Feature: How Harvey Karp Turned Baby Sleep Into Big Business

While filming it in 2002, Karp, then a pediatrician in Santa Monica with a growing reputation, had asked his patients to call him whenever their child was having a crying fit. He then drove across town to record the encounters — effectively making house calls for screaming babies. Montée, a documentary filmmaker, worked the camera. The result has a zany, homemade quality. Over and over again, Karp is seen swaddling, handling and shushing babies into submission while talking to the camera in a voice so hypnotic it could be trademarked. One exhausted-looking father praised Karp for turning his crying daughter “to Jell-O.” It wasn’t exactly revolutionary, but his method was built on fast, practical tips that, well, worked. So we clung to them, feeling a little sheepish to be following a parenting expert so literally.

Birndorf told Karp that a pediatrician had recently visited the center and suggested that babies not be put to sleep on nursing pillows or on bouncing chairs — a reversal of previous pediatric guidelines. The advice of parenting experts — many but not all of whom are doctors — kept changing, she complained. The contradictions she recounted, from conveying to women that motherhood is a natural state to instructing them on exactly how and where their babies should sleep, all while nullifying earlier recommendations, seemed to get at an inherent paradox at the heart of a profession whose stated goal is to empower parents. “Highlights from 100 years of expert solicitude confirm the dirty little secret of child rearing: Though parenting gurus preach the supreme importance of consistency, their own shifting wisdom is proof of its impossibility,” Ann Hulbert, the author of “Raising America” (2003), a sweeping history of child-rearing advice, wrote in this magazine.

Karp nodded at Birndorf sympathetically. That he is one of those gurus, peddling parenting products, didn’t seem to discomfit him. Whenever someone points out the hypocrisies of today’s parenting industry, which happens often enough, Karp doesn’t try to defend it, or himself. He commiserates, and it sounds genuine — the ambivalent doctor trying to help parents make sense of a chaotic world. That’s one reason many parents find his approach so reassuring. Unlike other parenting books, Karp’s doesn’t feel preachy or berating. His tips can be applied just as easily by fathers as by mothers, and his pragmatic advice and suggested baby schedules don’t feel like more than what they are: suggestions. But as I trailed him on his rounds, his suggestions invariably seemed to crescendo toward a pitch.

“Well,” he told Birndorf, “this is where they would use a SNOO.”

When explaining his philosophy of parenthood, Karp likes to quote his late mother: “Keep an open mind, but don’t let your brain fall out.” Karp grew up in Queens with two older sisters in a family he describes as Jewish but not Orthodox, Democratic but not political. His father was a building engineer and occasionally a door-to-door salesman; his mother was in charge of the business’s bookkeeping. As a child, Harvey was temperamental. At 12, he smashed a golf club into a painting his sister made. Later, he took up meditation. “It was right when the Beatles were doing it,” he said. This began for him a lifelong interest in Eastern and alternative practices even as he decided to enroll in medical school.


Hannah Whitaker for The New York Times

By his second year at the Albert Einstein College of Medicine in the Bronx, Karp knew that he wanted to care for children, whom he considered more “optimistic and resilient” than adults. He moved to Los Angeles for a residency at Children’s Hospital, meeting and marrying a woman who was studying to become a family counselor. At night, he pored over his wife’s textbooks about family dynamics. He trained under Barbara Korsch, a pediatrician who was among the first to study the field of doctor-patient communication and to call for “reducing the power gap” between physicians and parents. “Being smart is important, but you can’t get through the door by being an arrogant, smart doctor, unless you want to be a surgeon or a radiologist or something like that,” he said. “But if you’re dealing with patients, you’re knocking at the door and you’re being invited in. You have to be a good guest.”

In the early 1980s, he began working at U.C.L.A. hospital’s child-abuse team. He watched as babies were wheeled into the hospital in the middle of the night because their parents didn’t know how to soothe them or had badly shaken them when they screamed uncontrollably. “It was perplexing to me, because I thought: We could put a man on the moon. We could cure some types of cancer. We could make long-distance phone calls around the world. But we don’t know why babies cry, and we don’t know how to help them sleep.”

This issue of infant colic — of otherwise healthy babies who cry for more than three hours a day, at least three days a week, in the first three months of life — gnawed at him, and he immersed himself in books on evolution and anthropology. He learned about a Pygmy tribe that passes around babies between different community members all day long so that children develop multiple relationships early. He read the fieldwork of the anthropologist Melvin Konner about the infants of the !Kung San people in the Kalahari, who are carried in slings and rarely cry for more than a minute at a time. In the West, about 15 to 20 percent of babies have colic. “So either the !Kung babies were mutant babies — different from others — or those parents knew something.”

One day, when he was 29, Karp felt a dull pain in his neck as he was heading back to the hospital from lunch. He asked an intern to perform an EKG on him, but the intern didn’t know how to read the results. “So I’m showing him, ‘Here — oh, my God, this is cardiac ischemia.’ ” What he was reading was his own heart attack. He was kept in the hospital for a week for observation and advised to eat half a pound of salmon a day to reduce his cholesterol. The incident was mild enough that it didn’t have lasting effects, but it left him with a greater sense of urgency. “It was a crystalline moment,” he told me, of coming to terms with his own limitations. From then on, whenever he went for a run in Santa Monica and reached an area with outdoor stairs, he forced himself to think, as he descended, that at the very bottom “is the end of my life and to prepare for that.”

