Considered one of the greatest tennis players of all time, Serena Williams found herself fighting for much more than Grand Slams after complications from her recent pregnancy left her bed ridden for nearly a month. Scarier yet, it could have been much worse. It was only after Serena repeatedly advocated for herself with hospital staff that she they gave her the treatment that saved her life.  As detailed in an interview with Vogue last month:

The next day, while recovering in the hospital, Serena suddenly felt short of breath. Because of her history of blood clots, and because she was off her daily anticoagulant regimen due to the recent surgery, she immediately assumed she was having another pulmonary embolism. (Serena lives in fear of blood clots.) She walked out of the hospital room so her mother wouldn’t worry and told the nearest nurse, between gasps, that she needed a CT scan with contrast and IV heparin (a blood thinner) right away. The nurse thought her pain medicine might be making her confused. But Serena insisted, and soon enough a doctor was performing an ultrasound of her legs. “I was like, a Doppler? I told you, I need a CT scan and a heparin drip,” she remembers telling the team. The ultrasound revealed nothing, so they sent her for the CT, and sure enough, several small blood clots had settled in her lungs. Minutes later she was on the drip. “I was like, listen to Dr. Williams!”

So how did a well-known, extremely successful, wealthy, and smart black woman (who is also married to a major player in Silicon Valley) end up being overlooked by hospital staff? Unfortunately, this story is not new, especially for women of color. Women of color and their children are at a much higher risk for maternal and infant mortality in the United States. Research reveals shocking details about the United States’ either inability or unwillingness to give women of color the same level of care as their white counterparts.  According to the CDC, from 2011-2013, white women experienced 12.7 deaths per 100,000 live births while black women experienced a rate 3.5 times higher, at 43.5 deaths per 100,000 live births. So what is happening?

Serena Williams experience can give us some clues. After being sidelined in 2010 for nearly a year with a pulmonary embolism, which is when blood clots from the legs travel to the lungs, Williams has been on a prolonged therapy of blood-thinners. Since she is a professional athlete and understanding her body in detail is part of her job, it’s safe to say that Williams and her training staff were aware of the symptoms of blood clots and the drug therapy she’s been using for nearly 8 years. Williams saved her life because she repeatedly advocated for her own well-being. As Megan Bayer, a licensed lactation consultant and 14 year nursing veteran discussed with us, being an advocate for yourself is key. “Serena is a woman who knows how to advocate for herself and that probably did save her life. We don’t really teach women and even patients on the whole how to advocate for themselves always. They don’t know what to ask for…you just expect there is a trained professional who has your best interest in mind.”

Yet, women advocating for themselves is nothing compared to what reasonable, systemic changes to the medical system could do for women of color. Activist Maddy Oden, whose daughter Tatia Oden French and granddaughter Zorah died due to the off-label use of the drug Cytotec (a drug used to prevent stomach ulcers) is currently fighting for mandatory informed consent for all drugs used in childbirth and the passage of two maternal health bills in Congress. As Oden’s mother describes, Tatia felt pressured by the medical staff and confused as to what was happening. “[The medical staff] had put so much pressure on her, they even said, ‘well, you  don’t want to go home with a dead baby, do you?'”

In many medical situations, women of color feel pressured, disregarded, and misinformed about the treatments they are receiving or the potential side effects of those choices. And it is not getting any better. Since 1987 the maternal mortality rate has increased by nearly 2.5 times; and that is only the deaths that get reported. A 2005 study done by Dr. Isabelle L. Horon found that 38% of maternal deaths go unreported, primarily because physicians completing death certificates do not accurately report if the woman was pregnant or had a recent pregnancy. She also found that analyzing the medical examiners reports and linking death records of women of reproductive ages with birth and fetal death records offers a better representation of the maternal death rate.

Women in the United States also have a much higher infant mortality than other developed nations. We rank 55^th in the world, just behind Serbia and Bosnia-Herzgovinia. This is partially because women in the United States receive much worse care after leaving the hospital. In 2014, the Washington Post reported that while babies in the first few weeks of life has reduced infant mortality rates on par with other developed nations, those number rose dramatically after leaving the hospital. This can be due to a number of factors, but boils down to access to healthcare, poverty, and inequality. As the Post reported, “To put it bluntly, babies born to poor moms in the U.S. are significantly more likely to die in their first year than babies born to wealthier moms.” In short, how wealthy you are determines, in part, how likely your child is to live through the first year of life. This risk is even further increased if you are a black woman. According to the U.S. Department of Health and Human Services, non-Hispanic black women have infant mortality rates at twice the rate of their white counterparts. They are also twice as likely not to receive prenatal care and their children are 3 ½ times more likely to die from complications due to low birthweight.

