Abstract
Fear of state punishment joins medical mistrust and experiences of discrimination as Black women consider whether and where to seek medical care for themselves and their children.
Keywords
Johnny Silvercloud, Flickr CC
When Shaunte scheduled her first prenatal visit with an obstetrician, the last thing she expected was a report to child protective services (CPS). The appointment seemed normal enough. In addition to confirming her pregnancy and discussing her medical history, her doctor discussed the importance of testing for genetic disorders and provided Shaunte guidance for coordinating with her care team throughout her pregnancy. Two weeks later, a CPS caseworker knocked on Shaunte’s door. At that time, Shaunte was 10 weeks pregnant with her second child. The caseworker explained that CPS had received an anonymous report concerning the welfare of Shaunte’s 8-year-old son and unborn child. Shaunte thought back to the obstetrician, recalling the detailed intake survey she completed at the beginning of her appointment. One question on the survey asked about women’s living situations and whether they had been physically hurt by a partner in the past year. Shaunte answered honestly: She had been in a physically abusive relationship, but separated from her ex before finding out that she was pregnant.
CPS contacted Shaunte’s mother, a neighbor, and a family friend to comment on her ability to provide for and ensure the safety of her children, then declared Shaunte’s case “unfounded.” In short, the agency found no evidence regarding risk of child maltreatment. Still, the incident shook Shaunte. Would returning to the doctor for her second prenatal appointment trigger another CPS investigation? What if her children were taken away? Concerned about these possibilities, Shaunte decided to “go it alone.” For her, this meant relying on advice from her sister, a nurse, and the wisdom she’d gained while carrying her first child to guide her through her second pregnancy.
When people become pregnant, they make a variety of healthcare decisions. In this study, all participants identified as cis-gender Black women, and so we will refer to “women” and “mothers” throughout, without discounting the experiences of transgender men and nonbinary individuals who may also become pregnant. After deciding to carry a pregnancy to term, individuals decide on a birth location, a doctor or midwife for their childbirth experience, a labor pain management technique, and a pediatrician for their newborn. These decisions are shaped by the laws where individuals live, the resources they have at their disposal (such as health insurance), the quality and availability of maternity care and pediatric care in their communities, their past pregnancy experiences, and their comfort and knowledge navigating healthcare institutions.
For Black women, medical mistrust and previous experiences of medical discrimination play an additional role in maternity care and pediatric care decision-making. So, too, does the fear of state punishment. Recent Supreme Court decisions, such as the overturn of Roe v. Wade, and legislative maneuvers criminalizing people’s actions during pregnancy have made the state an increasingly important factor in maternity and pediatric care decision-making. And, as Shaunte’s story shows, government agencies like CPS now have a longer reach into women’s lives.
Drawing on interviews with a mixed-income sample of 35 Black mothers in Chicago, all of whom had been recently investigated by CPS, we find that fear of state punishment—in this case, fear of child removal—is a key factor in not only if, but how and where Black women access maternity and pediatric care. Mothers were recruited for this study through flyers posted in community centers, posts on Facebook pages dedicated to parents navigating CPS investigations, other posts on social media, personal contacts, and managed social network (“snowball”) sampling. Through detailed accounts of five mothers’ stories, this article shows how Black women who have access to maternity and pediatric care, and who actively seek it out, alter their care plans in the face of fear of child removal after being reported to CPS. Even when our respondents suspected they were not reported to CPS by anyone in the healthcare system, CPS contact altered their medical care decisions.
Medical decision-making and CPS
Medical mistrust and previous experiences of medical discrimination factor into many Black women’s dissatisfaction with and disengagement from healthcare services. A 2017 study by public health researchers Laura Attanasio and Katy Kozhimannil, for instance, documents how past experiences of medical discrimination decrease Black women’s likelihood of attending postpartum doctor’s visits.
Black mothers are highly aware of the collaboration between the health care system and punitive institutions like CPS.
Mistrust and personal experiences also factor heavily in Black women’s decisions about medical care for their children. Black women take up strategies to avoid discrimination such as seeking out Black maternity and pediatric care providers, as documented in a 2019 study led by researcher and former nurse-midwife Molly Altman. This often proves an onerous task, embedded within an already onerous healthcare system, given the underrepresentation of Black individuals, especially Black OB-GYNs in the medical profession.
We find that fear of state punishment, specifically the fear of children being taken away by CPS, is just as pivotal in shaping women’s medical decisions. In the United States, CPS investigations are incredibly common for Black families. Half of Black children in the United States are the subject of a CPS investigation before they reach the age of 18. These investigations can trigger temporary or permanent child removal, processes that, in many states, can be initiated by CPS without a court order. CPS may temporarily remove children while investigating claims of child abuse or neglect, or they may permanently remove children after a court terminates a parent’s parental rights.
