In my 20 years as a birth doula, I can attest to the effects of stress on pregnant women and how it can affect the birthing process. As I’ve researched the birthing process and its outcomes, specifically for women of color, it is clear to me that this population may be disproportionately impacted and that the presence of a supportive person during birth can greatly reduce pain levels and stress experienced by laboring mothers, resulting in better birth experiences—even in cases involving serious complications. How fascinating then to take what we know about stress and pregnancy and healthy touch and look at them through the lens of systemic racism and its potential stressful impact on the health of Black women in the US during pregnancy and childbirth. My argument follows.
According to the Centers for Disease Control and Prevention (CDC), African-American women are three to four times more likely to die from pregnancy-related complications (such as hypertension and eclampsia) than white American women—and African-American infants are also twice as likely to die than white infants in the US.1 African-American infant deaths are up to 11.3 per 1,000, compared with 4.9 per 1,000 for white infants in the US—a racial disparity that is greater than it was in 1850.2 Studies also show that African-American women with advanced degrees and higher socioeconomic status are not protected from these outcomes and are still “more likely to lose [their] baby than a white woman with an eighth-grade education.”3
Contributors to high infant and maternal mortality rates among African-Americans are the effects of hypertension (physiological) and anxiety (psychosocial) as a result of daily stress. These effects can be attributed to early deliveries and low birth weight—both key drivers of infant mortality.4 Since we know that stress can contribute to conditions that result in maternal and infant mortality, let’s consider how massage therapy might mitigate its impact.
A State of Constant Stress
Stress (either physiological or biological) is “any environmental or physical pressure that elicits a response from an organism,”5 and it is the “environmental demands that tax or exceed the adaptive capacity of an organism . . . that may place the organism at risk for disease.”6 When the sympathetic nervous system is triggered, stress often takes the body out of its internal equilibrium (homeostasis), transitions to a state of “fight or flight,”7 and sends signals to the adrenal medulla to release hormones (one of which is cortisol) that increase blood pressure and blood sugar and suppress the immune system.
This elevated response is characterized as the “alarm” stage—the first of three physiological stages that are part of the General Adaption Syndrome (GAS) developed by Hans Selye.8
GAS, a widely accepted model used for measuring long-term exposure to stress, characterizes three phases of response: alarm, resistance, and exhaustion. After the initial alarm stage, the resistance phase (known as the healing phase) is where the body begins to reduce cortisol and adrenaline, thereby reducing heart rate and blood pressure. Ideally, this allows the body to settle back into homeostasis. When we are under constant stress, however, our bodies remain in a state of high alert characterized by elevated levels of cortisol. This becomes the new normal. Observed behaviors attributed to the resistance phase include irritability, poor concentration, and frustration.9
The last phase—exhaustion—is considered the chronic phase, where one no longer has the ability to fight and overcome stress. The individual’s emotional, mental, and physical resources are depleted, and it is at this phase that those who live or work in stressful environments are more likely to suffer pathophysiological complications that can have life-threatening effects.10
Racism-Related Stress
For many years, the medical community attributed African-American infant mortality to poor nutrition and prenatal care predicted by socioeconomic status, as well as to risky health behaviors such as drinking and drug use. These perspectives, however, did not account for the infant mortality rate among Black women with a high socioeconomic status. Looking for additional contributing factors beyond economics, poor health, or a lack of prenatal care, researchers began identifying stress as an indicator of infant mortality in the Black community—and racism as a factor of that stress.11
When examining racism-related stress, researchers note that chronic stress begins in childhood as African-American parents begin educating their children about racism, trying to “arm” them by fostering ethnic pride and preparing them for the “horror and injustice” to come.12 Although the intent is to protect and allow children to cope with life in the US, one study found that the intended life lesson sets off a heightened alarm, or hyperarousal. The child’s “sense of security and emotional stability is dependent on the parents’ well-being,”13 and the perceived threat to security and safety inadvertently activates the chronic phase of stress, resulting in a negative physical and mental outcome.
