Black feminist theory in maternal health research: A review of concepts and future directions

Abstract

Black maternal health and well-being has become a necessary focal point for health researchers due to higher rates of maternal mortality and morbidity for Black women. However, what is often absent from this scholarship within medical sociology is Black Feminist Theory as a framework for understanding Black women’s health and well-being. Drawing on Black feminist and maternal health scholarship, I argue that integrating Black feminist approaches in maternal health research expands our understandings of what processes and mechanisms are impacting the health and well-being of Black mothers, while also highlighting the importance of maternal health research that solely centers Black women. Specifically, I focus on three concepts of Black Feminist Theory as it relates to Black maternal health research: (1) examining Black women’s standpoint as credible, (2) acknowledging the historical context of multiple systems of oppression against Black women, and (3) incorporating a perspective that acknowledges both disadvantages, as well as empowerment, in the lives of Black women. I end this review with a discussion of future directions for sociological research in maternal health, including the importance of acknowledging how Black mothers are both impacted by, and resisting, social structures that may add nuance to our current understandings of Black maternal health and well-being.

INTRODUCTION

In recent years, Black maternal health and mortality have been focal points in broader conversations surrounding Black women, families, and health. During Black Maternal Health Week of 2022, Vice President Kamala Harris made a declaration that disparate Black maternal health outcomes is an important issue that the United States is committed to resolving (Black Mamas Matter Alliance, 2022). However, although there is recent recognition of Black maternal health being an important and necessary focus of health professionals, researchers, policy makers, and community members, there are still tangible changes that are needed, such as additional theory generation and centering of Black women scholars, to promote sustainable solutions. Black mothers are 3–4x more likely to experience a pregnancy related death (CDC, 2018), have higher rates of hypertension (Shahul et al., 2015), and tend to experience physical “weathering” at higher rates due to chronic stress exposure (Geronimus, 1992) than their white counterparts. Additionally, research surrounding Black maternal health and well-being has found that Black mothers have higher morbidity rates than mothers of other races, even when considering other social factors, such as socioeconomic status (Louis et al., 2015). Much of the social science literature focuses on structural racism and bias among medical professionals as explanations for these disparities (Barr et al., 2018; D.-A. Davis, 2020; Giscombé & Lobel, 2005; Hartnett & Brantley, 2020; Roth & Henley, 2012; Saluja & Bryant, 2021; Walton, 2009), which is related to lower infant birth weight and worse subjective health for Black mothers. For example, Black mothers who reported high levels of racial discrimination were more likely to have experienced a negative birth outcome, such as preeclampsia or their baby being a low birth weight than those who did not report experiences of discrimination (Jackson et al., 2012). Although there has been recognition of Black maternal health as an important focus for health professionals, researchers, policy makers, and community members, there are still tangible changes that are needed, such as additional theory generation and centering of Black women scholars, to promote sustainable solutions.

Black feminist theory (BFT) allows space for Black women to individually and collectively make sense of what it means to be both “Black” and “woman,” while also legitimizing these experiences which have been historically discounted (Few, 2007). Although comparative frames maybe necessary at times – e.g., Black women’s health in comparison to white women’s health, prior, foundational scholarship has shown the importance of research that solely centers Black women’s experiences independently from women of other racial groups (Collins, 2002; Few, 2007; Frederick et al., 2022). As a theoretical lens, BFT centers Black women both theoretically and methodologically within maternal health research (Barlow & Johnson, 2021), which enhances our understandings of the social structures and mechanisms impacting Black women’s health and well-being. The general lack of maternal health scholarship solely centering Black women limits understandings of the social structures and pathways that could be negatively impacting their lived experiences and overall well-being, while also privileging white women as an exemplar to compare Black women to. This article provides an overview of the current state of sociological research focusing on Black maternal health over the life course, while highlighting the contributions that can be gained from applying a BFT framework, such as centering Black women both theoretically and methodologically, to understanding the social forces negatively impacting the health and well-being of Black mothers.

