6 Reproductive Injustice

Serena Williams’s Birth Story

On September 1, 2017, tennis star Serena Williams gave birth to her daughter Olympia.1 As is all too common for Black women in the United States, the event was life threatening. Her experience reveals the inadequacy of frequent explanations for high maternal mortality among Black women, such as poverty or failure to seek prenatal care. Even with all of the resources, expertise, and assertiveness that she was able to muster, Williams faced challenges in receiving the attention and intervention that she desperately needed. This chapter puts Williams’s account of her experience into the context of two intersecting elements: connections between Williams’s birth experience and those of far too many Black women and representations of Williams’s body over the course of her career that have combined hypervisibility with dehumanization. Doing so highlights the ways in which Black women’s bodies are simultaneously hypersurveilled and inadequately cared for. As a star within a neoliberal sports context, Williams is not an uncomplicated advocate for justice for Black women, yet there is rich potential for reproductive justice advocacy as she mobilizes her social media platform to call attention to racial disparities in access to safe births and to demand change.

Serena Williams is by any measure a major star. Not only is she a premier tennis player—a former world number 1 many times over with more major singles titles than anyone else (male or female) since the establishment of the professional tennis circuit in 1968—she is also a crossover celebrity, with huge endorsement deals, and she is extensively discussed in mainstream media and on social media. As a muscular and expressive Black woman who has often not conformed with the specific white feminine ideals of the sport in terms of either physique or behavior, she has been the subject of a very high degree of scrutiny. And yet in her experience of childbirth, she faced perilous invisibility.

A Harrowing Experience

In an interview-based account published in the fashion magazine Vogue, Williams tells readers that she had an easy pregnancy, but dangerous fetal heartbeat changes during labor led to an emergency surgical delivery by Cesarean section (C-section).2 Baby and mom were both fine at that point, but the next day, Williams had shortness of breath that, because of her history with blood clots, she immediately recognized as a pulmonary embolism. According to the Vogue article, “she walked out of the hospital room so that her mother wouldn’t worry and told the nearest nurse, between gasps, that she needed a CT scan with contrast IV and heparin (a blood thinner) right away. The nurse thought that her pain medication might be making her confused. But Serena insisted, and soon enough a doctor was performing an ultrasound on her legs.”3 Serena reflected, “I was like, Doppler? I told you, I need a CT scan and a heparin drip.” Serena described the experience of struggling to get the right test in an HBO Sports documentary, her voice trembling with emotion: “I’m like, listen, I need you to run a CAT scan, with dye, because I have a pulmonary embolism in my lungs, I know it—I’ve had this before, I know my body.”4 Once the medical staff finally did proceed to give her the CT scan, the blood clots settling in her lungs were confirmed, and she was given the drip that she needed. She said, “I was like, listen to Dr. Williams!” Several days of surgical medical interventions followed, to deal with Williams’s postpartum complications.

Williams made the story public in a Facebook post that featured a cute video of her baby daughter with this commentary:

I didn’t expect that sharing our family’s story of Olympia’s birth and all of complications after giving birth would start such an outpouring of discussion from women—especially black women—who have faced similar complications and women whose problems go unaddressed.

These aren’t just stories: according to the CDC, (Centers for Disease Control) black women are over 3 times more likely than White women to die from pregnancy- or childbirth-related causes. We have a lot of work to do as a nation and I hope my story can inspire a conversation that gets us to close this gap.

Let me be clear: EVERY mother, regardless of race, or background deserves to have a healthy pregnancy and childbirth. I personally want all women of all colors to have the best experience they can have. My personal experience was not great but it was MY experience and I’m happy it happened to me. It made me stronger and it made me appreciate women—both women with and without kids—even more. We are powerful!!!

