Delivering Better Maternal Healthcare? An Examination of Black Hospital Obstetrics Care across the Mid-Twentieth Century

In this blog post, Matthew Purcell of the London School of Economics describes how a research grant for graduate students from the Economic History Society has helped his doctoral research.

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My PhD thesis focuses on the maternal health of Black women in the US South across the mid-twentieth century. Over the first half of my research, I have analysed the role that Black midwives and state-run maternal health education campaigns, typically called Midwife Programs, had in shaping the maternal care southern Black women received. To close out my thesis, I turn to the clinical care some Black mothers received at Black hospitals in the southern US. I will travel to the Rubenstein Library at Duke University, generously aided by an EHS archival research grant, and examine obstetrics case records from Lincoln Hospital (Durham, NC), a preeminent Black hospital.

The main research questions I will address with the Lincoln Hospital records are: what were pregnancy outcomes, specifically rates of stillbirths, perinatal mortality, and maternal mortality, within Lincoln Hospital? How did pregnancy outcomes in Lincoln Hospital compare with findings from other hospitals in the historical maternal health literature? How did childbirth practices and outcomes change over time, given the introduction of critical innovations and health policy changes?

The research produced from this trip will use the delivery records of the Lincoln Hospital’s Obstetrical Ward from 1930 to 1974 to examine changes in the care and outcomes of Black mothers. There is a dearth of information on Black pregnancy outcomes before the 1960s when the first nationally representative birth surveys occurred. The historical quantitative studies that exist rely on records from hospitals outside of the US South and from urban centres like Boston, New York, or Baltimore. These hospitals served a multi-racial patient population, though people of European descent were the overwhelming majority.

Expanding our institutional sources to include southern Black hospitals is critical. First, most of the US’s Black population lived in the US South during the mid-twentieth century. Second, racial segregation manifested itself socially and politically in diverse ways across the US during this period. Third, the US’s Black population was the largest minority group in the twentieth century and had considerable influence on American social, economic, and political life throughout the twentieth century. A robust literature on US maternal health should include the legacy of Black hospitals, particularly in the US South, to achieve a more representative understanding of Black maternal health.

Spreading Innovations in Obstetrics Care Across Clinical Settings

The ratio of Black-to-White maternal mortality doubled between 1930 and 1963. In a period underscored by a dramatic decline in overall maternal mortality due largely to antibiotics, growing disparities question how the gains from healthcare innovations distribute across a population. The Lincoln Hospital records have the promise to answer the questions posed above in a way that will contribute to a better understanding of long-run racial disparities in maternal health.

Unlike with aggregated data, my analysis will be able to control for case-level differences in medical complications or gestational age when analysing mortality outcomes or rates of intervention. These factors change the risk of fatalities and the need for medical interventions, such as caesarean sections or the use of forceps. The archival records provide a rare, fine-grained view into how Black maternal health evolved as medical innovations and obstetrical practices changed across the twentieth century.

Though not representative of all southern Black hospital care, the Lincoln Hospital’s obstetrics records do represent the standards of care of one of the top Black hospitals in the US South. Evidence of poor obstetrical practices and outcomes would suggest that clinical care was poor across the US South for Black pregnant women. On the other hand, evidence of strong obstetrical practices and outcomes would indicate that Black hospitals might have played a positive role in improving maternal health in an absolute sense. Other drivers outside of clinical care would be at the root of the relative disparity between racial groups in the latter case.

Aside from gaining a stronger understanding of the disparity in maternal healthcare across the twentieth century, it is important to broaden the scope and see maternal health as a measure of well-being. Pregnancy outcomes in the twentieth century are correlated with other measures of well-being, such as income and education. Barker’s foetal-origin hypothesis argues that development conditions at the earliest stages of life influence later-life health outcomes. Specifically, there is some evidence that growth retardation leads to a greater risk of diabetes and cardiovascular disease. A better understanding of the health outcomes of a patient population, therefore, informs our understanding of a larger population.

Coming to Term with the History of Health Disparities

Today, in the US, Black mothers experience a maternal mortality rate that is three times higher than that of White mothers. Disparities between the two racial groups exist across the many markers of maternal health, including shares of preterm births, low birthweight births, or births for which mothers received late or no prenatal care. Infant health reflects a similar pattern of disparity.

To address these issues, the Biden-Harris Administration developed the White House Blueprint for Addressing the Maternal Health Crisis. The blueprint emphasizes the need for increased access to comprehensive high-quality maternal health services, which includes a more diversified and better-trained maternal care workforce. Echoing maternal health campaigns of the early twentieth century, the plan calls for expanded training of and access to midwives and doulas.

Enriching today’s health initiatives with an understanding of the historical path of maternal health in the US roots modern disparities to a larger narrative that lights both cautionary and encouraging signals along the path to maternal health progress.

I am grateful for the generosity of the Economic History Society, whose research fund for graduate students has aided and encouraged the work described above.

To contact the author:

Matthew Purcell

M.Purcell@lse.ac.uk

London School of Economics