BLACK FEMINISM AND MATERNAL HEALTH

A growing body of Black Feminist scholars have highlighted how, although the health of Black mothers is of the greatest concern, there lacks a focus and centeredness on Black women in the maternal health research (Barlow & Johnson, 2021; D.-A. Davis, 2020; Owens & Fett, 2019; J. K. Taylor, 2020). The work of Black feminist scholarship reveals that at the intersection of race and gender, Black women have specific experiences that are unique to being both “Black” and “woman” (Brewer, 1993; Collins, 1993; Crenshaw, 1989; K.-Y. Taylor, 2019), which lends itself as a necessary framework for examining Black maternal health. Indeed, BFT was a result of community activists and scholars being made invisible within a larger discourse surrounding gender inequality, which was often relegated to white, middle-class, women (Collins, 1996; Crenshaw, 1989).

The seminal work of Black Feminist Thought by Patricia Hill Collins (2002) built on the work of Black feminists, such as bell hooks and Angela Davis, to provide the groundwork for Black feminist sociologists to not only center Black women within their theoretical contributions and methodological practice, but also to be motivated by their lived experiences. The centrality of Black women in Black feminist thought is imperative due to Black women’s ability to empathize and relate to aspects of Black womanhood in way that those who live outside of those structures cannot (Collins, 2002). Moreover, Collins and other contemporary scholars suggest that Black women intellectuals who are contributing to Black feminist thought are not limited to the academy, but also (and in some ways must) include Black women in the community to integrate the full breadth of Black women’s lived experiences (Collins, 2002; Frederick et al., 2022; Oparah, 2021). Yet the applicability of these foundations of BFT to sociological research is not necessarily limited to Black women scholars and certain tenets of BFT can be used by all sociological researchers, particularly those with a focus on Black maternal health.

Explorations of Black maternal health and well-being within the social sciences have often examined: (a) direct interpersonal experiences of racism, (b) bias among medical professionals and the larger institution of medicine, and/or (c) patterns of racial disparities within maternal health. However, the application of BFT would expand these current understandings of Black maternal health, as well as provide new directions to be explored. I discuss the following aspects of BFT in the context of Black maternal health, specifically: (1) examining Black women’s standpoint as a credible lens, (2) acknowledging historical context of multiple oppressions against Black women, and (3) incorporating a perspective of activism that both acknowledges disadvantage, as well as empowerment, within the lives of Black women (Collins, 2002). These ideas are summarized in Table 1 and elaborated on below. Leaning on the scholarship of other Black feminist scholars, the application of a BFT should be explored as a necessary theoretical and analytical tool for Black maternal health research.

Table 1 –

Description of Black Feminist Theoretical (BFT) Concepts and Implications in Maternal Health Research

Black Feminist Concept	Definition	Application	Implication
Black women’s standpoint	A perspective formed by an intersectional understanding (and experience) of oppression based on race, class, and gender.	Recognizing Black women’s experiences as “fact.” Future medical sociological research would benefit from centering Black women and mothers in their approaches regarding maternal health research. Specifically, through including Black women on research teams, citing scholarship (academic and community-based) by Black women conducting this research, and centering Black women’s voices and experiences in the research.	Allowing for more accurate capturing of Black women’s maternal health experiences, which is useful in developing additional measurements of Black maternal health - e.g., survey measures.
Historical legacy of oppression	The documented experiences of gendered and racial subjugation and inequality in the U.S.	Utilizing BFT to draw linkages between contemporary issues for Black women and the history of Black women within the United States. For sociologists conducting Black maternal health research, this means placing research questions and subsequent findings within their historical context.	Viewing historical gendered racism as an upstream factor with downstream effects for Black maternal health. Researchers should recognize the perpetuating social forces impeding the health and well-being of Black mothers, which provides opportunity for new exploration into broader policy implications.
Responses to systems of oppression:	The acknowledgement of, and reaction to, multiple systems of inequality, such as racism and sexism.	Incorporating responses to systems of oppression in Black maternal health research means recognizing the potential health consequences of gendered racism, while also recognizing the role of resistance in the lives of Black mothers.	Providing nuance to Black maternal health discourse by recognizing the role of both oppression - i.e., gendered racism, and empowerment - e.g., protecting themselves and families from anti-Black racism, regarding health consequences.