I want to thank all of you who have opened up through online comments and other platforms to tell your story. I encourage you to continue to tell those stories. This helps. We can help others. Our voices are our power.5

For Serena Williams, it was a choice to align her story with the cause of addressing Black women’s high maternal mortality.6 As an unquestionably extraordinary woman who made it through the ordeal in the end, she might well have seen her experience as a singular one and moved on. She chose instead to articulate her experience as part of Black women’s experience. This is not to say that she denied her privilege relative to other Black women. In a subsequent interview published in the magazine Glamour, she underscored the unfairness of the fact that many women in her situation would not have been listened to, even after insisting, and, referring to the mortality statistic in her Facebook post, said, “If I wasn’t who I am, it could have been me.”7 As she has increasingly done in recent years, she took advantage of her high-profile platform and direct access to audiences online to raise awareness about this important social justice issue.8 A Black woman shouldn’t have to be a superstar to survive.9

Williams’s advocacy in her Facebook post—especially her insistence that “EVERY mother deserves a healthy pregnancy and childbirth” and her appreciation of all women, whether or not they have children—resonates with the Black feminist–led social movement called reproductive justice. Reproductive justice centers a broader understanding of freedom than “reproductive rights” generally does.10 Whereas reproductive rights generally focuses on access to contraception and especially abortion, reproductive justice not only demands access to these vital means to prevent pregnancy and birth but also demands the transformation of broader social conditions to enable safe birth and parenting. This is a necessary intervention, because as influential Black feminist legal scholar Dorothy Roberts highlights, access to abortion or lack thereof is not the only impediment to reproductive liberty that Black women face in a country that has long sought to decrease Black birthrates, including through forced sterilizations and involuntary forms of birth control.11 This history in turn informs the work of SisterSong Women of Color Reproductive Justice Collective, which “defines Reproductive Justice 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.”12 Community seems to be part of what Williams is reaching for in her post. And her words also resonate with the demand made by SisterSong and reproductive justice advocates more broadly: “Trust Black Women.”13

The relevance of Serena Williams’s birth story for reproductive justice was underscored for me at an event at Georgia Tech in Atlanta in March 2018: Dialogue on Race, Biomedicine, and Reproductive Justice, co-sponsored by the Working Group on Race and Racism in Contemporary Biomedicine and the Black Feminist Think Tank.14 The Dialogue featured one of the founders of the reproductive justice movement, Loretta Ross, in dialogue with public health scholar Whitney Robinson.15 In the Q&A portion of the event, one questioner identified herself as a student at Spelman—a renowned historically Black women’s college also located in Atlanta—who wanted to become a gynecological oncologist. Saying that she believed that Black women’s increased mortality was due to their fear of the medical system and waiting too long to go to the doctor, the student asked, how can medical professionals encourage Black women to seek preventative care and not just treatment? Loretta Ross’s response was to question the assumptions underlying the student’s framing, pointing to the experience of Serena Williams in childbirth. Even with all of the fame, power, status, and name recognition that she had, Williams was still not believed by her health care provider. One of the other members of the audience chimed in, saying, “And talk about someone who is in tune with her body!” And yet, Loretta Ross reminded us, Williams almost died, as too many Black women do. Ross encouraged those of us gathered at the event to focus “upstream,” on the untrusting health care providers.

The call to shift the focus from patient distrust to provider distrust resonates with anthropologist Dána-Ain Davis’s work on “reproductive injustice.” Davis argues that rather than blaming Black women for their own poor health outcomes, health care providers “must look racism in the face and question the ways that the system within which they work might contribute to racist outcomes, draw from racist discourse, or perpetuate racist ideas.”16

Sociologist and writer Tressie McMillan Cottom mentions the postchildbirth interview with Serena Williams in her essay on her own tragic birth story: “In the interview, Serena describes how she had to bring to bear the full force of her authority as a global superstar to convince a nurse that she needed treatment. The treatment likely saved Serena’s life. Many black women are not so lucky.”17 McMillan Cottom had been trying to get medical attention for pain and bleeding during pregnancy, but her concerns were dismissed. After giving birth to a preterm baby who died soon after her first breath, McMillan Cottom was chided by health care workers: “you should have said something.” But she had spoken up; the problem was that, as a Black woman, she had been “presumed incompetent.”18

