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On a melancholy Saturday this past February, Shalon Irving's "village" — the friends and family she had assembled to support her as a single mother — gathered at a funeral home in a prosperous black neighborhood in southwest Atlanta to say goodbye. The afternoon light was gray but bright, flooding through tall, arched windows and pouring past white columns, illuminating the flag that covered her casket.

Sprays of callas and roses dotted the room like giant corsages, flanking photos from happier times: Shalon in a slinky maternity dress, sprawled across her couch with her puppy; Shalon, sleepy-eyed and cradling the tiny head of her newborn daughter, Soleil.

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In one portrait, Shalon wore a vibrant smile and the crisp uniform of the Commissioned Corps of the U. Public Health Service, where she had been a lieutenant commander. Many of the mourners were similarly attired. Shalon's father, Samuel, surveyed the rows of somber faces from the lectern. I've never seen so many Ph. At 36, Shalon had been part of their elite ranks — an epidemiologist at the Centers for Disease Control and Prevention, the pre-eminent public health institution in the U. There she had focused on trying to understand how structural inequality, trauma and violence made people sick.

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Much of Shalon's research had focused on how childhood experiences affect health later on — examining how kids' lives went off track, searching for ways to make them more resilient. Her discovery in mid that she was pregnant with her first child had been unexpected and thrilling. Then the unthinkable happened. Three weeks after giving birth, Shalon collapsed and died from complications of high blood pressure. The researcher working to eradicate disparities in health access and outcomes had become a symbol of one of the most troublesome health disparities facing black women in the U.

The main federal agency seeking to understand why so many American women — especially black women — die, or nearly die from complications of pregnancy and childbirth had lost one of its own.

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Even Shalon's many advantages — her B. If a village this powerful hadn't been able to protect her, was any black woman safe? The sadness in the chapel was crushing. Shalon's long-divorced parents had already buried both their sons; she had been their last remaining. Wanda Irving had been especially close to her daughter — role model, traveling companion, emotional touchstone. She sat in the front row in a black suit and veiled hat, her face a portrait of unfathomable grief.

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Sometimes she held Soleil, fussing with her pink blanket. Sometimes Samuel held Soleil, or one of Shalon's friends. A few of Shalon's villagers rose to pay tribute; others sat quietly, poring through their funeral programs.

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Daniel Sellers, Shalon's cousin from Ohio and the baby's godfather, spoke for all of them when he promised Wanda that she would not have to raise her only grandchild alone. This child is a gift to us. When you remember this child, you remember the love that God has pushed down through her for all of us. Soleil is our gift.

The memorial service drew to a close, the bugle strains of taps as plaintive as a howl. Two members of the U. Honor Guard removed the flag from Shalon's coffin and held it aloft. Then they folded it into a precise triangle small enough for Wanda and Samuel to hold next to their hearts.

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In recent years, as high rates of maternal mortality in the U. According to the CDCblack mothers in the U. Put another way, a black woman is 22 percent more likely to die from heart disease than a white woman, 71 percent more likely to perish from cervical cancer, but percent more likely to die from pregnancy- or childbirth-related causes. In a national study of five medical complications that are common causes of maternal death and injury, black women were two to three times more likely to die than white women who had the same condition.

That imbalance has persisted for decades, and in some places, it continues to grow.

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In New York City, for example, black mothers are 12 times more likely to die than white mothers, according to the most recent data ; intheir risk of death was seven times higher. Researchers say that widening gap reflects a dramatic improvement for white women but not for blacks.

The disproportionate toll on African-Americans is the main reason the U. Black expectant and new mothers in the U. What's more, even relatively well-off black women like Shalon Irving die and nearly die at higher rates than whites. Again, New York City offers a startling example: A analysis of five years of data found that black, college-educated mothers who gave birth in local hospitals were more likely to suffer severe complications of pregnancy or childbirth than white women who never graduated from high school.

The fact that someone with Shalon's social and economic advantages is at higher risk highlights how profound the inequities really are, said Raegan McDonald-Mosley, the chief medical director for Planned Parenthood Federation of America, who met her in graduate school at Johns Hopkins University and was one of her closest friends. You can't health care-access your way out of this problem. There's something inherently wrong with the system that's not valuing the lives of black women equally to white women. For much of American history, these types of disparities were largely blamed on blacks' supposed susceptibility to illness — their "mass of imperfections," as one doctor wrote in — and their own behavior.

But now many social scientists and medical researchers agree, the problem isn't race but racism. The systemic problems start with the type of social inequities that Shalon studied — differing access to healthy food and safe drinking water, safe neighborhoods and good schools, decent jobs and reliable transportation.