BLACK WOMEN’S STANDPOINT

Interpersonal experiences of racism have long been examined as a key determinant of racial health inequality (C. P. Jones, 2000; Phelan & Link, 2015). More specifically, studies have found that racism over the life course has detrimental effects on the health and well-being of Black Americans. For example, the work of Harrell (2000) highlights how racism is embedded into multiple domains of our society, which in turn creates racism-related stressors that disrupt the lives of Black Americans. Additionally, applying the stress perspective distinguishes racism as a form of chronic stress that damages health both directly and indirectly (Gee & Ford, 2011; Geronimus et al., 2006; Krieger, 2014; Paradies, 2006; Paradies et al., 2015). The impact of racism as a chronic stressor on the health of Black mothers is gaining a necessary focus among health researchers. Several studies find an association between racism and poor health, including higher rates and earlier onset of physical illness among Black mothers, such as maternal mortality, heart disease, and diabetes (Gee & Ford, 2011; Geronimus, 1992; Geronimus et al., 2010; Jackson et al., 2001; Krieger, 2014; Paradies et al., 2015; Phelan & Link, 2015).

The continual exposure to racism places Black mothers in a constant state of fear that may result in cumulative stress over the life course (Barr et al., 2018; J. C. Hall, 2018b; Jackson et al., 2012). The cumulative stress for Black mothers may contribute to their higher cortisol levels (Center for Reproductive Rights, 2014), as well as a number of disorders during pregnancy, such as preeclampsia (Shahul et al., 2015), which can also translate into mental health consequences as well.

Additionally, a key source of stress for Black women is gendered racism (Essed, 1991; Laster Pirtle & Wright, 2021; Nuru-Jeter et al., 2008; Rosenthal & Lobel, 2011; Spates et al., 2020). Gendered racism highlights the unique experiences of Black women at the intersection of racism and sexism (Essed, 1991), and intersectionality captures how this gendered racism is uniquely structured within American society to produce burdens that cannot be readily examined solely through a lens of racism or sexism (Bowleg, 2012; Hill, 2009; Laster Pirtle & Wright, 2021). The role of gendered racism in Black maternal health outcomes is especially apparent, and research in this area shows that Black women’s maternal mortality rates are double that of their white counterparts (Patterson et al., 2022). Taking an intersectional lens when exploring Black mothers’ well-being allows for an understanding of the unique stressors experienced by Black women. Additionally, the scholarship of Rosenthal and Lobel (2011) emphasizes how Black women recognize and contend with the stereotypes placed on Black mothers, such as “welfare queens,” which can contribute to their stress during pregnancy. Experiences of racism among Black mothers has also been associated with increased levels of psychological distress (Rosenthal & Lobel, 2011), and psychological distress is often a pathway linking racism and physical health measures– e.g., self-rated health (D. R. Williams, 2018). Recognizing the ways that both race and gender intersect to expose Black women to unique social stressors and create a particular health experience for Black women is key to BFT approaches. While current scholarship has advanced our understanding of the association of experiences of racism and Black maternal health, integrating BFT has the potential to extend current definitions of racism and how it intersects with gender, how we explore its impact over the life course, and whose voices are being centered within that process.

Black feminist approaches look to recognize and accept Black women’s standpoint (Collins, 2002), as well as recognize Black women as experts on their experiences. For example, Evans-Winters (2019) highlights the importance of utilizing the language of Black women within research approaches, as well as centering them within the framing. These efforts not only center Black women in both the conceptualization of racism’s impact on Black maternal health, but it also recognizes Black women’s analysis of their experiences as “fact.” Specifically, this approach provides a more thorough understanding of the experiences of Black American women and mothers, highlighting the realities of racism and sexism within their lived experiences that impact well-being (Bowleg, 2012; Collins, 2002). In doing so, we can more accurately interrogate of the ways Black women are subordinated in the U.S., which shapes their experiences and life chances in various domains (Crenshaw, 1989).