Any individual woman might have difficulty being listened to by her health care provider, and indeed the medical complaints of women in general are all too often dismissed.19 Yet the magnitude of the inequality makes it clear that there is a racialized pattern when it comes to experiences in childbirth. As Williams notes in her post, racial disparities in maternal mortality are stark: indeed, according to the CDC, in the United States “pregnancy-related mortality ratios are 3–4 times higher among black than white women.”20 The causes of Black women’s high risk of morbidity and mortality in childbirth are highly contested. As with so many health disparities, the question of race is sometimes reduced to socioeconomic class—and with it, education and access to care. And yet the maternal health and infant mortality disparities are so great that middle-class Black women with college degrees have worse outcomes than poorer white women with less than a high school education.21

Black women with privileged class status are not exempt from this problem. The magazine of the Harvard School of Public Health described Serena Williams’s case together with that of a fellow thirty-six-year-old elite Black woman, Shalon Irving, who was a PhD epidemiologist at the CDC and yet died of complications a few weeks after giving birth.22 Like many such accounts, the magazine piece describes a possible mechanism: the “weathering” that Black women experience as a result of living in a racist society, an increased allostatic load of stress that operates rather like premature aging.23

“Weathering” is a powerful concept that resonates with Black literary theorist Christina Sharpe’s concept of “the weather”: “the weather is the totality of our environments; the weather is the total climate; and that climate is antiblack.”24 The specific weather that individuals face is variable, and indeed the need to be adaptable in the face of changing weather conditions is itself a form of stress, but it is always inextricable from the context of a climate of anti-Black racism.

And yet the Harvard article’s focal goal is not explanation but action: in the context of the U.S. medical system, it is not Black women’s complicated health conditions that are the direct cause of the excess morbidity and mortality but the challenges in accessing care that could effectively treat those complications.25 To put it into terms laid out in this book’s introduction, if the differential rates of complications of pregnancy are the result of “the accumulated insults” of living in a racist society, their deadliness also comes from medical “inaction in the face of need.”26 For Shalon Irving, as was almost the case for Serena Williams, skepticism in the face of her description of her symptoms was a key locus of denial of care.

Anthropologist of racialization in childbirth Khiara Bridges discusses a report about inequity in treatment for childbirth complications as a contributor to maternal health disparities, which found that African American women are less likely to receive treatment for pregnancy-related hemorrhage even when the severity of bleeding was the same across racial groups. Bridges highlights the problematic explanation that the authors of the report provide for the unequal treatment: “In the case of post-partum haemorrhage, reluctance to report or under-reporting on the part of the patient or difference in history taking on the part of the physician could lead to differences in treatment for the same degree of hemorrhage.”27 Bridges suggests that the idea that Black women would be silent amid massive blood loss is implausible, reflective of “discourses of Black women’s fantastical stoicism and strength,” and that the “difference in history taking” should be named as physician racism.28 In a way that is highly racially patterned, doctors are not listening to Black women.

When it comes to maternal health in the United States, even closing the racial disparities would not be enough. As neonatologist Richard David points out in the powerful documentary that explores the problem of Black women’s and newborns’ high levels of morbidity and mortality, “white Americans, if they were a separate country, [their infant mortality] would still rank 23rd in the world.”29 In this broken system, the women who are already most vulnerable are rendered more vulnerable still.