In addition, black women and women of color have societal pressures and daily microaggressions that affect their stress levels and ability to have a healthy birth.As Bayer notes, “The stunning thing is that if you look at college educated white women and college educated black women, the infant mortality rate is still double.”In a 2017 interview with NBC news, neonatologist Terry Lynn Major-Kincade discussed a recent study that asked pregnant women what their biggest fear was during pregnancy;

“Caucasian women said gaining weight and having a healthy child. Do you know how African-American women responded? Fear of bringing their child into this world. Fear that their son may be killed because of the color of his skin. When I shared this with obstetricians, they were shocked. How many are screening for that type of chronic stress during the visit? What are the effects of that type of chronic stress during the entire pregnancy?”

This reality is certainly not lost on Serena Williams. When her and her sister, Venus, appeared on the world tennis stage, they forever changed the sport.  Historically rooted in the white middle and upper classes of England, tennis was an undeniably stuffy, aristocratic, quiet game of well-to-do citizens in their back yards. There were pioneers; Arthur Ashe won 3 Grand Slam Titles in the 1960’s and 70’s. Althea Gibson was the only African-American woman to win a Grand Slam, a streak Serena Williams broke 48 years later. The Williams sisters were from the notoriously tough neighborhood of Compton, California, their father was outspoken, and they were teenagers beating players ten years their senior with confidence. Throughout their career, they endured racist behavior from fans, journalists, referees, and even other players. In the 2001 Indian Wells Tournament, fans relentlessly booed the sisters, cheered for double faults, yelled racial epithets, and threatened their father’s life. The tournament directors and referee did nothing. In return, the Williams family boycotted the tournament for 15 years.  In a 2015 New York Times piece, journalist Ben Rothenberg reported that other professional female tennis players considered “bulking up” like Williams, but chose not to because they wanted a more feminine body. “Her rivals could try to emulate her physique, but most of them choose not to.” She isn’t feminine enough; she looks like a man; she is just stronger than everyone else. These critiques either erase her femininity or disregard her talent because of her physique. It is implicit bias at its best. Rather than explicit comments or jeers at tournaments, this reporter framed his argument around unconscious biases that he has learned from society, the media, television, and American culture more broadly. Implicit bias could very well be why Serena Williams was also ignored at the hospital. The same could likely be said for Tatia Oden French.

These are not new stories. It is simply that we have not heard them or have not cared enough to listen. Yet, in the face of heightened mental, physical, and emotional pressure, Serena has kept fighting. She is the only player to win 3 Grand Slam Titles after saving match point. She has won 23 Grand Slams, and 13 of them after her 30^th birthday. That doesn’t mean issues of race and gender do not affect her. In a FaceBook post from 2016, she describes being pulled over while her nephew, who is black, was driving her to work.

Then I remembered that horrible video of the woman in the car when a cop shot her boyfriend. All of this went through my mind in a matter of seconds. I even regretted not driving myself. I would never forgive myself if something happened to my nephew. He’s so innocent. So were all “the others”

I am a total believer that not “everyone” is bad It is just the ones that are ignorant, afraid, uneducated, and insensitive that is affecting millions and millions of lives.

Why did I have to think about this in 2016? Have we not gone through enough, opened so many doors, impacted billions of lives? But I realized we must stride on- for it’s not how far we have come but how much further still we have to go.

I than wondered than have I spoken up? I had to take a look at me. What about my nephews? What if I have a son and what about my daughters.”

The fear of prejudice, of how she would react or talk with her own children about issues of race and police brutality were on her mind months before she got pregnant with her own daughter. No doubt they are on her mind now. What we can be grateful for is that Williams is alive to see her daughter through those challenges in every way she can. All women deserve to have healthy pregnancies, both pre- and post-delivery. All women deserve a healthcare system that cares for them and their children equally and without bias. Improving our society requires an honest assessment of its systems. What happened to Williams, Tatia Oden French, and the countless women of color who have died or nearly died when giving birth, needs to stop.