Black mothers who have been investigated by CPS may carry fears of child removal with them as they navigate institutions such as maternity and pediatric care. These fears are well-founded, given that seemingly innocuous interactions with obstetricians, gynecologists, and pediatricians can trigger CPS investigations. For instance, declining certain procedures during childbirth hospitalization, such as a cesarean delivery, an epidural, an episiotomy (a surgical cut made to enlarge the vaginal opening during childbirth), cord clamping, or advocating for intermittent rather than continuous fetal monitoring can lead to CPS reports.
As noted by Black feminist legal scholar Dorothy Roberts, Black mothers have long been targeted by CPS. During the “War on Drugs” in the 1980s, punitive legislation criminalized poor Black women for substance use during pregnancy. Today, Black women remain 10 times as likely as White women to be reported to CPS on those grounds, despite having similar rates of substance use. Medical practitioners and other professionals who are legally mandated to report child abuse and neglect draw on racist fallacies about the competency of Black mothers and the structure of Black families to justify such disparities.
Adding the fear of CPS investigations to Black women’s already disproportionate likelihood of experiencing medical discrimination and adverse health outcomes (for both themselves and their children) creates a particularly complex matrix of healthcare considerations. Yet, to receive respectful, humane, and high-quality maternity and pediatric care, this is the matrix Black women must navigate.
How to receive care
When Marcia, a pregnant 30-year-old mother of two, returned home from vacation, the first thing she did was schedule an appointment with her 7-year-old son’s pediatrician. She noticed her son seemed to have less energy than usual, which troubled Marcia, given his recent diabetes diagnosis.
Marcia thought she had a “great relationship” with the pediatrician and took comfort in the fact that he’d been her children’s pediatrician for five years and knew the intricacies of her son’s complex health history. During the appointment, the pediatrician told Marcia that it seemed like her son had been receiving an incorrect dose of insulin. Marcia shared that her son’s father “must have got confused” about the correct dosage and “mixed things up,” assuring the doctor that the mistake wouldn’t be repeated. Shortly after the appointment, though, Marcia received a call from CPS. After discussing her situation with a close friend, Marcia considered the possibility that her son’s pediatrician could be responsible for the report.
Black women take up strategies to avoid medical discrimination such as seeking out Black maternity and pediatric care providers, a tough task given the underrepresentation of Black individuals, especially Black OB-GYNs in the medical profession.
SIM USA, Flickr CC
Explaining how being investigated by CPS affected her relationship with the pediatrician, Marcia stated, “I definitely keep it short and sweet. I don’t converse too long or get into every single thing going on with us, and that’s just going to be how it is.” This tactic, aimed at minimizing the possibility of another report while still receiving the necessary care for her son, is similar to a practice that sociologist Kelley Fong calls “concealment.” In her 2018 study of low-income mothers in Connecticut, Fong found women concealed information from social service providers in order to avoid triggering CPS reports. Marcia is a middle-class, Black mother who is statistically unlikely to be reported to CPS again and has far more resources than the mothers in Fong’s sample, but she explained that she now takes a similar approach when she sees her obstetrician:
“This whole thing just made me so careful and so protective of my kids. Like, even with the doctor I’m seeing now about being pregnant, it’s like, I’m so cold to her, because if I tell you something that happened, are you going to do the same thing [report me to CPS]? But I have to go to checkups and stuff, so that’s when it comes back to not telling them every single thing.”
Being reported to CPS has informed not only how Marcia interacts with the pediatrician that she thinks reported her to CPS, but how she interacts with her obstetrician. With both doctors, Marcia avoids providing intimate details about her life and the lives of her children. Quality medical care requires well-informed physicians and patients, and so Marcia’s reticence potentially affects her family’s health outcomes.
It’s important to understand that, for Marcia, interacting with healthcare professionals is not only about medical mistrust, but about fear of child removal. Describing how she felt when CPS showed up at her door, Marcia remembered:
“My mind automatically went to them [my children] being placed in foster care and getting stuck in the system. A lot of kids end up stuck there, and it is hard to get them out. I thought they [CPS] wouldn’t do that to me, but also we’re Black in America, so I don’t put it past them. You don’t know. You really can’t know.”
Marcia believes that she is a good mother and hasn’t done anything wrong, yet she also feels that, because she is Black, her children can be taken from her at any moment.
Jessica, a 39-year-old mother of three who described being investigated by CPS as “the most terrifying thing that has happened,” adopted a similar approach to navigating interactions with medical professionals as Marcia. Jessica suspected that one of the workers at her children’s daycare reported her to CPS because of scars they found on her 5-year-old daughter’s legs. Jessica and her husband promptly removed their children from the daycare and placed them in the care of Jessica’s grandmother. Even though a medical professional didn’t report her to CPS, she described feeling nervous about taking her children to the doctor for their injuries after being reported. She recounted feeling like doctors might not believe how her “accident prone” children got injured and felt like she might have to tell a different story or leave parts out.
Aware that doctors often trigger CPS reports, Jessica described wanting to keep doctors “out of [her] business as much as possible.” While Jessica suspects that she was reported to CPS by her children’s daycare, her fears extend beyond daycare workers to medical professionals.