The high rate of C-sections may play a role in the riskiness of childbirth in the United States. Although the procedure can be life saving for both women and infants, it brings its own risks—for example, as in Serena Williams’s case, the risk of internal bleeding. It is not clear why Williams’s labor was induced in the first place—in her documentary series filmed for HBO Sports, all she says about it is that “the doctor said it was time, so I guess it was time”30—but induction often contributes to an escalation of medicalization. Market-driven health care is a key driver of the high C-section rate in the United States—from a hospital’s perspective, surgical deliveries are both easier to manage in terms of scheduling and more lucrative in terms of payments.31 Even Serena Williams herself, speaking on the day that she went to the hospital to have her labor induced, seemed to be under the misapprehension that having a C-section “seems easier,” though her doula corrected her—saying “not the recovery part!”32 In her reflections on her pregnancy and childbirth experience in the documentary, Williams reflects, “I was so healthy, my pregnancy was so easy, like I didn’t have any problems, but unfortunately, once I had the C-section, everything, from there, was pretty much a nightmare.”33 It is impossible to know what might have happened in her particular case had the birth not been induced and a C-section avoided, but broadly we can say that overuse of C-sections adversely impacts maternal health, and Black women are even more likely than white women to undergo C-sections—a form of overtreatment that exacerbates risk in the face of systemic undertreatment. This reflects what Alondra Nelson has characterized as a central tension in the health inequality of African Americans: poor Black communities have long been “both underserved by and overexposed to the medical system.”34

Hypervisibility and Dehumanization

In Serena Williams’s articulation of her birth experience as a Black woman’s experience, it is not Black women’s bodies that are problematic; rather, it is the system that is, by failing to meet Black women’s needs. This is an important intervention, because the field of obstetrics and gynecology is deeply implicated in the colonialist biopolitical paradigm that treats Black women’s bodies as sites of extraction rather than of care. Marion Sims, hailed as the founder of gynecology, based his research on enslaved women, who were in turn configured as completely passive.35 Exploiting myths about Black women’s high tolerance for pain, Sims and his colleagues denied these women their full humanity even while treating them as ideal research subjects.36 Although it may well be true that the enslaved women were eager for any care they could get for excruciating conditions such as fistula—even when that meant unanesthetized backyard surgeries—for Sims, the women were not treated as suffering patients in need. They were treated as damaged reproductive property, and because of their expendability, their bodies were for him promising terrain for the medical breakthroughs that would make him famous.

Sims’s lack of deference to the pain of enslaved women is emblematic of the way that Black women’s femininity itself was and is often thrown into question. It resonates with abolitionist and feminist Sojourner Truth’s nineteenth-century provocation, in the face of white men’s dismissal of equal rights for women on the grounds that women’s delicacy required special care and her own experience of no such deference as a hardworking and abused enslaved woman, “ar’n’t I a woman?”37 If, ideologically, to be a woman is to receive accommodation and care, Black women’s membership in the category of “woman” has never been universally sufficiently recognized. Even in today’s biopolitical paradigm, denials of full citizenship and denials of femininity remain intertwined, and expendability and exploitability are linked.

The inherently political quality of the insistence on including Black women in the category of “woman” provides an opportunity to expand the scope from Williams’s experience in childbirth and link that experience with the ways in which her broader life and career provide windows into the racialized denigration of Black women. Indeed, in some ways, Williams represents an extreme example of the denial of femininity to Black women. Invoking her muscularity and strength, internet abusers, among others, have gone so far as to question Serena Williams’s status as female.38 Throughout their careers, Serena and her sister Venus have faced accusations that their superior strength and physicality are somehow an unfair advantage: a 1998 article in the mass-market news magazine Newsweek stated that “American tennis legend Chris Evert says both sisters’ athletic ability and raw aggression make it hard for ‘the women who aren’t Amazons’ to compete with them.”39 Serena Williams, in particular, has been subjected to abuse online that has taunted her as “half man, half gorilla!,” “built like an NFL linebacker,” and more.40 Like the Black South African runner Caster Semenya, whose appearance and performance prompted layers of sex testing, Serena Williams has been confronted with intertwined misogyny and racism that Black feminist health science studies scholar Moya Bailey has powerfully characterized as “misogynoir,” a term that “describes the co-constitutive, anti-Black, and misogynistic racism directed at Black women, particularly in visual and digital culture.”41 Women athletes’ femininity might always be in question to a certain degree, but for the Williams sisters, and especially for Serena, this derision has been inextricably bound to Blackness as well.42

