals and/or those using publicly funded insurance or services. Given the historical grounding that opens this piece, it should be obvious that the public infrastructure has been inadequate to meet the health needs of Black people. Therefore, to address the findings of the scoping review, that include patients, people, seeking services, as well as clinical treatment and procedures, in context of the historical data presented in the introduction, we propose adopting reproductive justice as a foundational and theoretical frame for intervention research. This path forward should begin essential work to resolve the myth of the default human in the context of maternal morbidity and mortality.
So, what is the way forward? How do we dismantle the myth of the default human and what will it take to build new standards in education, provision of care, research, policies, public health praxis, and workforce development, and ultimately improve Black maternal health outcomes? First, we must acknowledge that the people most impacted by health disparities are best positioned to determine the solutions. This means that Black communities and Black women specifically need to be centered and prioritized in discussions and decisions about Black maternal health. This includes the mapping of assets, and the development and testing of interventions. Best practices and standards in the conduct of research with, for, and by Black mamas have been proposed to improve the quality of research questions that decenter whiteness (
Adopting reproductive justice is an essential component for the design of all clinical health services and educational programs. Specifically, understanding every person has a human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities (
The preservation of Black maternal health is just one aspect of reproductive justice that not only calls for accountability but also requires radical reimagination. This radical reimagination centers Black women, trusts Black women, and invests in Black women. Imagine this: the solution to reducing Black maternal mortality and morbidity already exists within the community that carries the greatest burden. Imagine if Black women defined for themselves the standards by which their agency is measured. Imagine if they harnessed that same self-determination and agency that would have enslaved Black women control whether they would bear a child conceived in rape, to carry and give birth to a much-wanted child to term without sacrificing her life. Imagine if cultural rigor– the operationalization of critical race theory, reproductive justice, research justice, and big data intersected with health services provision, health services research, quality improvement, and health care policy–was used to build those new standards (
Recent developments have provided some cause for optimism including a recently announced public-private partnership that was established to address maternal morbidity and mortality from the Department of Health and Human Services, The Office of the Surgeon General, and the March of Dimes (
Additional action steps should include:
Targeted Investments in Black Students, Educators, Healthcare Providers, and Researchers
Targeted Investments in the Social Safety Net and Black Communities
Establishing Community Engagement as a Default Mechanism of Accountability
Center the Voices, Strategies, and Interventions of Black Birthing People
Retrofit, Reform, and Reimagine Clinical Health Services Provision, Education, Research, and Policy Development
Establish Authentic Partnership with Black Women and Femme led Organizations as Leaders of the Work to Reduce Maternal Morbidity and Mortality
Believe When Interventions are Developed and Implemented to Improve Black Maternal Health that the Health of All Populations Will Improve.
There are limitations and strengths to this work that need to be acknowledged. First, this work is limited to history documented by individuals immersed in and responding to the myth of the default human. We have paid close attention to our citational practices to center the perspectives of Black authors and scholars. Next, articles included in the scoping review were exclusive to those published in English—which misses nuance of Black or African American experiences of people who use speak other languages. Recent work has focused on colorism and the domains of racism and discrimination and this scoping review was unable to be as granular in our analysis—although some of those citations do appear in the review. Finally, we do not proport to have mapped all dimensions of the evidence of the myth of the default human in health services, education, research, and policy related publications. The limited purpose of the scoping review was to clarify concepts and identify gaps to make recommendations about areas where public health interventions could be reimagined.
In conclusion, we have read or heard countless stories of Black women who have nearly died or have died during or after childbirth. We know them. They are our friends, our neighbors, our co-workers, our family members, and our partners. While we know that higher socioeconomic status is a predictor of health outcomes, this couldn't be further from the truth when it comes to Black maternal health outcomes. How much money or education Black people have, how they construct families, what they wear, their hairstyles, diction, and their very breath are constantly under assault even as Black people aspire to be the “right” kind of people as defined by the default standard of whiteness. It begs the question of whether any default standard is the right exemplar for preventing Black maternal death when we examine the maternal health outcomes in lower income countries where the default standard is not whiteness (
MM co-wrote this manuscript with SB, principal—Black Women Write. Both authors conceptualized, wrote, and analyzed the data in this manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The Supplementary Material for this article can be found online at: