Reproductive Injustice: Racism, Pregnancy, and Premature Births. Dana—Ain Davis, New York: NYU Press, 2019. 272 pp.
Reproductive Injustice is a brilliant investigation of racial disparities in premature birth rates. Davis’s ethnographic exploration of the fact that black women in the United States are two times more likely than white women to give birth prematurely leads her to a range of sites: labor and delivery wards, neonatal intensive care units, the offices of the March of Dimes, the homes of women who recounted their experiences with giving birth to preterm infants, and historical archives housing the narratives of enslaved women, among many others. The result is a “deterritorialized ethnographic inquiry” (p. 21) that analyzes its subject from a variety of angles, providing an exceedingly nuanced view of a multifaceted problem.
Davis is forthright that she understands racial disparities in premature birth rates to be a problem not of race, but rather of racism. She is clear in her rejection of the claim that higher premature birth rates among black women can be attributed to some pre-social racial biology that predisposes black women and their infants to poor birth outcomes. Rather, she approaches the phenomenon of racial disparities in premature birth rates as a consequence of “medical racism.” In Davis’s rendering, medical racism is much more than inferior treatment that an individual healthcare provider offers her black patients—although it is definitely that. (Indeed, in many of the narratives of preterm births that Davis recounts, either Davis or her subject suggests that the prematurity of the birth can be traced back to poor health care offered by an identifiable individual provider.) For Davis, medical racism is also institutional and structural. It “includes the sometimes subtle and sometimes not-so-subtle ways in which the medical complex, in each of its parts, cumulatively dismisses, misdiagnoses, and undermines women’s feelings and intuitions about their reproducing bodies and, more specifically, disproportionately undermines Black women’s reproduction” (p. xv). Thus, Davis’s conceptualization of medical racism is complex. The consequences of this complexity are illuminating. Attending to it allows Davis to go beyond searching for the bad actor who acts badly and, in so doing, is responsible for a black woman’s preterm delivery. Instead, Davis’s rendering of medical racism allows her to look at the systems, discourses, policies, and practices that, in concert, lead black women to have higher rates of negative birth outcomes.
Another central framing of the book is the “afterlife of slavery,” which posits that racial disparities in health—as well as the overincarceration of black people, the disproportionate indigence that black people bear, and the shorter lives that black people can expect to live relative to their white counterparts—are continuances from the days of chattel slavery. This is more than the claim that racial disparities in premature birth rates have persisted over time since the antebellum period. (Although this is also true.) Viewing racial disparities in premature birth rates within the framework of the afterlife of slavery is to affirm that the “dystopian past is not just the past,” but rather that it “inhabits present practices, including the practice of medicine” (p. 13). As such, Davis searches for—and finds—remnants of 17th-, 18th-, and 19th-century racial thinking in present-day thought. Thus, Davis gives the lie to the assertion that we have evolved past the bad old days of yesteryear, when racism and bigotry foiled our attempts at scientific objectivity and perverted the claims that science made. Devastatingly, Davis demonstrates that the past endures.
One of the most important interventions that Davis makes is to underscore that racial disparities in preterm birth rates are not simply an issue of class. There is a widespread tendency to believe that the rates at which black women give birth to preterm babies simply reflect the disproportionate indigence that black people bear. This (mis)understanding of the problem proposes that black women are more likely to give birth prematurely because they are poor. But Davis emphasizes that racial disparities in premature birth rates persist across socioeconomic status. That is, class-privileged black women give birth to preterm babies at higher rates than class-privileged white women. Indeed, the class privilege that wealthier black women enjoy cannot insulate them from the deleterious effects of their lack of racial privilege.
As Davis writes, “To believe that one’s educational attainment and insurance coverage will serve as a protective mechanism against adverse birth outcomes in an anti-Black society is ideological pablum and offers a false sense of security” (p. 202). Thus, Davis importantly stresses that race matters, independent of class. Moreover, her interviews with health care providers and others thinking about the problem of racial disparities in premature birth rates show that most of these actors insist on conceptualizing the issue as one that is fundamentally about class—even though they undoubtedly are familiar with the evidence that demonstrates that premature birth rates cannot be understood fully in those terms. In this way, Davis shows the deep discomfort that her interlocutors felt when it came to thinking and talking about race. Indeed, class was the language that they used to talk about a racial problem—although the use of the language of class obscures the nature of the problem that it purports to describe. Davis offers the concept of racial refusal to index this phenomenon. She proposes that racial refusal—i.e., declining to talk about race—is not at all benign, operating both to “render prematurity raceless” and to “justif[y] a particular ordering of society” in which white people’s superior health outcomes and black people’s inferior health outcomes go unproblematized (p. 88). Conceptual gems like the idea of racial refusal can be found throughout the book.
Although Reproductive Injustice is theoretically sophisticated, it is also highly readable. As such, it can be assigned in introductory courses in cultural anthropology and medical anthropology. Indeed, the book can be put to good use in courses outside of anthropology departments—in classes exploring questions around public health, race and racism, and women and gender. As anthropologists, we should hope that Reproductive Injustice finds audiences outside of the academy, as it is an excellent example of the continuing relevance of the discipline, generally—and ethnography, specifically—in contemporary conversations about race in the United States.