Indeed, media representations have often simultaneously questioned the femininity of the Williams sisters while characterizing them—Serena Williams in particular—as too much of a woman, for displaying sexuality in ways inappropriate for the tennis court, an overwhelmingly elite white sport. The sexualized “grotesque” trope has led some Black feminist analysts and others to put Williams into the line of representation with the “Hottentot Venus” Saartjie Baartman, a South African woman who was displayed in London and Paris in the nineteenth century.43 Those parodying Serena have emphasized large breasts and buttocks—notably her competitor (and friend) Danish player Caroline Wozniacki, who spurred controversy when she shoved towels down her shirt and skirt in a parody of Serena (a form of mocking in which white men have engaged as well).44 The troubling of femininity that is going on in the obsession with large buttocks and breasts is different from the troubling of femininity that focuses on muscularity, because it is not evoking masculinity. However, this trope, too, is emblematic of distance from white feminine ideals.

Serena Williams has also been harshly criticized and occasionally penalized for expressing anger on the court.45 She has been chided for “not keeping her head.”46 Because of the pervasiveness of stereotypes about “angry black women,” this kind of approbation cannot be extricated from gender and race.47 The fact that Williams rarely expresses anger off the court can be read as a strategy for navigating these stifling expectations.48

Representations of Serena Williams throughout her career can be understood as a paradoxical combination of hypervisibility and invisibility. She has long experienced surveillance of her body as a suspect category, an unbelievable Black body. Perhaps the most famous moment of this was the controversy around her 2002 Wimbledon “catsuit,” which was both admired and derided as animalistic and sexy, displaying a combination of muscularity and curves that deviated from the lithe white feminine tennis norm.49 Media representations of her body as emblematic of natural ability and yet deviant in terms of both gender and race have continued in coverage of tournaments for decades.50 Her celebrity has not shielded her from ridicule.

It is worth noting that Serena Williams herself loved the catsuit and described it as “really innovative” and “sexy.”51 Williams can and does contest the ways that images of her are read. In this sense, Williams has been an unusually skilled navigator of the bind described by Black feminist sociologist Patricia Hill Collins:

Surveillance operates via strategies of everyday racism whereby individual women feel that they are being “watched” in their desegregated work environments. Surveillance also functions via media representations that depict the success of selected high-achieving Black women. Surveillance seems designed to produce a particular effect—Black women remain visible yet silenced; their bodies become written on by other texts, yet they remain powerless to speak for themselves.52

Even if it can be difficult to hear her voice amid the cacophony, Serena Williams certainly does speak for herself.

Postpregnancy, Williams wore another controversial catsuit to compete in the French Open, which covered not just her body but also her legs in a tight-fitting way designed to help with her blood-clotting issues. The appeal of the outfit was not exclusively medical—Serena made reference to the movie Black Panther as she told reporters, “I feel like a warrior in it, a warrior princess . . . from Wakanda, maybe,” adding, “I’ve always wanted to be a superhero, and it’s kind of my way of being a superhero.”53 Health and expression are not mutually exclusive—while noting that she herself had specific problems with blood clots that made wearing pants helpful to keep blood circulation going,54 Williams dedicated the catsuit to “all the moms out there that had a tough pregnancy and have to come back and try to be fierce, in [the] middle of everything. That’s what this represents.”55 The tournament officials responded by imposing a stricter dress code that would exclude such clothing going forward.