The impact of societal and systemic racism continues into adulthood. In 2002, researchers argued that exposure to highly threatening situations in childhood may generate stress-induced emotional and physiological changes that have long-range mental and physical health consequences.14 In addition, findings from studies on lifetime perceived racism suggest that the accumulation of racism-related stress across the life course should also be considered.15
It was US public health researcher Arline Geronimus who proposed the “weathering hypothesis,” which looked at the effects of anticipating and managing the idea of racism. Her 2006 study found that racism increases stress levels, and one manifestation of this effect is the increase in infant and maternal deaths among African-American women in the US.16
Homing in on racism’s impact in the US, Tiffany Green found that Black women who immigrated to America—and were not raised in an environment of racism—had better birth outcomes than African-American women born in the US, as well as the same distribution of birth weights as white women born in the US.17
Another study, conducted in Illinois over a 15-year period, looked at gene mutation to see if it played a role in low birth-weight differential outcomes across US-born white women, US-born Black women, and African-born Black women. The hypothesis of the low birth-weight study assumed that due to the fact that “African-American women have significant European genetic admixture,” women who were born in Africa would have the lowest birth-weight outcomes compared to the Black or white women born in the US.18 But the results of the study determined quite the opposite. After 15 years of data collection, researchers found that both US-born white women and African-born Black women had the same overall birth-weight distribution—even after “appropriate confounders were controlled.” African-American women, however, had the lowest birth weights, with infants often weighing hundreds of grams less than the other groups.
Furthering this line of inquiry, a similar study (using the Illinois data) looked at birth-weight outcomes for Caribbean-born Black women versus African-born Black women who immigrated to the US, and the results were similar. The Black Caribbean immigrants delivered babies that were hundreds of grams heavier than infants born to African-American women.19
So why this anomaly for African-American mothers and their newborns?
Stress and Hypertension
When we feel unsafe (physically, emotionally, or mentally), the body’s sympathetic response activates and releases cortisol. This key hormone has the ability to increase blood pressure levels by directing various blood vessels to dilate or contract to either increase pressure, or to manipulate the myocardial mechanism to increase the heart and stroke volume. This process enhances the blood flow to muscles, enabling them to function at a heightened level for self-preservation.20 It is when this process doesn’t normalize, that the body can become prone to disease.
Complications that arise due to hypertension are the leading cause of US infant and maternal mortality rates across all races. Common complications include:
• Preeclampsia—a condition of pregnancy that includes high blood pressure, usually presenting around the 20th week of pregnancy (or after birth) and indicates that the liver and kidneys are not working normally. Preeclampsia is the cause of 15 percent of premature births.
• Premature birth—babies born before 37 weeks.
• Low birth weight—often a result of premature birth, low birth weight refers to babies that weigh less than 5 pounds, 8 ounces.
• Placental abruption—when the placenta partially separates from the wall of the uterus before birth, often resulting in growth problems, premature birth, and stillbirth.
• HELLP syndrome—a serious pregnancy complication that affects the blood and liver due to breakdown of red blood cells that carry oxygen from the lungs to the rest of the body, elevated liver enzymes that can be an indication of liver problems, or low platelets—tiny fragments of blood cells that help form clots to stop bleeding.21
Stress and Blood Pressure During Pregnancy
A 2008 study of 170 pregnant white and African-American women looked to see whether there were racial differences associated with stress and blood pressure, including the combined effects on infant birth weight.22 Many measures and parameters were put into place, including the general societal percentage of hypertension among Black versus white American women. The study took into account both systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurements and how each number was affected based on the combination of stressors for both African-American and white women on study entry.
Results found that both elevated SBP and DBP were associated with stress for African-American pregnant women but not white American women. When looking at elevated stress and blood pressure as separate influences on birth weight, though, it was noted that white women had higher birth weights. When looking at birth weight and high stress levels, DBP had a negative association. These results indicated that the higher the DBP, the greater the predictor of the lowest birth weight. The research also noted that Black American women are twice as likely to suffer from the combination of higher stress and DBP than white American women, or any other racial groups. It was concluded that racism was a “uniquely salient psychosocial stressor.”23
Differentiating Physiological from Racial Stress
Two separate studies focused on differentiating physiological stress from racial stress among pregnant women to see if there was an effect on birth outcomes in weight and gestational age. “Very Low Birthweight in African American Infants: The Role of Maternal Exposure to Interpersonal Racial Discrimination” (2004) looked at 312 Black women over a three-year period to identify any mitigating factors to determine why some Black women suffered preterm deliveries resulting in very low birth weight for their babies, on average 3.3 pounds, while others were able to carry their babies to full terms with an average weight of 5.5 pounds or greater. Researchers concluded that the frequency of perceived encounters of racism over the span of the woman’s lifetime “constitutes an independent risk factor for preterm delivery” resulting in very low birth weight.24