Before the heart attack, he had planned on going into child-development research, but now he thought the demands of academia would be too taxing. Instead, he joined a practice in Los Angeles with two other pediatricians and began to develop a local following. He threw himself into the job. Early in his career, he resolved never to do a checkup for less than half an hour. On some days, he visited six different hospitals to meet his newborn patients. As his work got more demanding, Karp and his wife grew apart and divorced.


Hannah Whitaker for The New York Times

Karp was beginning to develop his concept of the “missing fourth trimester.” Human babies are born about three months prematurely, the theory goes, because their heads, which grow rapidly, need to be able to fit through the birth canal. Some scientists dispute Karp’s notion that human gestation is too short. “Sadly, the evidence doesn’t support that,” Daniel Lieberman, an evolutionary biologist at Harvard, told me. But Karp insists that this explains why during the first months of life, babies can be lulled back into a womblike “trance” through the use of certain cues that Karp calls the 5 S’s: a combination of swaddling, shushing, placing the baby on her side or stomach, swinging her and letting her suck. He noticed that for each baby the “symphony of sensations” was slightly different — some babies needed extra movement, others a light jiggle — though all the infants responded well to swaddling, even if they seemed resistant at first.

By the early 1990s, Karp was running his own clinic, with a playground out back, and eventually he hired four pediatricians to work with him. “At the time, if you could get in to see Dr. Karp, then you’ve got it made,” Elaine Hall, whose son became a patient of Karp’s in 1996, told me. “He had a kind of hippie vibe to him then. He was gentle and comforting, and he had a long ponytail.” Karp gave her son a diagnosis of severe autism when he was 2. “Dr. Karp took me aside, and I’ll never forget — I get teary — he said: ‘You’re going to go on a journey. It’s a different path than you envisioned, but I can promise you you’re going to have lots of experiences that are going to make your life richer than you even imagined.”

Karp became famous for what were then unconventional methods for bonding with infants. Deena Goldstone, the mother of one of Karp’s first patients, remembers Karp suggesting that she swaddle her newborn at night, “which I thought made no sense,” she told me. Karp also advised Goldstone’s husband to hold their baby against his bare chest, in what doctors now tout as the importance of skin-to-skin contact. As his reputation grew, Hollywood celebrities took their children to see him; he treated the kids of Madonna, Michelle Pfeiffer and Larry David.

He also had a new family. He and Montée met at a party in Hollywood in 1991, when he was 40, divorced with no children. She was 11 years younger, with a 7-year-old daughter, Lexi, from a previous marriage. Montée is from Belgrade and has a highly polished complexion and the kind of thick, open-syllabled accent in English that makes “best” sound like “bast.” (Her uncle is Milan Panic, a pharmaceutical multimillionaire and former prime minister of Yugoslavia.) Karp appeared to her so unassuming that when he told her that he took care of the hosts’ son, “I thought, Oh, he’s their ‘manny,’ ” Montée told me.

In 2000, a famous actress brought in her young son to see Karp. She was accompanied by her baby nurse, a British woman named Tracy Hogg. Karp demonstrated his methods for soothing babies, including swaddling and his theory about the calming reflex. About six months later, he says, he heard that Hogg was working on a manuscript about how to calm a baby. That book, called “Secrets of the Baby Whisperer,” went on to become a best seller later that year: “You have to re-create the womb,” it advises, before going on to recommend swaddling infants tightly. “It had nothing to do with my stuff,” Karp said diplomatically. “But it got publishers interested.” Hogg, who died in 2004, advocated what she called a “structured routine” for a newborn — with precise hours for feeding, “activity,” sleeping and “you” time. Karp got to work on his own book, wanting to document his techniques for calming crying while promoting a more lenient approach. He visited his patients at home in order to test out his theories. “I needed to understand, When does it not work?” he said. “I needed to see it in the wild.” He often worked through the night, reciting bullet-pointed thoughts into dictation software because he was frustrated by the pace of his typing, then drove Lexi to school in the mornings wearing the same outfit as the day before.


Hannah Whitaker for The New York Times

Karp’s agent turned down a $450,000 advance for the manuscript, and Karp grew apprehensive that they wouldn’t get a better offer. That morning, Montée gave her husband a pep talk. “Act like you have a million dollars in your backpack,” she told him, a joke that is now part of the family lore. She turned out to be right: Karp ended up securing a $1.1 million advance for “The Happiest Baby on the Block,” along with a sequel for toddlers. Karp describes Montée as the one in the household who “seals the deal.” At Happiest Baby Inc., she is in charge of business strategy and creative direction (“As a co-founder, Ruth, I’m so excited,” she told me more than once, having mastered the marketing technique of first-name repetition).

A segment on “Good Morning America” in 2002 helped cement Karp’s success, and Montée had the idea of bringing the book’s testimonial sections to life by recording Karp’s interactions with his patients on DVD. Their timing couldn’t have been better. “The Happiest Baby on the Block” came out just as parenting literature was undergoing a transition of its own.

For years, the prevailing philosophy on child rearing had been Dr. Benjamin Spock’s rallying call to parents: “Trust yourself. You know more than you think you do.” Spock’s “The Common Sense Book of Baby and Child Care,” which was published in 1946 and sold more than 50 million copies worldwide, was so thoroughly embraced that some women kept copies of his paperback all over the house, including in their glove compartments. Detractors later blamed him for the permissiveness that they argued set the stage for the 1960s counterculture — for children being “Spocked when they should have been spanked.” In the late ’60s, Spock’s involvement in the anti-Vietnam War movement caused some of his readers to turn on him. His sales figures soon dropped by half, though he remains, to this day, the world’s most famous pediatrician.