Integrating BFT into maternal health scholarship may provide suggestions regarding the framing of, and future approaches to, empirical findings on Black women’s health. For example, the work of Frederick and colleagues (2022) utilizes qualitative interviews to explore Black women’s involvement in studies on sexual health, where they highlight the saliency of race and gender in Black women’s decisions to participate in sexual health-related studies. Other empirical studies have found that the presence of Black women within the research process – e.g., recruitment and/or interviewers – increase the likelihood of Black women’s participation (Coker, Huang, and Kashubeck-West, 2009; Frederick et al., 2022). In addition to initial engagement, the utilization of methodological approaches, such as qualitative interviews, is an important aspect of BFT in gaining insight on the lived experiences and health of Black women. Because BFT acknowledges Black women as the experts regarding their own lived experiences, scholars would benefit from citing qualitative studies interviewing Black women as well as Black women scholars, healthcare professionals, and community leaders who are utilizing a BFT praxis in their examinations of Black maternal health, such as the Black Mamas Matter Alliance. As highlighted by Collins (2002), “scholars” should not be limited to those within the academy. Rather, BFT recognizes the intellectual contributions of Black women and mothers through experiential knowledge, praxis, and/or community efforts (Collins, 2002).

Likewise, utilizing a BFT framework to empirically understand the pathways linking interpersonal experiences of racism and Black maternal health may include prioritizing different methodological practices, such as an increase in qualitative interviews, ethnographies, and focus groups that are grounded in BFT praxis. Grounding methodological practices in BFT means engaging in participatory research efforts, that supports those already engaging with these initiatives, such as SisterSong Women of Color Reproductive Justice Collective, and partnering with Black women and mothers within the research process (Barlow & Johnson, 2021; Collins, 2002; Evans-Winters, 2019; Oparah, 2021; Sweet et al., 2008). For example, the work of Davis-Floyd and Davis (1996) highlights the importance of including experiential knowledge in understandings of healthcare for birthing women as an authoritative voice. In other words, it is important to value the voices and experiences of those who are most affected – i.e., Black mothers. Allowing Black mothers to define and operationalize their lived experiences, such as stress burdens, for themselves lets sociological researchers utilize mothers’ own language when developing measurements and survey tools for exploring Black maternal health (Nuru-Jeter et al., 2008). These developments may allow scholars to better capture the health implications of unique forms of stress for Black mothers. BFT urges researchers to take up the responsibility of centering Black mothers in reference to their own health and well-being, as well as including Black women in multiple stages of the research process.

INCLUSION OF HISTORICAL CONTEXT

There are numerous studies that provide empirical evidence of Black women receiving poorer quality of healthcare than their White counterparts (Chin et al., 2007; Feagin and Bennefield, 2014; Creanga et al., 2014). Racial bias is more likely to impact treatment decisions for Black women (W. J. Hall et al., 2015), and they are more likely not to be believed when declaring pain (Saluja & Bryant, 2021). Moreover, Black women are more likely to be recommended for certain procedures, such as cesarean deliveries than women of other races, which is associated with a number of health outcomes – e.g., infection, hemorrhaging, etc. (Roth & Henley, 2012). Prior work reveals that many white physicians may assume that Black women lack the ability to adhere to medical instruction (W. J. Hall et al., 2015), which suggests a lack of confidence that Black women can successfully govern their own bodies. Due to the patterns previously listed, Black women are often left feeling unheard regarding their healthcare. An illustration of the lack of visibility that Black women often feel regarding their health can be found in the now infamous story of Serena Williams, which she detailed in a personal essay for Elle Magazine. Williams nearly lost her life to a blood clot after giving birth and doctors did not believe her when she stated that she was in pain (S. Williams, 2022). The disparate treatment of Black women patients is associated with racial bias. Previous studies have found that medical professionals hold negative or stereotypical images of Black women in comparison to women of other races (Saluja & Bryant, 2021), such as Black women having a higher pain tolerance than other women (Bougie et al., 2019; Hoffman et al., 2016; Rao, 2020). The lack of recognition that racial bias is institutionalized, and historically founded, places Black mothers in a position to be assumed responsible for their own health outcomes, instead of addressing the historical barriers potentially perpetrated through actions by physicians, nurses, etc. that are impeding on their health and well-being.

