Written by Gabriella A. Nelson
As a student of city planning, there is no question that participants in the field have the ability to run upstream and enact change. Just imagine if in that parable there was a city planning policy that regulated how people were able to use the river, put in place physical barriers upstream if necessary, and created an agenda getting to the root of the problem with overarching goals and objectives focused on how to keep babies safe through community input and local expertise. Through thoughtful agendas, relevant visions, equitable design, and strategic frameworks, the skills of city planners can truly help change the trajectory of disparities throughout our communities, especially in areas of public health. In the early histories of American cities, the planning and public health professions were often inextricably linked. But a split emerged as municipal governments grew, divided into more departments, and consequently separated the academic fields. Today, city planning and public health efforts must be relinked as our nation struggles with alarming rates of infant and maternal mortality in the Black Community.
And how can city planners become the second fisherman, running upstream to address the root of it all? In order to suggest solutions, we have to understand the problem. The United States is the only developed nation where maternal mortality rates are going up.(1) For decades Black women have died of pregnancy-related complications at higher rates than white women and are now suffering the most from an escalating maternal morality crisis. Black babies are experiencing dismal birth outcomes, even as Black women are breaking beyond barriers in their careers and at universities. Even Serena Williams’ life-threatening experience after birth engrossed the minds of many as people began to think about what maternal and infant mortality and almost-deaths mean for Black women across the spectrum of education, income, and even celebrity.
The issue of Black maternal and infant mortality has been very prominent in the public
eye over the last few years. Recently an article in the NY Times addressed the disparity
and focused on the lived experiences of systemic oppression as a main contributing
factor.(2) In fact, scholars have researched how using a life course perspective while
studying health disparities often leads to evidence that racism is a contributing factor,
stating that disparities developed in one generation may further disadvantage the “starting point” for the next.(3) Stress that accompanies subtle and overt discrimination, violence, and domestic terrorism through racism can biologically alter the body and can travel to the fetus in utero, negatively affecting birth outcomes and taking a toll on the mother through all stages of maternity.
In response to the recent NY Times article, chilling accounts of Black mothers across the nation joined forces to speak on their own experiences coming face-to-face with infant and maternal mortality; sometimes speaking for those that are no longer with us. Some of the worst statistics on pre- and post-natal outcomes can be found down south in the Mississippi Delta where a key element is rural living conditions that make it hard for people to access medical services.(4) But this epidemic is also happening right in our own urban backyard. In a big city like Philadelphia, where our claim to fame (besides winning Superbowl 52) is our stronghold on “Eds and Meds,” Black infant mortality is effecting families at a rate much higher than their white counterparts. In the Preliminary Vital Statistic Report for 2015-2016, Philadelphia’s infant mortality rates remained 3 times higher among non-Hispanic Blacks (12.9 and 12.4 per 1,000) compared to non-Hispanic whites (3.9 and 4.2 per 1,000).(5) Low birth weights, which can lead to further complications and sometimes death, are effecting Black babies nearly two times as much as white babies. And in 2015 and 2016, the highest rate of preterm births was among non-Hispanic Black women.
While the thought of conceiving, being pregnant, and giving life to another human seem like a series of sacred events, Black women’s reproductive capacity has always been a point of public discourse in this country. Many times, Black women have been dictated on how, when, where, and to what extent they were allowed to reproduce. Let’s be real, this country was built on the backs of Black folks who were carried in the wombs of Black women. Dorothy Roberts, University of Pennsylvania professor of law, sociology and civil rights, thoroughly writes about the history of Black women’s bodies and how, many times, they were used to preserve an oppressive social structure. In her book, Killing the Black Body, Dr. Roberts chronicles how reproduction played a role in slavery through the ownership of Black bodies, unconsented medical experimentation, the Eugenics and Birth Control movements, and even in welfare and criminal justice policy through the modification of people’s behavior.(7) Her book gives keen insight into understanding the disconnect and distrust between Black people and medical institutions that continues to build upon the existing disparities we see today in infant and maternal birth outcomes.
City planners were no innocent bystanders in the abusive history of Black women’s bodies. In fact, city planning efforts have and continue to directly impact Black women’s reproduction through the creation and segregation of neighborhoods, systematic housing instability, disproportionate economic development and access to resources, and environmental injustice. In the book Infectious Fear, Samuel Kelton Roberts chronicles just how influential segregationist city planning politics were to public health during the tuberculosis epidemic in Baltimore during the first half of the twentieth century.(8) In a recent article on Rewire.com, housing instability is earmarked as an important, yet overlooked, risk factor for maternal death from pregnancy-related causes. Evidence indicates that housing instability is associated with low and very low birth weights, preterm delivery, infants that are small for their gestational age, and maternal and infant mortality.(9) City planning whether through policy implementation, real estate and infrastructure development, or urban design has had a heavy hand in creating the injurious circumstances for a modern day maternity and infant crisis in the Black community.
Racial segregation of American communities was the intentional and malicious work of federal policies. Thanks in part to city planning efforts, the creation of inner city ghettos, concentrated poverty, racial stereotypes, white flight, and suburban oases are apart of a discriminatory narrative the shapes the lives of many Black people. As a Black person living in America, there are virtually no safe spaces where we can be free of judgment. No matter where we live or how successful we are, encounters of discrimination and prejudice are almost a sure thing. Imagine living your entire life in a state of constant stress, fear or anger brought about simply because of the color of your skin. What does that do to psyche? What does that do to the body of an adult? Now, throw a developing fetus in the mix encountering stress as its baseline for homeostasis. It’s almost as if America is playing a cruel joke on Black people, robbing us of our rights to life well before we have the chance to experience liberty and the pursuit of happiness.