As Spock lost ground, the field of expert advice became more polarized between a “hard” camp, which stressed discipline and conformity, and a “soft” camp, which believed in the importance of bonding and individuality. The issue of baby sleep was particularly contentious. In 1985, Dr. Richard Ferber, who founded what is now known as the Sleep Center at Boston Children’s Hospital, published a sleep manual so popular that his name became a verb. To “Ferberize” is now synonymous with letting a child cry it out (even though his book doesn’t quite advocate that). Following Ferber’s best seller, child-rearing literature was inundated with sleep guides, each with its own impossibly alluring title — “Twelve Hours Sleep by Twelve Weeks Old,” “The No-Cry Sleep Solution.”

The soaring popularity of sleep guides may have been propelled by an observable, objective deterioration in baby sleep, which can be traced back to a single year, 1992, when the American Academy of Pediatrics, upon reviewing research on sudden infant death syndrome, or SIDS, came out with the recommendation that parents put babies to sleep exclusively on their backs in the first year of life. The number of SIDS cases did in fact fall — by half, according to the National Center for Health Statistics. But the change came at a price. Babies sleep significantly worse on their backs, a fact that pediatricians openly acknowledge.


Hannah Whitaker for The New York Times

Certain parental concerns have vanished with technological advances like infant formula or polio vaccines. Others — like our anxiety about said technological advances — are perennial: Speaking to mothers in 1910, the pediatrician L. Emmett Holt worried about sensory overload in “these days of factory and locomotive whistles, trolley cars and automobiles.” But sleep — how much our children, and by extension we, get; whether it’s continuous or interrupted, light or deep, crying-induced or self-soothed — is a particularly of-the-moment obsession, particularly among well-off parents. The intense focus on sleep may have less to do with babies and more to do with parents, especially middle-class mothers, who provide as much as or more child care today than housewives did in the 1960s. Highly educated working mothers, Brigid Schulte, the author of “Overwhelmed: Work Love and Play When No One Has the Time,” told me in an email, have “made their children such a priority” that they spend “virtually all of their leisure time with their children.”

As baby sleep came to be seen as a national problem, the pressure intensified on parents to enforce stricter regimens. Champions of “hard” advice became known as parent-centered. Many of these advocates were from the Christian right, including Gary Ezzo, whose “On Becoming Baby Wise,” published in 1995, promoted rigid feeding schedules, “highchair manners” and physical punishment, or “chastisement” — preferably with a rubber spatula. (These recommendations have since changed.) Ezzo’s and other parent-centered advice books grew in direct opposition to the “ideological humanists” of the child-centered approach, with their insistence on feeding on demand, co-sleeping and a shunning of schedules and training methods.

Parent-centered advocates inveighed against the 1993 “Baby Book” — the bible of child-centered parents, written by William and Martha Sears, a pediatrician-and-nurse couple and parents of eight children. The “Baby Book” begins with an aphorism that puts many women at a disadvantage before they’ve even started mothering: “Feeling good about your baby’s birth carries over into feeling good about your baby.” (Tell that to the woman recovering from an emergency C-section.) They go on to ask, hypothetically, “Won’t holding our baby a lot, responding to cries, breast-feeding on cue and even sleeping with baby create a spoiled and overly dependent child?” To which they provide an emphatic answer: “No!” (Their son Robert, who is also a pediatrician and a “Baby Book” co-author, has become a vocal critic of vaccination laws, counter to evidence-based medical consensus.) Though they see themselves as Spock’s disciples, experts from the soft camp can seem exceedingly hard on parents, especially mothers, not to mention downright punitive for anyone with a full-time job.

Karp’s manual represented a welcome middle ground. “I try to be an omnivore and just reflect on each issue and judge it on its own merit or lack of merit, but I’m much closer to the Dr. Sears approach,” he said. He emphasizes the benefits of breast-feeding but argues that experts have become “dogmatic and inflexible about it to the point where we could be hurting kids and certainly hurting mothers.” He includes sections in his books on weaning — from swaddling, pacifiers, rocking — even as he dismisses professionals who warn that children could become addicted to these crutches. (“Are we ‘addicted’ to sleeping on a bed with a pillow?” he retorts.)

Karp “kind of serves the purpose that Grandma would have served in the past,” Alison Gopnik, a professor of psychology at the University of California, Berkeley, and author of the book “The Philosophical Baby,” told me. “But what science tells us is that variability is the most distinctive feature in terms of what children are like, what parents are like and what caregiving is like. So it’s unlikely that you’re going to find one piece of advice that’s going to suit all the different varieties of children and cultures.”


Hannah Whitaker for The New York Times

Karp’s manner is open, engaging, empathetic, inviting confession; ask him about his work, though, and the layers of humility begin to peel off. “Nobody else noticed this stuff in the whole world!” he told me at the end of dinner one evening when we talked about the 5 S’s. “No one knew about swaddling. Nobody knew about sleep.” As “The Happiest Baby on the Block” began to take off, Karp left his pediatric practice and with Montée turned the “Happiest Baby” into a franchise that now includes three books, two DVDs, a line of swaddles and white noises for purchase on iTunes, as well as SNOO, which rocks and plays white noise continuously and has sensors that respond to a baby’s cry by changing intensities; it keeps the baby swaddled and fastened inside the crib and can be controlled from afar on a smartphone.