“Racial Differences in Birth Outcomes: The Role of General, Pregnancy, and Racism Stress” (2008) included a sample of 51 pregnant African-American women and 73 pregnant non-Hispanic white women, with both groups holding a college degree or higher and earning a higher income than the general population of their corresponding groups. The results indicated that Black Americans had a less favorable birth outcome than the non-Hispanic whites.25
Although there were earlier studies on perceived racism, the researchers claimed that (to their knowledge) no research had been done that focused on a lifetime of perceived racism experienced—or vicariously experienced—from childhood through to adulthood.26 These studies concluded that this lifelong struggle created an “independent risk factor for preterm delivery” and could be used to predict birth weight in African-Americans once the medical and sociodemographic risk factors had been considered.27
Massage and Stress Reduction
Reliable double-blind studies on the efficacy of massage are rare due to the complexities of attributing cause and effect to human touch. Studies that do exist tend to use a small sample size, and very few look at ethnic race and the use of complementary and alternative medicine. No studies, to date, focus specifically on the effects of massage and racial stress. Smaller studies suggest, however, that massage has a real and measurable impact on our overall parasympathetic systems by increasing relaxation, lowering blood pressure, and calming the central nervous system. Some notable studies to consider in this area include:
Stress Relief with Trigger Point Therapy
A 2002 study was conducted to look at trigger point therapy on the head and shoulder area in healthy clients. Researchers wanted to assess areas that were easily accessible to nurses to incorporate into their normal care protocol. The study was conducted on 30 healthy individuals (both male and female; all about the same age), at similar overall emotional and physical states. Measurements taken before and after trigger point therapy showed an increased parasympathetic nervous system response with a decrease in heart rate and blood pressure, and an increase in internal autonomic body functions, often referred to as the system that allows us to rest and digest.28
Effects of Heat and Massage on the Autonomic Nervous System
In 2011, researchers looked at the effects of heat and massage on the autonomic nervous system. Major factors being tested were heart rate variability, cortisol and norepinephrine hormones, and sympathetic skin response.
At the end of the two-week study period, a significant reduction in the clients’ serum cortisol levels was observed. At four weeks, a significant decrease in norepinephrine levels—neurotransmitters of the sympathetic nervous system responsible for increased heart rate, glucose levels, and blood flow to the skeletal system—was found, suggesting an overall reduction of sympathetic activity and a reduction in overall stress.29
Effects of Swedish Massage on Hypertension
In 2013, a single-blind US clinical trial examined the effects of Swedish massage on the reduction of hypertension in 50 female participants who were diagnosed with pre-hypertension. The study focused on creating a relaxing environment for all participants for the same frequency and duration—three times a week for 10 weeks. Of the 50 recipients, 25 received an extra 10–15 minutes of relaxing Swedish massage. Results indicated that the participants who received the additional massage component experienced positive effects of lowered blood pressure for up to 72 hours post massage.30
Swedish Massage Versus Resting
A separate study, in Malaysia, examined the correlation of a full-body Swedish massage versus resting one hour per week and its effects on stress and hypertension. Although both Swedish massage and rest resulted in significant reductions in blood pressure, anxiety, and heart rates, results showed that the effects of Swedish massage lasted up to four weeks and reduced the heart rate of hypertensive participants.31
Effects of Massage on Biochemistry
The International Journal of Neuroscience published a review of research studies that focused on the effects of massage therapy in relation to biochemistry, with an emphasis on its effects on decreased levels of cortisol and increased levels of serotonin and dopamine, in relation to medical conditions and stressful experiences.
The measurable component of the studies reviewed were urine and saliva samples, with data from combined samples showing an average decrease of 31 percent in cortisol levels; when studies evaluated parasympathetic neurotransmitters in urine, there was an increase in both serotonin (28 percent) and dopamine (31 percent).32 Studies seem to indicate that massage may reduce sympathetic hormones (like cortisol) while simultaneously increasing parasympathetic hormones (such as serotonin and dopamine), which contribute to the reduction of stress, pain, trauma, and disease.
Discussion
African-American women are at the highest risk for maternal mortality in the US, and their babies are the most susceptible to infant mortality. A key risk factor for maternal and infant mortality among this population is hypertension, and it is my belief that significant contributors to this condition are related to chronic racial stress. Stress is increasingly seen as one of the major risk factors for the leading diseases we face today, including anxiety, cancer, depression, diabetes, gastrointestinal issues, headaches, heart disease, and now eclampsia, preeclampsia, and preterm labor.