The wariness that Jessica and Marcia had toward medical professionals was amplified by the realistic fear that CPS might remove their children. They each spoke about seeking out their own informal medical advice, whether online or among friends and family. Marcia told us she now wants “to do more [online] research and know what’s going on with my son so I’m not so dependent on these doctors.” To her, it was “when you have to depend on them so much” that “stuff” like CPS reports happened. And, like Shaunte who went to her sister for medical advice, Jessica began relying heavily on her grandmother, who “had a remedy for everything” if her children got sick or hurt.
Aware that doctors often trigger CPS reports, Jessica described wanting to keep doctors “out of [her] business as much as possible.”
The strategies that Marcia and Jessica use may very well protect their families from future CPS involvement. Their decisions could also have negative health consequences for themselves and their children. For Marcia, not speaking openly with her pediatrician could have negative consequences for the health of her diabetic son. Similarly, for Jessica, forgoing medical care when her children have injuries could prevent her children from receiving treatment for common but serious childhood injuries that have lasting developmental implications.
Fear of CPS investigations adds another dimension to Black women’s complex matrix of healthcare considerations.
CMRF Crumlin, Flickr CC
Where to receive care
Fear of child removal not only shapes how Black mothers receive maternity and pediatric care for themselves and their children but also where they receive care. After suspecting that her newborn son’s White pediatrician in the suburbs reported her to CPS, Naomi, a 25-year-old mother, began taking him to a Black pediatrician in her Chicago neighborhood. Naomi believed that her son’s previous pediatrician “called because she was racist.” Naomi stood by her decision to change pediatricians even though her mother worried that her new pediatrician was at a less reputable health care institution in a dangerous area. According to Naomi, her mother viewed the local hospital as “where people go to die, not to be treated.” Naomi knew the poor reputation of the hospital but felt confident that her newborn son could still receive the care he needed.
Similarly, after being investigated by CPS, Alyssa, a 40-year-old mother experiencing her first pregnancy, changed obstetricians. Alyssa wasn’t sure who reported her to CPS but decided to change obstetricians “just in case.” “Nosey” questions from her obstetrician about her past drug use and unstable housing situation made her suspicious that her obstetrician could have made the report. Alyssa remembered telling her obstetrician that she didn’t have a reliable place to sleep and that she had slept at multiple people’s houses during her pregnancy, including a cousin, a close friend, a boyfriend, and a friend of her mother’s. Like other mothers, Alyssa believed that telling her doctor personal information about her life resulted in the CPS report. Expressing fear that her unborn child could be placed into foster care, Alyssa said, “the baby’s not even here yet, and already they tryin’ to take her.”
On the one hand, all the mothers we spoke to practiced agency. They sought out informal medical advice, they engaged with doctors in ways that made sense to them, and they changed doctors when they believed it was necessary. It would be a mistake, however, to think of these practices as free choices.
Black mothers are exercising agency, but they are doing so in the face of fear that accessing medical care could result in child removal. Additionally, the decisions that mothers are making are not innocuous. For Naomi, choosing a medical provider with a poor reputation could have consequences for the quality of care that her newborn son receives as new health care needs arise. For Alyssa, moving from a local obstetrician to one far from where she lives could affect her ability to receive timely, even lifesaving care.
New frameworks of care
One thing is clear from the stories above: Black mothers are highly aware of the collaboration between the health care system and punitive institutions like CPS. In her latest work, Dorothy Roberts calls us to imagine a world where CPS does not exist and where families’ needs are met without tearing families apart. Medical care providers can do their part in rising to Roberts’s call by challenging the often taken-for-granted collaboration between the health care system and CPS. Medical care providers can also follow the lead of Black women who have been imagining new frameworks for providing medical care.
Since launching what has become known as the reproductive justice movement in the 1990s, Black women-led organizations committed to transforming how the medical system approaches reproduction and bodily autonomy have proliferated across the United States. Reproductive justice is defined by SisterSong, a national activist organization dedicated to reproductive justice for women of color, as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” Organizations like the Black Mamas Matter Alliance (BMMA), the National Association to Advance Black Birth (NAABB), the National Birth Equity Collaborative (NBEC), and the National Black Doula Association (NBDA) have been working to promote reproductive justice by increasing Black representation among medical providers and amplifying the medical experiences of Black women and Black birthing people. These organizations have created tools such as NAABB’s “Black Birthing Bill of Rights” and BMMA’s key 2018 report “Setting the Standard for Holistic Care of and for Black Women.” These tools advocate for new frameworks of medical care that are trauma-informed, holistic, community-driven, and centered on personal empowerment.
These frameworks exist in opposition to current medical frameworks, which invest little energy, training, and resources into addressing the traumas, concerns, and fears of patients. Medical providers can take up the tools that Black women have created to begin fostering a medical environment in which Black women and their children receive respectful and humane care without fear of child removal.