Karp earnestly compares the $1,200 bassinet to the advent of penicillin — “I’m not here to promote a product, but I am saying if someone developed penicillin, wouldn’t it be important to tell people about it?” — and insists that it can save lives by stopping babies from rolling into an unsafe position in their sleep. Raising the money for SNOO, Karp drew on his celebrity appeal: Justin Timberlake and Jessica Biel are investors, as are Scarlett Johansson, Gwyneth Paltrow and Zoe Saldana. (Or, as Montée put it, “We have Justin and Jessica and Gwyneth and Scarlett and Zoe.”)

So far, 30,000 beds have gone into production, and of those, some were given free or at a steep markdown to social “influencers” — a far cry from Karp’s days of working with abused children. Hulu and Activision have begun offering discounted SNOOs as a benefit to their employees. Karp says he hopes to take SNOO beyond the gated precincts of Los Angeles and Silicon Valley: “Once we get medical studies, we can get insurance companies and employers to subsidize this. It will be like breast pumps ultimately. That’s the goal.”

Other “Happiest Baby” innovations can be viewed as truly helpful or slightly ominous, depending on your level of credulity. Its engineers are aiming to update the SNOO app to serve as a dutiful personal assistant, providing parents a full report on their child in the morning, like “Baby Sophie’s diaper is full; she had a runny nose; the humidifier is on,” Montée explained one morning when I visited the company’s headquarters in a squat building on a main drag in Santa Monica. She saw my face. “I know,” she said. “At the beginning I thought, Come on, really? But then I see Lexi’s friends, and they turn to an app just to tell them which breast they fed from last. It’s a different generation.”

“Hey, love!” Karp called out to Montée as we walked through their house on a recent weekend afternoon. They live in a converted A-frame chalet nestled deep in the hills of the Pacific Palisades that looks like the ideal location for a dream sequence in a film set in 2030. It has a hydraulic door with a laser-perforated metal screen, smooth white terrazzo floors, white floating stairs and an arresting view of the ocean. There are no visible light switches anywhere (Montée is “allergic”) and nothing made of plastic: Karp and Montée are environmental activists, and both serve as directors of the Environmental Working Group, a nonprofit research and advocacy organization. With its glass facades and sharp corners, their house also looks decidedly un-baby-proofed. Perhaps the only indication of Karp’s profession can be found upstairs, in his study, where there is a first-edition Dr. Spock and a cloth baby carrier from the Peruvian Amazon — a gift from Olivia Newton-John and her husband.

Karp has devoted his entire career to babies, so it came as a surprise to learn that he has never raised one of his own. For two years after he and Montée married, they tried to conceive but couldn’t. Devastated, they considered surrogacy or adoption but in the end decided against it. “We had Lexi,” Karp explained. He came back to that decision in a later conversation. “I kind of feel like everyone is my child,” he told me, his eyes glistening. “I don’t feel the barriers. There’s this passage in ‘Siddhartha,’ by Hermann Hesse, where Siddhartha’s friend Govinda looks into his face and sees the flow of thousands of human faces like a procession. It’s our joining of humanity.” Does this mean that he views all the children he has treated over the years as, in some sense, his own? “And their parents,” he said keenly.

Part of the appeal of Karp’s methods for calming babies was that they didn’t require anything fancy, not even the pre-made swaddles that are sold today — any old blanket would do. As he himself noted in his book, “For thousands of years, the most skilled parents have used the 5 S’s to soothe their babies.” Now he was suggesting that, actually, the best way to improve your baby’s sleep required splurging on a sensory bed. Effective as his invention may be, its forbidding price reflects an old-fashioned idea: that child rearing is inherently tied to social status, that you have to spend in order to care.

As the sun began to set over the ocean, the light glinting on the water like sequins, Karp and Montée still had a long night of work ahead. “We can stay up more than any youngsters and do — how do you say? Overnighters?” Montée said. In the coming months, they would launch SNOO in China, and Karp would go on the Home Shopping Network to advertise it. For him, though, that was just the beginning. He mused about Gutenberg’s invention of movable type and how his contemporaries had been alarmed that people wouldn’t memorize anything anymore because of it. He chuckled. “You can’t get in the way of progress,” he said. Then, standing by the patio with his hands in his pockets, he put it differently: “The idea is that I could be in every nursery in America.”

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Feature: Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis

Black infants in America are now more than twice as likely to die as white infants — 11.3 per 1,000 black babies, compared with 4.9 per 1,000 white babies, according to the most recent government data — a racial disparity that is actually wider than in 1850, 15 years before the end of slavery, when most black women were considered chattel. In one year, that racial gap adds up to more than 4,000 lost black babies. Education and income offer little protection. In fact, a black woman with an advanced degree is more likely to lose her baby than a white woman with less than an eighth-grade education.

This tragedy of black infant mortality is intimately intertwined with another tragedy: a crisis of death and near death in black mothers themselves. The United States is one of only 13 countries in the world where the rate of maternal mortality — the death of a woman related to pregnancy or childbirth up to a year after the end of pregnancy — is now worse than it was 25 years ago. Each year, an estimated 700 to 900 maternal deaths occur in the United States. In addition, the C.D.C. reports more than 50,000 potentially preventable near-deaths, like Landrum’s, per year — a number that rose nearly 200 percent from 1993 to 2014, the last year for which statistics are available. Black women are three to four times as likely to die from pregnancy-related causes than their white counterparts, according to the C.D.C. — a disproportionate rate that is higher than that of Mexico, where nearly half the population lives in poverty — and as with infants, the high numbers for black women drive the national numbers.