Black women are more likely to be uninsured outside of pregnancy, when Medicaid kicks in, and thus more likely to start prenatal care later and to lose coverage in the postpartum period. They are more dating services in little rock Irving to have chronic conditions such as obesity, diabetes and hypertension that make having a baby more dangerous. The hospitals where they give birth are often the products of historical segregation, lower in quality than those where white mothers deliver, with ificantly higher rates of life-threatening complications.

Those problems are amplified by unconscious biases that are embedded in the medical system, affecting quality of care in stark and subtle ways.

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In the more than stories of African-American mothers that ProPublica and NPR have collected over the past year, the feeling of being devalued and disrespected by medical providers was a constant theme. There was the new mother in Nebraska with a history of hypertension who couldn't get her doctors to believe she was having a heart attack until she had another one. The young Florida mother-to-be whose breathing problems were blamed on obesity when in fact her lungs were filling with fluid and her heart was failing.

The Arizona mother whose anesthesiologist assumed she smoked marijuana because of the way she did her hair.

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Over and over, black women told of medical providers who equated being African-American with being poor, uneducated, noncompliant and unworthy. Hakima Payne, a mother of nine in Kansas City, Mo. Anything that doesn't fit that identity is suspect," she said.

Payne, who lectures on unconscious bias for professional organizations, recalled "the conversations that took place behind the nurse's station that just made assumptions; a lot of victim-blaming — 'If those people would only do blah, blah, blah, things would be different.

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Chan School of Public Health, 33 percent of black women said that they personally had been discriminated against because of their race when going to a doctor or health clinic, and 21 percent said they have avoided going to a doctor or seeking health care out of concern they would be racially discriminated against. Black expectant and new mothers frequently said that doctors and nurses didn't take their pain seriously — a phenomenon borne out by numerous studies that show pain is often undertreated in black patients for conditions from appendicitis to cancer.

When Patrisse Cullorsa co-founder of the Black Lives Matter movement who has become an activist to improve black maternal carehad an emergency C-section in Los Angeles in Marchthe surgeon "never explained what he was doing to me," she said. The pain medication didn't work: "My mother basically had to scream at the doctors to give me the proper pain meds.

But it's the discrimination that black women experience in the rest of their lives — the double whammy of race and gender — that may ultimately be the most ificant factor in poor maternal outcomes. It's everywhere; it's in the air; it's just affecting everything," said Fleda Mask Jackson, an Atlanta researcher who focuses on birth outcomes for middle-class black women.

It's a type of stress for which education and class provide no protection. It's being followed around when you're shopping at a nice store, or being stopped by the police when you're driving in a nice neighborhood. An expanding field of research shows that the stress of being a black woman in American society can take a physical toll during pregnancy and childbirth.

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Chronic stress "puts the body into overdrive," Lu said. Arline Geronimus, a professor at the University of Michigan School of Public Health, coined the term "weathering" for stress-induced wear and tear on the body. Weathering "causes a lot of different health vulnerabilities and increases susceptibility to infection," she said, "but also early onset of chronic diseases, in particular, hypertension and diabetes" — conditions that disproportionately affect blacks at much younger ages than whites.

Weathering has profound implications for pregnancy, the most physiologically complex and emotionally vulnerable time in a woman's life. Stress has been linked to one of the most common and consequential pregnancy complications, preterm birth.

Black women are 49 percent more likely than whites to deliver prematurely and, closely related, black infants are twice as likely as white babies to die before their first birthday. Here again, income and education aren't protective. The repercussions for the mother's health are also far-reaching. Maternal age is an important risk factor for many severe complications, including pre-eclampsia, or pregnancy-induced hypertension.

This means that for black women, the risks for pregnancy start at an earlier age than many clinicians — and women— realize, and the effects on their bodies may be much greater than for white women. In Geronimus' view, "a black woman of any social class, as early as her mids should be attended to differently. That's a concept that professional organizations and providers have barely begun to wrap their he around.

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Should doctors and clinicians be taking into this added layer of vulnerability? Shalon Irving's history is almost a textbook example of the kinds of strains and stresses that make high-achieving black women vulnerable to poor health. The child of two Dartmouth graduates, she grew up in Portland, Ore.

Even in its current liberal incarnation, Portland is one of the whitest large cities in the U. Thirty years ago, Portland was a much more uncomfortable place to be black. African-American life there was often characterized by social isolation, which Geronimus' research has shown to be especially stressful.