DOI: 10.31038/IGOJ.2022521

Short Commentary

Operationalizing diverse forms of racism is essential to dismantling inequities in maternal and perinatal health and is a necessary step toward reproductive health justice for Black women in the United States (U.S.). Despite the well-known negative association between racism and health outcomes among U.S. minority racial groups [1,2], scant research exists examining the associations between internalized racism and stress and their impact on maternal mental health and birth outcomes [3]. This limitation is problematic. Among non-Hispanic Black Americans living in the U.S., exposure to racism significantly correlates to poor mental health, including psychological stress, anxiety, and depression, which have a positive relationship to poor birth outcomes among Black women [4].

Research has found that the prevalence of Low Birthweight (LBW) babies among African American populations is approximately two times higher (13.9%) than in White, non-Hispanic populations (7.0%) [5]. While Preterm Births (PTB) were found to have generally declined in 2020, this rate continues to be much higher among Black non-Hispanic women than in White women at 14.39% and 9.10%, respectively [5]. The health implications for LBW and PTB infants are substantive and can lead to a life course of poor health. Adding to this concern, the infant mortality rate among Black births was 10.6 per 1,000 deaths, which is nearly 2.5 times higher than that of White infants (4.5 times per 1,000 deaths) [6].

Structural racism remains a constant threat to Black women’s reproductive health. Manifesting in personally-mediated discrimination and inequitable policies, racism is often based on historical and sociocultural tropes or stereotypes, which characterize Black Americans as inadequate and inferior. One response of stigmatized racial populations to pervasive negative racial stereotypes is to internalize this racism with significant repercussions to maternal and perinatal health.

Internalized racism is the unconscious appropriation of the dominant White culture’s actions, beliefs, and stereotypes about racialized peoples [3]. Not to be mistaken for individual pathology, it takes shape through frequent and enduring exposure to multiple layers of racial oppression in the U.S. [7,8]. One mechanism by which internalized racism can cause mental and physical harm is through an understudied specific internalized representation of racism, the Strong Black Woman (SBW). Intergenerationally, Black women perceive the Strong Black Woman as a natural and normal aspect of identity as it characterizes Black women’s pride, persistence, and imperviousness to everyday occurrences of racism, allowing for their survival and that of their families and communities within an adversarial social context [9]. As such, the SBW presents with certain normative behaviors, such as enduring strength, the suppression of emotions, resistance to vulnerability or dependence, persistence to succeed despite limited resources, and a responsibility to help others. While the SBW has been touted as a coping mechanism encouraging self-efficacy and perseverance, this caricature of Black women’s strength is rooted in attitudes and beliefs that justified their enslavement during chattel slavery in the U.S. to maintain White power and privilege [10].

Complicit with racist ideology, the SBW schema harms self-image with far-reaching implications for Black mothers [11-13]. The SBW is a norm to which Black women’s behavior is compared and modulated, leading to maladaptive perfectionism, affect, and coping. With few opportunities for expressing emotions or vulnerabilities, unrealistic expectations allow shame, guilt, and low self-esteem to surface when women perceive themselves as not meeting the standards. These factors are associated with strained interpersonal relationships, stress-related health behaviors, the embodiment of stress, delayed self-care, decreased help-seeking behaviors, and a lack of social or emotional support [12-16], which erodes resilience and compounds psychological stress, depression, and anxiety [2,14,17]. Further research demonstrates that health practitioners often dismiss Black mothers’ concerns using perceptions informed by a skewed understanding of Black women’s strengths [18]. The SBW schema reinforces a longstanding stereotype that Black women can “naturally endure” pain, affecting how their pain is perceived and managed in the healthcare setting, especially during labor and delivery [18]. As a form of internalized racism, the SBW stereotype threatens Black women’s health and well-being at individual and health system levels with severe implications for maternal and perinatal health.

There is an urgent need for health practitioners to mitigate these adverse maternal and perinatal outcomes [19]. One way is moving away from a physician-centered model of care toward a reproductive justice (RJ) framework of healthcare delivery, which addresses social and structural determinants of health, such as access to quality care, housing, nutrition, education, and diverse forms of racism [20]. RJ seeks to increase access to just and equitable care, improving adverse health outcomes and disparities. In the context of the SBW stereotype, health practitioners work to understand racism and its internalization. They encourage self-determination in perinatal health care experiences [20]. Furthermore, within an RJ framework, health practitioners make timely and appropriate recommendations for therapy while considering factors like racial or cultural concordance [21]. Removing language and policies within healthcare systems that rely on harmful stereotypes, such as the SBW schema, is necessary to improve Black perinatal and infant health outcomes.