Monica Simpson is the executive director of SisterSong, the country’s largest organization dedicated to reproductive justice for women of color, and a member of the Black Mamas Matter Alliance, an advocacy group. In 2014, she testified in Geneva before the United Nations Committee on the Elimination of Racial Discrimination, saying that the United States, by failing to address the crisis in black maternal mortality, was violating an international human rights treaty. After her testimony, the committee called on the United States to “eliminate racial disparities in the field of sexual and reproductive health and standardize the data-collection system on maternal and infant deaths in all states to effectively identify and address the causes of disparities in maternal- and infant-mortality rates.” No such measures have been forthcoming. Only about half the states and a few cities maintain maternal-mortality review boards to analyze individual cases of pregnancy-related deaths. There has not been an official federal count of deaths related to pregnancy in more than 10 years. An effort to standardize the national count has been financed in part by contributions from Merck for Mothers, a program of the pharmaceutical company, to the CDC Foundation.

The crisis of maternal death and near-death also persists for black women across class lines. This year, the tennis star Serena Williams shared in Vogue the story of the birth of her first child and in further detail in a Facebook post. The day after delivering her daughter, Alexis Olympia, via C-section in September, Williams experienced a pulmonary embolism, the sudden blockage of an artery in the lung by a blood clot. Though she had a history of this disorder and was gasping for breath, she says medical personnel initially ignored her concerns. Though Williams should have been able to count on the most attentive health care in the world, her medical team seems to have been unprepared to monitor her for complications after her cesarean, including blood clots, one of the most common side effects of C-sections. Even after she received treatment, her problems continued; coughing, triggered by the embolism, caused her C-section wound to rupture. When she returned to surgery, physicians discovered a large hematoma, or collection of blood, in her abdomen, which required more surgery. Williams, 36, spent the first six weeks of her baby’s life bedridden.

The reasons for the black-white divide in both infant and maternal mortality have been debated by researchers and doctors for more than two decades. But recently there has been growing acceptance of what has largely been, for the medical establishment, a shocking idea: For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions — including hypertension and pre-eclampsia — that lead directly to higher rates of infant and maternal death. And that societal racism is further expressed in a pervasive, longstanding racial bias in health care — including the dismissal of legitimate concerns and symptoms — that can help explain poor birth outcomes even in the case of black women with the most advantages.

“Actual institutional and structural racism has a big bearing on our patients’ lives, and it’s our responsibility to talk about that more than just saying that it’s a problem,” says Dr. Sanithia L. Williams, an African-American OB-GYN in the Bay Area and a fellow with the nonprofit organization Physicians for Reproductive Health. “That has been the missing piece, I think, for a long time in medicine.”

After Harmony’s death, Landrum’s life grew more chaotic. Her boyfriend blamed her for what happened to their baby and grew more abusive. Around Christmas 2016, in a rage, he attacked her, choking her so hard that she urinated on herself. “He said to me, ‘Do you want to die in front of your kids?’ ” Landrum said, her hands shaking with the memory.


Landrum and her doula, Latona Giwa.

LaToya Ruby Frazier for The New York Times

Then he tore off her clothes and sexually assaulted her. She called the police, who arrested him and charged him with second-degree rape. Landrum got a restraining order, but the district attorney eventually declined to prosecute. She also sought the assistance of the New Orleans Family Justice Center, an organization that provides advocacy and support for survivors of domestic violence and sexual assault. Counselors secreted her and her sons to a safe house, before moving them to a more permanent home early last year.

Landrum had a brief relationship with another man and found out in March 2017 that she was pregnant again and due in December. “I’m not going to lie; though I had a lot going on, I wanted to give my boys back the sister they had lost, ” Landrum said, looking down at her lap. “They don’t forget. Every night they always say their prayers, like: ‘Goodnight, Harmony. Goodnight, God. We love you, sister.’ ” She paused and took a breath. “But I was also afraid, because of what happened to me before.”

Early last fall, Landrum’s case manager at the Family Justice Center, Mary Ann Bartkowicz, attended a workshop conducted by Latona Giwa, the 31-year-old co-founder of the Birthmark Doula Collective. The group’s 12 racially diverse birth doulas, ages 26 to 46, work as professional companions during pregnancy and childbirth and for six weeks after the baby is born, serving about 400 clients across New Orleans each year, from wealthy women who live in the upscale Garden District to women from the Katrina-ravaged Lower Ninth Ward and other communities of color who are referred through clinics, school counselors and social-service organizations. Birthmark offers pro bono services to these women in need.

Right away, the case manager thought of her young, pregnant client. Losing her baby, nearly bleeding to death and fleeing an abusive partner were only the latest in a cascade of harrowing life events that Landrum had lived through since childhood. She was 10 when Hurricane Katrina devastated New Orleans in 2005. She and her family first fled to a hotel and then walked more than a mile through the rising water to the Superdome, where thousands of evacuees were already packed in with little food, water or space. She remembers passing Charity Hospital, where she was born. “The water was getting deeper and deeper, and by the end, I was on my tippy-toes, and the water was starting to go right by my mouth,” Landrum recalls. “When I saw the hospital, honestly I thought, I’m going to die where I was born.” Landrum wasn’t sure what doulas were, but once Bartkowicz explained their role as a source of support and information, she requested the service. Latona Giwa would be her doula.