Yet even as she has repeatedly faced censure, Serena Williams’s story of rising from humble beginnings through natural talent and hard work fits a particular narrative of the “American Dream,” in which success can be achieved regardless of characteristics such as race, class, and gender.56 This narrative of achieving the American Dream has helped to make Serena Williams’s body ripe for commodification through advertising. Insofar as the success of the Williams sisters has been appropriated by the sport of tennis as symbolic of diversity and progress, it has also been used to let the Women’s Tennis Association “off the hook” for its long-standing and ongoing lack of racial equality in the sport.57

Narrative Return

For Serena Williams, tying her harrowing experience in childbirth to the experiences of other Black women marks something of a narrative return. Early in her career, when their father was a prominent spokesperson, the family often spoke about racism directly, most famously at Indian Wells in 2001, when the sisters were subjected to racial epithets and excessive booing from an angry crowd who suspected their father of match fixing, and went on to sit out that tournament for years.58 As their careers developed, the Williams sisters shifted their focus in their public comments from talking about racism to trying to integrate themselves more—while still donating money to racial justice projects.59

By connecting her childbirth experience to those of other Black women, Serena Williams has come full circle. Whereas throughout her career, she has been in the white elite feminine space of tennis, in childbirth, she was in the white space of medicine. Tennis may be less segregated than it had been, but it has not escaped its elitist legacy. In the medical sphere, remaining exclusions are higher stakes. Many medical practitioners are not white, but they still participate in a structure that is fundamental to white supremacy. Williams’s laboring body has been a resource for the spectacle of sport, but she has striven to maintain agency and voice. Her body in labor, she faced an analogous struggle.

In her voice-over on footage recorded by HBO Sports from the day that her labor was induced, Serena Williams reflected, “It shouldn’t have been scary, going to the hospital to be induced. Or maybe it should have. But the more I think about it, fear has always been valuable in my life. Without fear, without doubt, without discomfort in what we are doing, what is there for any of us to overcome?”60 She put that fear and overcoming into terms of taking on tennis opponents. But why should the experience of childbirth be similarly adversarial? Williams’s husband, Alexis Ohanian, described his fear for her life in the HBO Sports documentary: “She was undoubtedly battling for her life, and I was terrified that she might die. But I was grateful that she had the wherewithal to speak because she knew her body better than any of us.”61

Serena Williams advocating for herself in childbirth and speaking out about her experience thereafter highlights the political quality of Black women insisting on bodily well-being. As the important Black lesbian feminist poet, essayist, and memoirist Audre Lorde has famously argued, “caring for myself is not self-indulgence, it is self-preservation, and that is an act of political warfare.”62 In the contemporary era of the neoliberalization of “self-care,” in which “care” denotes modest indulgences like spa treatments and bubble baths, it is easy to forget that when Lorde wrote her powerful statement, she was struggling with life-threatening liver cancer. Self-care can be life or death.

Within hours of Serena Williams’s Facebook post describing her experience and highlighting the racial disparities in maternal mortality, stories from other women poured in to the comments. Serena Williams was moved, writing, “I’m in tears with all these stories I have almost read every single one of them—and plan on doing so! I’m glad we can speak out about this. Let’s continue to let our voices be heard. That’s the only way we can make change. <3 <3”

There are plenty of things that this kind of articulation leaves out. As important as it is to “let our voices be heard” as we share individual experiences, we can and should question whether that move itself is “the only way to make change.” And yet there is something powerful in the mobilization of social media to share these personal stories, connect them to larger patterns of experience, and demand change. Serena Williams’s sharing of her birth story in this way is an urgent contestation of the biopolitical paradigm that has rendered Black women’s bodies expendable, and it offers an important locus for demanding full citizenship for Black women in both medical and public spheres.

In Serena Williams’s decision to frame her experience along the lines of African American experience, we can see that intersections of race and biomedicine have an open-endedness to their mobilization. On one hand, biomedical ideas of race can be and in many spheres are used to maintain historically entrenched ideas about race—for example, arguing that oppressed racialized groups are somehow inherently and essentially inferior. Yet this is a site in which we can see race in medicine being mobilized in the other direction: to stake a claim to the right to full citizenship and health and to resist race-based injustice. As exceptional as Serena Williams is, her birth story and the dissemination and mobilization of that story on social media and beyond have much to offer for advocacy for reproductive justice.