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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. 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 74 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 2 0 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 In

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