Giwa, the daughter of a white mother and a Nigerian immigrant father, took her first doula training while she was still a student at Grinnell College in Iowa. She moved to New Orleans for a fellowship in community organizing before getting a degree in nursing. After working as a labor and delivery nurse and then as a visiting nurse for Medicaid clients in St. Bernard Parish, an area of southeast New Orleans where every structure was damaged by Katrina floodwaters, she devoted herself to doula work and childbirth education. She founded Birthmark in 2011 with Dana Keren, another doula who was motivated to provide services for women in New Orleans who most needed support during pregnancy but couldn’t afford it.

“Being a labor and delivery nurse in the United States means seeing patients come in acute medical need, because we haven’t been practicing preventive and supportive care all along,” Giwa says. Louisiana ranks 44th out of all 50 states in maternal mortality; black mothers in the state die at 3.5 times the rate of white mothers. Among the 1,500 clients the Birthmark doulas have served since the collective’s founding seven years ago, 10 infant deaths have occurred, including late-term miscarriage and stillbirth, which is lower than the overall rate for both Louisiana and the United States, as well as the rates for black infants. No mothers have died.

A scientific examination of 26 studies of nearly 16,000 subjects first conducted in 2003 and updated last year by Cochrane, a nonprofit network of independent researchers, found that pregnant women who received the continuous support that doulas provide were 39 percent less likely to have C-sections. In general, women with continuous support tended to have babies who were healthier at birth. Though empirical research has not yet linked doula support with decreased maternal and infant mortality, there are promising anecdotal reports. Last year, the American College of Obstetricians and Gynecologists released a statement noting that “evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor.”


A note of affirmation from one of Giwa’s prenatal visits with Landrum.

LaToya Ruby Frazier for The New York Times

In early November, the air was thick with humidity as Giwa pulled up to Landrum’s house, half of a wood-frame duplex, for their second meeting. Landrum opened the door, happy to see the smiling, fresh-faced Giwa, who at first glance looked younger than her 23-year-old client. Giwa would continue to meet with Landrum weekly until her Dec. 22 due date, would be with her during labor and delivery and would make six postpartum home visits to assure that both mother and baby son remained healthy. Landrum led Giwa through her living room, which was empty except for a tangle of disconnected cable cords. She had left most of her belongings behind — including her dog and the children’s new Christmas toys — when she fled from her abusive boyfriend, and she still couldn’t afford to replace all her furniture.

They sat at the kitchen table, where Giwa asked about Landrum’s last doctor visit, prodding her for details. Landrum reassured her that her blood pressure and weight, as well as the baby’s size and position, were all on target.

“Have you been getting rid of things that are stressful?” Giwa asked, handing her a tin of lavender balm, homemade from herbs in her garden.

“I’m trying not to be worried, but sometimes. …” Landrum said haltingly, looking down at the table as her hair, tipped orange at the ends, brushed her shoulders. “I feel like my heart is so anxious.”

Taking crayons from her bag, Giwa suggested they write affirmations on sheets of white paper for Landrum to post around her home, to see and remind her of the good in her life. Landrum took a purple crayon, her favorite color, and scribbled in tight, tiny letters. But even as she wrote the affirmations, she began to recite a litany of fears: bleeding again when she goes into labor, coming home empty-handed, dying and leaving her sons motherless. Giwa leaned across the table, speaking evenly. “I know that it was a tragedy and a huge loss with Harmony, but don’t forget that you survived, you made it, you came home to your sons,” she said. Landrum stopped writing and looked at Giwa.

“If it’s O.K., why don’t I write down something you told me when we talked last time?” Giwa asked. Landrum nodded. “I know God has his arms wrapped around me and my son,” Giwa wrote in large purple letters, outlining “God” and “arms” in red, as Landrum watched. She took out another sheet of paper and wrote, “Harmony is here with us, protecting us.” After the period, she drew two purple butterflies.

Landrum’s eyes locked on the butterflies. “Every day, I see a butterfly, and I think that’s her. I really do,” she said, finally smiling, her large, dark eyes crinkling into half moons. “I like that a lot, because I think that’s something that I can look at and be like, Girl, you going to be O.K.”


Landrum and Giwa during a prenatal visit at Landrum’s home last November.

LaToya Ruby Frazier for The New York Times

With this pregnancy, Landrum was focused on making sure everything went right. She had switched to a new doctor, a woman who specialized in high-risk pregnancies and accepted Medicaid, and she would deliver this baby at a different hospital. Now she asked Giwa to review the birth plan one more time.

“On Nov. 30, I go on call, and that means this phone is always on me,” Giwa said, holding up her iPhone.

“What if. …” Landrum began tentatively.

“I’m keeping a backup doula informed of everything,” Giwa said. “Just in case.”

“I think everything’s going to be O.K. this time,” Landrum said. But it sounded like a question.

When the black-white disparity in infant mortality first became the subject of study, discussion and media attention more than two decades ago, the high rate of infant death for black women was widely believed by almost everyone, including doctors and public-health experts, to affect only poor, less-educated women — who do experience the highest numbers of infant deaths. This led inevitably to blaming the mother. Was she eating badly, smoking, drinking, using drugs, overweight, not taking prenatal vitamins or getting enough rest, afraid to be proactive during prenatal visits, skipping them altogether, too young, unmarried?