Although additional research is needed, an accumulation of studies suggests that massage can play a role in the fight against disease by supporting the healing effects on the autonomic systems in the body. Through massage, we may be able to reduce the fight-or-flight sympathetic hormones (such as cortisol), and possibly increase the parasympathetic hormones that allow us to feel happy, calm, and relaxed (such as dopamine and serotonin). As a result, pregnant African-American women and their babies may benefit from prenatal massage to increase their chances of a healthy, full-term delivery. It’s a line of inquiry I challenge us in the field of manual therapies to pursue.
Notes
1. Centers for Disease Control and Prevention, “Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States,” November 14, 2017, accessed October 2020, www.cdc.gov/grand-rounds/pp/2017/20171114-maternal-mortality.html; CDC, “Infant Mortality,” reviewed October 2020, accessed October 2020, www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm.
2. Linda Villarosa, “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis,” New York Times Magazine, April 11, 2018, accessed October 2020, www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html.
3. Richard V. Reeves and Dayna Bowen Matthew, “6 Charts Showing Race Gaps within the American Middle Class,” Social Mobility Memos, October 21, 2016, accessed October 2020, www.brookings.edu/blog/social-mobility-memos/2016/10/21/6-charts-showing-race-gaps-within-the-american-middle-class.
4. Clayton J. Hilmert et al., “Stress and Blood Pressure During Pregnancy: Racial Differences and Associations with Birthweight,” Psychosomatic Medicine 70, no. 1 (January 2008): 57–64, https://doi.org/10.1097/PSY.0b013e31815c6d96.
5. Editors of Encyclopaedia Britannica, “Stress: Psychology and Biology,” in Encyclopaedia Britannica (Chicago: Encyclopaedia Britannica, 2020), www.britannica.com/science/stress-psychology-and-biology.
6. S. Cohen, R.C. Kessler, and L. Gordon, “Strategies for Measuring Stress in Studies of Psychiatric and Physical Disorders,” in Measuring Stress: A Guide for Health and Social Scientists, eds. S. Cohen, R.C. Kessler, and L. Gordon (New York: Oxford University Press, 1995): 3–26.
7. Neil Schneiderman, Gail Ironson, and Scott D. Siegel, “Stress and Health: Psychological, Behavioral, and Biological Determinants,” Annual Review of Clinical Psychology 1 (2005): 607–28, https://doi.org/10.1146/annurev.clinpsy.1.102803.144141.
8. Valencia Higuera, “What is General Adaptation Syndrome?,” Healthline, updated October 6, 2008, accessed September 21, 2020, www.healthline.com/health/general-adaptation-syndrome#model.
9. Habib Yaribeygi et al., “The Impact of Stress on Body Function: A Review,” EXCLI Journal 16 (July 2017): 1057–72, https://doi.org/10.17179/excli2017-480.
10. “Exhaustion Stage of Stress: Psychology Overview,” Study.com, January 5, 2016, accessed October 2020, www.study.com/academy/lesson/exhaustion-stage-of-stress-psychology-lesson-quiz.html.
11. Jamila Taylor et al., “Eliminating Racial Disparities in Maternal and Infant Mortality: A Comprehensive Policy Blueprint,” Center for American Progress, May 2, 2019, accessed October 2020, www.americanprogress.org/issues/women/reports/2019/05/02/469186/eliminating-racial-disparities-maternal-infant-mortality.
12. Diane Hughes et al., “Parents’ Ethnic-Racial Socialization Practices: A Review of Research and Directions for Future Study,” Developmental Psychology 42, no. 5 (September 2006): 747–70, https://doi.org/10.1037/0012-1649.42.5.747.
13. L. Allen Sroufe, “Attachment: The Dyadic Regulation of Emotion,” in Emotional Development, ed. A. Sroufe (New York: Cambridge University Press, 1996): 172–191.
14. Rena L. Repetti, Shelley E. Taylor, and Teresa E. Seeman, “Risky Families: Family Social Environments and the Mental and Physical Health of Offspring,” Psychological Bulletin 128, no. 2 (March 2002): 330–66.
15. Tyan Parker Dominguez et al., “Racial Differences in Birth Outcomes: The Role of General, Pregnancy, and Racism Stress,” Health Psychology 27, no. 2 (May 2010): 194–203, https://doi.org/10.1037/0278-6133.27.2.194.
16. Arline T. Geronimus et al., “ ‘Weathering’ and Age Patterns of Allostatic Load Scores Among Blacks and Whites in the United States,” American Journal of Public Health 96, no. 5 (May 2006): 826–33, https://doi.org.10.2105/AJPH.2004.060749.