In the past, Black women relied heavily on Black midwives to guide them through pregnancy, labor, and the post-partum period. Midwives, in those days, weren’t regarded as medical professionals but were spiritual leaders and cornerstones of the community at a time when Black people stayed away from clinics to have children due to mistrust and lack of access to medical institutions. In the documentary, All My Babies, Marry Coley, a midwife in the rural South, described the birthing process as a 10-day period. She would stay with the family before, during, and after labor doing anything she could to help the family.(10) She didn’t have a car so she would walk and average of 5-10 miles to attend births in Albany, GA sometimes barely getting paid. But for Black midwives of those days, it was their choice and their life decision to give this much time and energy to others regardless of payment.
Today, despite a long cultural history of midwifery in the Black community, Black women currently represent less than 2% of the nation’s midwives after decades of race-based professionalization of the field.(11) But an emerging cohort of Black doulas is currently taking stronghold of the fight to keep Black women and babies healthy. A doula is not trained to make medical decisions like a midwife. Instead she provides emotional support and works as an advocate for the mother. Her role is to stay with the mother through the entire birth, working along side medical staff, amplifying her clients voice and protecting the mother’s memory of her birth. Doula-assisted mothers see less instances of medical intervention, cesarean births, and birth complications altogether. We know that increased inductions, cesarean section, and epidurals have all been linked to an increase in the morbidity and mortality of baby and mother.(12) Why aren’t we using doulas more in our efforts to keep people alive?
City planners can work as advocates for equitable policy to make doulas accessible to all mothers, regardless of location, income, or healthcare coverage. Recently, New York City expanded the use of doulas under Medicaid to help combat infant mortality rates.(13) Although there are kinks and coils to iron out, this is a win for Black women that is derived from a rich history of reproductive agency and the traditions of Black granny midwives. Other programs like the Philadelphia Alliance for Labor Support at the University of Pennsylvania and the Maternity Care Coalition should be applauded and funded for their efforts to train community doulas and extend services to clients free of charge, empowering mothers of all backgrounds to exert their reproductive rights.
At its core, city planning curriculum in universities around the country can do a better job of linking policy and plans to real people, real places, and real problems. There is no better place to explore innovative, blue-sky, and radical approaches to some of our countries biggest problems than inside the walls and with the resources of an academic institution. JeffDESIGN is a collaborative academic program between Philadelphia University and Thomas Jefferson University. This program teaches design and creative problem solving methods and it aims to equip the next generation of doctors with the skills and confidence to transform healthcare systems, services, spaces, and devices.(14) The way our current healthcare system is designed has greatly affected the health disparities we see today. Have you seen the inside of a labor room at your local hospital lately? How did it make you feel? Were you satisfied with your experience? The physical aspects of labor and delivery rooms and encounters with medical staff are a crucial component in addressing infant and maternal mortality. Studies analyzing women’s childbirth experiences and obstetric outcomes found that satisfaction with childbirth is considered the most important qualitative outcome in assessing childbirth experience, given that women’s satisfaction with this experience affects their health and their relationship with their infant.(15) Despite this research, the United States is a country with the shortest hospital stays and hardly any postpartum follow-up for mother, a very sensitive window for maternal mortality. While we appreciate the role our hospitals provide for moms-to-be, we also know that there is room to improve especially in areas of design, client comfortability, and even some medical practices.
City Planning directly effects the built environment around us. Pressing for incentives and policies to allow different kinds of real estate and infrastructure development is an elemental component of the profession. Creating housing programs specifically catering to the needs of at-risk pregnant women and mothers could really impact the way maternal and infant mortality is experienced in America. Impetus through federal, state, and local programs for the construction of non-hospital birthing centers in communities can help give mothers access to opportunities that can totally alter the course of their birthing experience. We can move the world for an Amazon HQ2, but what about healing our communities through tax incentives, funding opportunities and subsidies that consciously elevate birthing communities to keep women and babies alive?
Nurses and doctors in neonatal intensive care units are some of this country’s bravest heroes. There is no dollar value that can be put on the work they do to save lives as policies continue to reinforce the same cycles they work so hard to impede. Somewhere in the mix are city planners who learned from a profession that socially isolated families through redlining, displacement, and other brash efforts. The legacy of city planning has had some pretty negative and lasting physical, emotional, and biological effects on Black communities. Maternal and infant mortality is one. But moving forward, city planners will work in partnership with professionals across all fields of study to run upstream, while those who wade in the water to catch the babies already drifting down the river face the true consequences of what decades of institutional and systemic oppression breeds.
Gabriella A. Nelson is a city planner, possessing a strong affinity at the confluence of urban development and public health. She currently works as a Project Analyst with the Philadelphia Housing Authority to help house some of the city’s most vulnerable residents and maintain a much needed level of affordability as the city re-surges. She believes the city is for everyone, especially for those who want to stay after bearing decades of disinvestment and devastation. Gabriella identifies as a problem-solver, an inquisitive thinker, and a creative whose experiences and opinions are deeply rooted in her Blackness, womanhood, and humanness.