At Essence magazine, where I was the health editor from the late ’80s to the mid-’90s, we covered the issue of infant mortality by encouraging our largely middle-class black female readers to avoid unwanted pregnancy and by reminding them to pay attention to their health habits during pregnancy and make sure newborns slept on their backs. Because the future of the race depended on it, we also promoted a kind of each-one-teach-one mentality: Encourage teenagers in your orbit to just say no to sex and educate all the “sisters” in your life (read: your less-educated and less-privileged friends and family) about the importance of prenatal care and healthful habits during pregnancy.

In 1992, I was a journalism fellow at the Harvard T.H. Chan School of Public Health. One day a professor of health policy, Dr. Robert Blendon, who knew I was the health editor of Essence, said, “I thought you’d be interested in this.” He handed me the latest issue of The New England Journal of Medicine, which contained what is now considered the watershed study on race, class and infant mortality. The study, conducted by four researchers at the C.D.C. — Kenneth Schoendorf, Carol Hogue, Joel Kleinman and Diane Rowley — mined a database of close to a million previously unavailable linked birth and death certificates and found that infants born to college-educated black parents were twice as likely to die as infants born to similarly educated white parents. In 72 percent of the cases, low birth weight was to blame. I was so surprised and skeptical that I peppered him with the kinds of questions about medical research that he encouraged us to ask in his course. Mainly I wanted to know why. “No one knows,” he told me, “but this might have something to do with stress.”

Though I wouldn’t learn of her work until years later, Dr. Arline Geronimus, a professor in the department of health behavior and health education at the University of Michigan School of Public Health, first linked stress and black infant mortality with her theory of “weathering.” She believed that a kind of toxic stress triggered the premature deterioration of the bodies of African-American women as a consequence of repeated exposure to a climate of discrimination and insults. The weathering of the mother’s body, she theorized, could lead to poor pregnancy outcomes, including the death of her infant.

After graduating from the Harvard School of Public Health, Geronimus landed at Michigan in 1987, where she continued her research. That year, in a report published in the journal Population and Development Review, she noted that black women in their mid-20s had higher rates of infant death than teenage girls did — presumably because they were older and stress had more time to affect their bodies. For white mothers, the opposite proved true: Teenagers had the highest risk of infant mortality, and women in their mid-20s the lowest.

Geronimus’s work contradicted the widely accepted belief that black teenage girls (assumed to be careless, poor and uneducated) were to blame for the high rate of black infant mortality. The backlash was swift. Politicians, media commentators and even other scientists accused her of promoting teenage pregnancy. She was attacked by colleagues and even received anonymous death threats at her office in Ann Arbor and at home. “At that time, which is now 25 or so years ago, there were more calls to complain about me to the University of Michigan, to say I should be fired, than had happened to anybody in the history of the university,” recalls Geronimus, who went on to publish in 1992 what is now considered her seminal study on weathering and black women and infants in the journal Ethnicity and Disease.

By the late 1990s, other researchers were trying to chip away at the mystery of the black-white gap in infant mortality. Poverty on its own had been disproved to explain infant mortality, and a study of more than 1,000 women in New York and Chicago, published in The American Journal of Public Health in 1997, found that black women were less likely to drink and smoke during pregnancy, and that even when they had access to prenatal care, their babies were often born small.

Experts wondered if the high rates of infant death in black women, understood to be related to small, preterm babies, had a genetic component. Were black women passing along a defect that was affecting their offspring? But science has refuted that theory too: A 1997 study published by two Chicago neonatologists, Richard David and James Collins, in The New England Journal of Medicine found that babies born to new immigrants from impoverished West African nations weighed more than their black American-born counterparts and were similar in size to white babies. In other words, they were more likely to be born full term, which lowers the risk of death. In 2002, the same researchers made a further discovery: The daughters of African and Caribbean immigrants who grew up in the United States went on to have babies who were smaller than their mothers had been at birth, while the grandchildren of white European women actually weighed more than their mothers had at birth. It took just one generation for the American black-white disparity to manifest.

When I became pregnant in 1996, this research became suddenly real for me. When my Park Avenue OB-GYN, a female friend I trusted implicitly, discovered that my baby was far smaller than her gestational age would predict, even though I was in excellent health, she put me on bed rest and sent me to a specialist. I was found to have a condition called intrauterine growth restriction (IUGR), generally associated with mothers who have diabetes, high blood pressure, malnutrition or infections including syphilis, none of which applied to me. During an appointment with a perinatologist — covered by my excellent health insurance — I was hounded with questions about my “lifestyle” and whether I drank, smoked or used a vast assortment of illegal drugs. I wondered, Do these people think I’m sucking on a crack pipe the second I leave the office? I eventually learned that in the absence of a medical condition, IUGR is almost exclusively linked with mothers who smoke or abuse drugs and alcohol. As my pregnancy progressed but my baby didn’t grow, my doctor decided to induce labor one month before my due date, believing that the baby would be healthier outside my body. My daughter was born at 4 pounds 13 ounces, classified as low birth weight. Though she is now a bright, healthy, athletic college student, I have always wondered: Was this somehow related to the experience of being a black woman in America?