Black feminist scholars have long challenged the (often unconscious) notion that patterns and trends happen within a vacuum. More specifically, the work of BFT raises the point that patterns and experiences of Black women today must be linked to, and placed within, their historical context (Collins, 2002). Placing Black women’s experiences of multiple oppression within historical context, also builds on the dimension of BFT epistemology placing Black women’s lived experiences as truth (Rousseau, 2013). This aspect of BFT challenges scholars and researchers to recognize the link between Black women’s history in the US and the contemporary structural disadvantages. The lack of trust between Black women and healthcare professionals has been evident throughout social science research, and its historical context cannot be denied. Black feminist theory recognizes that the historical treatment of Black women’s bodies in the US, including their ability to have children, was rooted in gendered-racialized violence (Owens & Fett, 2019; Roberts, 2009; Washington, 2006). This violence holds its roots in both enslavement – e.g., Black women being seen as “breeders” (A. Y. Davis, 1983) and being subject to experimentation (Washington, 2006), as well as the threats of gendered racism, during and post-Jim Crow, against themselves and their children that placed them in a constant state of stress and fear (Dow, 2019; Elliott & Reid, 2016; Giscombé & Lobel, 2005; J. C. Hall, 2018; Smith, 2016). For example, the work of Washington (2006) highlights how the treatment of enslaved Black women regarding birthing and medical experimentation is likely linked to the increased medical mistrust seen among Black women and is structured by a system rooted in gendered racism and working to disrupt the health and well-being of Black women. The elevated levels of medical mistrust amongst Black women patients, compared to their white counterparts are the remnants of the exploitation and stolen control over their bodies (A. Y. Davis, 1983; D.-A. Davis, 2020; Rao, 2020; Saluja & Bryant, 2021). The historical subjugation of Black mothers should not be ignored, but rather, utilized in framing our current understandings of the health of Black mothers and the social forces and pathways impeding on them.

RESPONSES TO OPPRESSION

As previously mentioned, research has pointed to stress stemming from gendered racism being associated with deleterious health outcomes for Black mothers (D.-A. Davis, 2020; Giscombé & Lobel, 2005; Owens & Fett, 2019; Rosenthal & Lobel, 2011; J. K. Taylor, 2020). Additionally, applying an intersectional lens reveals the influence of multiple systems of oppression in the lives of Black women that extend beyond their direct experiences. Specifically, prior scholarship has highlighted the various domains that multiple systems of oppression indirectly plague the lived experiences of Black mothers, particularly within a familial context. Hartnett and Brantley (2020) found that Black mothers are less happy about their pregnancy in comparison to white mothers, even when accounting for intention, which is likely associated with the stress that comes with raising a Black child in an anti-Black society. Moreover, among Black women, mothers who were having sons were less happy than those who were having daughters, which may speak to the fears mothers may have regarding raising Black boys and the racialized violence they may face (Hartnett & Brantley, 2020). However, these experiences of stress at the intersection of race and gender occur over multiple stages of motherhood. For instance, the work of Nomaguchi and House (2013) found that Black mothers experience higher levels of parenting stress than white mothers, and this gap continues to increase throughout children’s grade school years. Looking specifically at mid-life, Holloway and Varner found that Black mothers also experienced increased stress in response to difficult circumstances in the lives of their children (2021). Because Black families are more likely to experience a number of structural barriers linked to racism, such as economic hardship (D. T. Williams & Baker, 2021) or mass incarceration (Muller, 2021), Black mothers experience increased levels of stress surrounding their children. This heightened level of parenting stress for Black mothers is another unique stressor that cannot always be captured without an intersectional lens. However, while prior scholarship has made evident the negative consequences of multiple systems of oppression on Black mothers, further attention should be paid to Black women’s responses to these systems. The integration of BFT would allow for a nuanced understanding of Black women’s well-being that extends beyond relegating them to a place of despair.