Until harmful narratives surrounding Black women’s strength are disassembled, emotional dysregulation, poor mental health, and medical racism will likely continue, allowing for the persistence of poor maternal and perinatal outcomes. RJ seeks to understand better and mitigate the impacts of racism on perinatal and infant health outcomes. Clinical research examining internalized racism and its association with stress, maternal mental health, and birth outcomes are imperative for improving perinatal health care inequities.

Keywords

Perinatal health, Internalized racism, Structural racism, Reproductive justice, Maternal health care, Health communication

References

1. Gale MM, Pieterse AL, Le DL, Huynh K, Powell S, et al. (2020) A meta-analysis of the relationship between internalized racial oppression and health-related outcomes. The Counseling Psychologist 48: 498-525.
2. Jefferies K (2020) The strong black woman: insights and implications for nursing. Journal of the American Psychiatric Nurses Association 28: 332-338. [crossref]
3. Treder K, White KO, Woodhams E, Pancholi R, Yinusa-Nyahkoon L (2022) Racism and the reproductive health experiences of U.S.-born black women. Obstetrics & Gynecology 139: 407-416. [crossref]
4. Paradies Y, Ben J, Denson N, Elias A, Priest N, et al. (2015) Racism as a determinant of health: A systematic review and meta-analysis. PLOS ONE 10: e0138511. [crossref]
5. Bridgeman-Bunyoli AM, Cheyney M, Monroe SM, Wiggins N, Vedam S (2022) Preterm and low birthweight birth in the United States: Black midwives speak of causality, prevention, and healing. Birth 49: 526-539. [crossref]
6. Hoyert D (2022, February). Maternal mortality rates in the United States, 2020. Centers for Disease Control and Prevention.
7. Brown DL, Rosnick CB, Segrist DJ (2017) Internalized racial oppression and higher education values: The mediational role of academic locus of control among college African American men and women. Journal of Black Psychology 43: 358-380.
8. David EJR, Schroeder TM, Fernandez J (2019) Internalized racial oppression: A systematic review of the psychological literature on racism’s most insidious consequence. Journal of Social Issues 75: 1057-1086.
9. Woods-Giscombe CL, Allen AM, Black AR, Stee TC, Li Y, et al. (2019) The Giscombe Superwoman schema questionnaire: Psychometric Properties and associations with mental health and health behaviors in African American women. Issues in Mental Health Nursing 40: 672-681. [crossref]
10. Collins PH (2000) Gender, black feminism, and Black Political Economy. The ANNALS of the American Academy of Political and Social Science 568: 41-53.
11. Evans SY, Bell K, Burton NK (2017) Black Women’s Mental Health: Balancing Strength and Vulnerability. SUNY Press.
12. Nelson T, Cardemil EV, Overstreet NM, Hunter CD, Woods-Giscombé CL (2022) Association between superwoman schema, depression, and resilience: The mediating role of social isolation and gendered racial centrality. Cultural Diversity and Ethnic Minority Psychology. [crossref]
13. Harrington EF, Crowther JH, Shipherd JC (2010) Trauma, binge eating, and the “strong Black woman”. Journal of Consulting and Clinical Psychology 78: 469. [crossref]
14. Silva PH, Aiquoc KM, Silva Nunes AD, Medeiros WR, Souza TA, et al. (2022) Prevalence of access to prenatal care in the first trimester of pregnancy among black women compared to other races/ethnicities: A systematic review and meta-analysis. Public Health Reviews 43. [crossref]
15. Jhingoeri N, Tarini BA, Barber J, Parikh K (2022) Elevated parental stress is associated with lower self-efficacy in provider communication during a pandemic. Hospital Pediatrics 12: 673-679. [crossref]
16. Liao KYH, Wei M, Yin M (2020) The misunderstood schema of the strong Black woman: Exploring its mental health consequences and coping responses among African American women. Psychology of Women Quarterly 44: 84-104.
17. Danieli Y, Norris FH, Engdahl B (2016) Multigenerational legacies of trauma: Modeling the what and how of transmission. American Journal of Orthopsychiatry 86: 639-651. [crossref]
18. Adebayo CT, Parcell ES, Mkandawire-Valhmu L, Olukotun O (2022) African American Women’s maternal healthcare experiences: a Critical Race Theory perspective. Health Communication 37: 1135-1146. [crossref]
19. Essien U, Molina R, Lasser K (2019) Strengthening the postpartum transition of care to address racial disparities in maternal health. Journal of the National Medical Association 111: 349-351. [crossref]
20. Julian Z, Robles D, Whetstone S, Perritt JB, Jackson AV, et al. (2020) Community-informed models of perinatal and reproductive health services provision: A justice-centered paradigm toward equity among black birthing communities. Seminars in Perinatology 44: 151267.
21. Donovan R, West L (2015) Stress and mental health: Moderating role of the strong Black woman stereotype. Journal of Black Psychology 41: 384-296.