Though it seemed radical 25 years ago, few in the field now dispute that the black-white disparity in the deaths of babies is related not to the genetics of race but to the lived experience of race in this country. In 2007, David and Collins published an even more thorough examination of race and infant mortality in The American Journal of Public Health, again dispelling the notion of some sort of gene that would predispose black women to preterm birth or low birth weight. To make sure the message of the research was crystal clear, David, a professor of pediatrics at the University of Illinois, Chicago, stated his hypothesis in media-friendly but blunt-force terms in interviews: “For black women,” he said, “something about growing up in America seems to be bad for your baby’s birth weight.”


Another note of affirmation.

LaToya Ruby Frazier for The New York Times

On a December morning three days before her due date, Landrum went to the hospital for her last ultrasound before the birth. Because of the stillbirth the previous year, her doctor did not want to let the pregnancy go past 40 weeks, to avoid the complications that can come with post-term delivery, so an induction had been scheduled in 48 hours.

During Giwa’s last prenatal visit, the day before, she explained to Landrum that she would be given Pitocin, a synthetic version of the natural hormone that makes the uterus contract during labor, to start her contractions. “Will inducing stress out the baby?” Landrum asked. “I can’t lie; I used to wake up and scream, when I’d be dreaming about getting cut open again. I know my body is fine, and I’m healthy, but I don’t want to die.”

“I respect how honest you are, and your trauma is real,” Giwa told her, slowing down her words. “But my hope for you is, this birth can be a part of your healing. Your uterus is injured and has been scarred, but you’ve pushed out two babies, so your body knows what it’s doing.”

Now, lying on the table, Landrum looked out the window, smiling as the sound of her baby’s heartbeat filled the room. A few minutes later, the technician returned and looked at the monitor. The baby’s heart rate appeared less like little mountains than chicken scratching. He was also either not moving consistently or not breathing properly. A nurse left the room to call Landrum’s doctor to get her opinion. The nurse returned in 20 minutes and gave Landrum the news that the baby would be induced not in two days but now. “We don’t want to wait; we’re going to get him out today,” she said to Landrum.

“I’m very anxious,” Landrum told Giwa on the phone as she walked to labor and delivery, a few floors up in the same hospital, “but I’m ready.” An hour later, Giwa arrived, wearing purple scrubs, her cloth bag filled with snacks, lavender lotion and clary sage oil. She made sure the crayon-drawn affirmations were taped on the wall within Landrum’s line of vision, then settled into a chair next to the bed, low-key but watchful. Though some doctors resent or even forbid the presence of a doula during labor and delivery — and some doulas overstep their roles and create conflict with doctors and nurses — Giwa says she and the other Birthmark doulas try to be unobtrusive and focused on what’s best for the mother.

A medical resident, who was white, like all of the staff who would attend Landrum throughout her labor and delivery, walked into the room with paperwork. Right away, she asked Landrum briskly, “Have you had any children before?”

She hadn’t read the chart.

“Yes, I’ve had three babies, but one died,” Landrum explained warily, for the third time since she had arrived at the hospital that day. Her voice was flat. “I had a stillbirth.”

“The demise was last year?” the resident asked without looking up to see Landrum stiffen at the word “demise.”

“May I speak to you outside,” Giwa said to the nurse caring for Landrum. In the hall, she asked her to please make a note in Landrum’s chart about the stillbirth. “Each time she has to go over what happened, it brings her mind back to a place of fear and anxiety and loss,” Giwa said later. “This is really serious. She’s having a high-risk delivery, and I would hope that her care team would thoroughly review her chart before walking into her room.”

One of the most important roles that doulas play is as an advocate in the medical system for their clients. “At the point a woman is most vulnerable, she has another set of ears and another voice to help get through some of the potentially traumatic decisions that have to be made,” says Dána-Ain Davis, the director of the Center for the Study of Women and Society at the City University of New York, the author of a forthcoming book on pregnancy, race and premature birth and a black woman who is a doula herself. Doulas, she adds, “ are a critical piece of the puzzle in the crisis of premature birth, infant and maternal mortality in black women.”

Over the next 10 hours, Giwa left Landrum’s side only briefly. About five hours in, Landrum requested an epidural. The anesthesiologist required all visitors to leave the room while it was administered. When Giwa returned about a half-hour later, Landrum was angry and agitated, clenching her fists and talking much faster than usual. She had mistakenly been given a spinal dose of anesthesia — generally reserved for C-sections performed in the operating room — rather than the epidural dose usually used in vaginal childbirth. Now she had no feeling at all in her legs and a splitting headache. When she questioned the incorrect dose of anesthesia, Landrum told Giwa, one nurse said, “You ask a lot of questions, don’t you?” and winked at another nurse in the room and then rolled her eyes.

As Landrum loudly complained about what occurred, her blood pressure shot up, while the baby’s heart rate dropped. Giwa glanced nervously at the monitor, the blinking lights reflecting off her face. “What happened was wrong,” she said to Landrum, lowering her voice to a whisper. “But for the sake of the baby, it’s time to let it go.”

She asked Landrum to close her eyes and imagine the color of her stress.

“Red,” Landrum snapped, before finally laying her head onto the pillow.

“What color is really soothing and relaxing?” Giwa asked, massaging her hand with lotion.

“Lavender,” Landrum replied, taking a deep breath. Over the next 10 minutes, Landrum’s blood pressure dropped within normal range as the baby’s heart rate stabilized.

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