The work of Black feminist scholarship looks to recognize how multiple systems of oppression – e.g., anti-Black racism, sexism, etc., impacts the well-being of Black women, while also highlighting their responses to these systems. Black feminist scholars elucidate the ways that Black women respond to the social and structural barriers that disadvantage both themselves and their families (Dow, 2019; Powell & Coles, 2020; Rodriguez, 2016; Smith, 2016). For instance, Black mothers are working to fight against the “controlling images” of their families and motherhood (Collins, 2002; Dow, 2015). An example of this stems from the work of Beauboeuf-Lafontant (2007), who coined the term the “superstrong Black woman” (SBW), which confronts the notion that Black women are forced to be strong in an effort to manage the effects of a racist and sexist society. In addition to highlighting Black women’s efforts in managing these effects, recent scholarship focusing on the SBW also highlight the ways in which the “strength” that Black women must exude may be both protective and harmful in particular ways. Embodying the image of the SBW may be useful in functioning in regular daily activities, and, particularly in the context of motherhood, Black mothers may feel the need to convey strength to maintain regular obligations of motherhood, while simultaneously being able to emotionally and physically available to the needs of others. However, as Elliot and Reid (2016) discuss, the SBW image at the intersection of motherhood – i.e., the Superstrong Black Mother, may be an emotionally taxing and stressful reality for Black mothers over their life course. Black maternal health scholarship often lacks the nuance that is introduced through the discussion of the SBW image to recognize how Black mothers are responding to, and impacted by, oppression in numerous ways. The responses to oppression by Black mothers can be a source of strength, or detriment, regarding their well-being that current sociological scholarship does not always consider.

DISCUSSION AND FUTURE DIRECTIONS

The current scholarship on Black maternal health has provided tremendous insight on the multiple social structures and pathways that are inhibiting the health and well-being of Black mothers. While this work has provided understanding for sociologists, and researchers more generally, the growing body of literature pointing to Black feminist approaches may offer new and necessary understandings of Black maternal health patterns. The application of BFT in research pertaining to Black maternal health will not only better situate and contextualize findings, particularly as they point to structural racism as a fundamental cause of health (Phelan & Link, 2015), but this application will also allow nuance into understanding the ways in which Black mothers are affected by, and managing, systems of oppression and the subsequent stress.

As researchers continue to explore the impacts of structural racism on Black maternal health, it is important to complicate what we know as health, particularly due to much of the conflicting findings surrounding the mental health of Black people, especially women (Erving & Smith, 2021). The consuming nature of racism for Black mothers and its health consequences have often revealed the interconnectedness between multiple dimensions of health – e.g., emotional health having consequences for physical health outcomes (D. R. Williams & Mohammed, 2013). Exploring these additional dimensions, outside of solely physical health outcomes, may provide additional insight into the factors impacting the health and well-being of Black mothers.

Lastly, another aspect of Black maternal health research that can be evolved utilizing BFT is exploration of Black maternal health across the life course. Some research has examined Black maternal health at differing life stages, such as mothers with children in early childhood (Turney, 2011) and mothers at mid-life with children no longer in the household (Colen et al., 2019; Goldman, 2019). However, much of the Black maternal health research continues to focus on pre- and post-natal when examining the health and well-being of Black mothers. While this is a necessary point in the life course to examine, it leaves out other life stages that Black mothers may be experiencing stress that can have a toll on their health and well-being.

Despite the clear advances in Black maternal health research in recent years, there is still much to understand regarding the health and well-being of Black mothers. The integration of Black feminist approaches in Black maternal health scholarship is critical in gaining a deeper understanding of the processes by which Black mothers are impacted. Additionally, integrating BFT allows for exploration beyond pregnancy and childbirth, which could add clarity to current patterns of morbidity seen over the life course for Black mothers. Moreover, the incorporation of Black feminist approaches encourages researchers, medical professionals, and policy makers to center the voices and experiences of Black mothers when discussing or making decisions regarding their health. Utilizing BFT as a framework to guide maternal health research may also give rise to potential health policy implications that are culturally sensitive and focused on the issues plaguing Black maternal health specifically. Highlighting the experiences of Black mothers as reality moves away from discussions of saviorism and deficit and towards interventions and conversations at the structural/institutional level to improve the health and lived experiences of Black mothers and families.