17. Tiffany L. Green, Black and Immigrant: Exploring the Effects of Ethnicity and Foreign-Born Status on Infant Health (Washington: Migration Policy Institute, 2012), www.migrationpolicy.org/research/CBI-infant-health.
18. Richard J. David and James W. Collins, Jr., “Differing Birthweight Among Infants of US-Born Blacks, African-Born Blacks, and US-Born Whites,” New England Journal of Medicine 337 (October 1997): 1209–14, www.nejm.org/doi/full/10.1056/NEJM199710233371706#:~:text=Results,black%20women%20was%203089%20g.
19. Eugenia K. Pallotto, James W. Collins, Jr., and Richard J. David, “Enigma of Maternal Race and Infant Birth Weight: A Population-Based Study of US-Born Black and Caribbean-Born Black Women,” American Journal of Epidemiology 151, no. 11 (June 2000): 1,080–85, https://doi.org/10.1093/oxfordjournals.aje.a010151.
20. Neil Schneiderman, Gail Ironson, and Scott D. Siegel, “Stress and Health: Psychological, Behavioral, and Biological Determinants.”
21. “High Blood Pressure During Pregnancy,” March of Dimes, reviewed February 2019, accessed October 2020, www.marchofdimes.org/complications/high-blood-pressure-during-pregnancy.aspx.
22. Clayton J. Hilmert et al., “Stress and Blood Pressure During Pregnancy: Racial Differences and Associations with Birthweight.”
23. Clayton J. Hilmert et al., “Stress and Blood Pressure During Pregnancy: Racial Differences and Associations with Birthweight.”
24. James W. Collins, Jr. et al., “Very Low Birthweight in African American Infants: The Role of Maternal Exposure to Interpersonal Racial Discrimination,” American Journal of Public Health 94 (December 2004): 2132–38, https://doi.org.10.2105/ajph.94.12.2132.
25. Tyan Parker Dominguez et al., “Racial Differences in Birth Outcomes: The Role of General, Pregnancy, and Racism Stress,” Health Psychology 27, no. 2 (March 2008): 194–203, https://doi.org/10.1037/0278-6133.27.2.194.
26. James W. Collins, Jr. et al., “Very Low Birthweight in African American Infants: The Role of Maternal Exposure to Interpersonal Racial Discrimination.”
27. Tyan Parker Dominguez et al., “Racial Differences in Birth Outcomes: The Role of General, Pregnancy, and Racism Stress.”
28. Joseph P. A. Delaney et al., “The Short-Term Effects of Myofascial Trigger Point Massage Therapy on Cardiac Autonomic Tone in Healthy Subjects,” Journal of Advanced Nursing 37, no. 4 (February 2002): 364–71, https://doi.org/10.1046/j.1365-2648.2002.02103.x.
29. Young-Hee Lee, Bit Na Ri Park, and Sung Hoon Kim, “The Effects of Heat and Massage Application on Autonomic Nervous System,” Yonsei Medical Journal 52, no. 6 (November 2011): 982–89, https://doi.org/10.3349/ymj.2011.52.6.982.
30. Mahshid Givi et al., “Long-Term Effect of Massage Therapy on Blood Pressure in Prehypertensive Women,” Journal of Education and Health Promotion 7 (April 2018): 54, www.ncbi.nlm.nih.gov/pmc/articles/PMC5903169/.
31. Izreen Supa’at et al., “Effects of Swedish Massage Therapy on Blood Pressure, Heart Rate, and Inflammatory Markers in Hypertensive Women,” Evidence-Based Complementary and Alternative Medicine (August 2013), https://doi.org/10.1155/2013/171852.
32. Tiffany Field et al., “Cortisol Decreases and Serotonin and Dopamine Increase Following Massage Therapy,” International Journal of Neuroscience 115, no. 10 (November 2004): 1397–1413, https://doi.org/10.1080/00207450590956459.
Machelle Varma, LMT, owns a 60-acre farm in Sherwood, Oregon, where she started an organic co-op—Our Table Cooperative—and will soon have a Pilates and massage studio called InnerConnections on the property with a focus on women’s health and empowerment. A professionally trained dancer, Varma’s fascination with the mental, physical, and energetic connection of movement and its influence on health and well-being, along with the experience of birthing her first child, led her to becoming a birth doula in 2000, a certified Pilates instructor in 2006, and a licensed massage therapist in 2020. Contact her at machelle@innerconnectionspdx.com.