Racial Disparities in U.S. Maternal Outcomes
"The most feminine of all women's rights: To choose where and with whom to birth. If we lose that right, what right will we ever be able to protect?" Carla Hartley, Founder, Ancient Art Midwifery Institute (2011).
Introduction
The United States has the higher spending on health care than any other country, yet the maternal mortality rate in the United States is dismal. According to the Amnesty International report "Deadly Delivery, The Maternal Health Crisis in the USA", maternal mortality in the United States has risen. In 2010, the United States has fallen from 41st in the world to 50th in the world in regards to maternal mortality (Amnesty International, 2011). In fact, in the United States two to three women die every day as the result of pregnancy- and birth-related complications (Amnesty International, 2011). The statistics are even more dire for Black women in the United States.
The rate of maternal mortality for Black women in the United States is "at least three times higher than among white women", and higher then that of any other racial or ethnic group (Medical News Today, 2007). In addition, Black infants have 2.4 times higher infant mortality rates than white infants, and are "four times as likely to die as infants due to complications related to low birth weight" (The Office of Minority Health, 2011). This remains true even when controlling for factors such as income, education, unemployment, and medical risk. Are there other factors leading to these statistics that are not being taken into account? If so, what are they and how can we rectify these racial disparities in maternal outcomes?
Literature Review
According to the 2007 study "Racial Disparity in the Frequency of Recurrence of Preterm Birth" racial disparitites in preterm birth and low birth weight infants is the result of genetics (Kistka, Palomar, Lee, Boslaugh, Wnagler, Cole, DeBaun & Muglia, 2007). Black women in the United States have higher rates of preterm birth and low birth weight infants than any other racial group in the United States. This study concluded that the disparities in birth outcomes was due to genetic factors "must be caused by an underlying genetic factor because of the observed regularity in timing of repeat preterm births" (Kistka, et al., 2007).
While Kistka, et al. claimed to have controlled for factors such as socioeconomic status, the only qualifying factor they used to determine socioeconomic status was whether the study participant was receiving public assistance, such as Medi-Caid, Food Stamps (now known as SNAP), or WIC (Women, Infants & Children). This is not an adequate measure of socioeconomic status, as not everyone living in poverty is receiving public assistance. The study also failed to take into account the length of time the participant had lived in the United States and the education level of the participant.
Due to the failure to take these and other sociological factors into consideration, this study did not yield results that others in the same field of research consider valid, as seen in the letter "Racial Disparities in Preterm Birth: The Role of Social Determinants" written to the editor of the American Journal of Obstetrics & Gynecology written by Aubrey L. Spriggs, MA (2007). In the letter Spriggs points out the flaws in the study stating that "the authors overstated the adequacy of their adjustment for socioeconomic status" and "other aspects of socioeconomic status not included in their analysis are also important independent determinants of preterm birth", and that for this reason "the authors could not rule out the contribution of socioeconomic status" to the disparities in birth outcomes noted in the study (2007).
In contrast, "Low Birth Weight: Race and Maternal Nativity- Impact of Community Income" looks at which sociological factors may cause the high number of preterm and low birth weight babies born to Black women in the United States. According to the study, while the United States spends more money on health care than any other industrialized nation, low birth weight remains a significant problem and "non-US-born black mothers tend to have more favorable birth outcomes than do their US-born counterparts" (Fang, Madhaven & Alderman, 1999). This suggests that reasons other than race/ethnicity are factors in the higher number of low birth weight babies born to Black women.
Also noted in the study was the fact that low birth weight is a "major determinant of infant mortality" (Fang, Madhaven & Alderman, 1999). The study showed that African-born Black women and Caribbean-born Black women had lower incidences of low birth weight babies than American-born Black women, and that after controlling for socioeconomic status, African-born Black women and Caribbean-born Black women had similar outcomes to those of white mothers (Fang, et al., 1999). In poor communities, African-born Black mothers and Caribbean-born Black women had better birth outcomes than white women (Fang, et al., 1999).
The study "Variations in Low Birth Weight and Preterm Delivery Among Blacks in Relation to Ancestry and Nativity: New York City, 1998-2002" produced similar results, showing that there "was substantial variation in risks of preterm birth and low birth weight among the black subgroups", and that American-born Black women had significantly higher numbers of adverse birth outcomes and of low birth weight and preterm babies than other subgroups of Black women (Howard, Marshall, Kaufman & Savitz, 2006). This study showed that American-born Black women had higher numbers of adverse birth outcomes even after controlling for income, education, employment, and medical risk factors (Howard, et al., 2006). In fact, according to "Discrimination and racial disparities in health: evidence and needed research", "African American women with a college degree or more education have a higher rate of infant mortality than white, Hispanic (or Latino), and Asian and Pacific Islander women who have not completed high school" (Williams & Mohammed, 2008).
The results of these studies lead to the question, "If race and ethnicity do not account for the disparities in maternal outcomes among American-born Black women, then what is leading to these disparities?". According to "An Ecological Approach to Understanding Black–White Disparities in Perinatal Mortality" there is a correlation between poverty, stresses related to poverty, internalized racism, and intimate partner violence and adverse birth outcomes among Black women (Alio, Richman, Clayton, Jeffers, Wathington & Salihu, 2009). The study stated that "While the reported incidence of violence during pregnancy is higher among White women, Black abused mothers are more likely to die from abuse" and that "physical abuse during pregnancy has also been linked to both fetal and neonatal death" (Alio, et al., 2009). This is a sociological issue that none of the other studies touched on, and one of importance.
According to The American Bar Association, "Black females experience[d] intimate partner violence at a rate 35% higher than that of white females" (Domestic Violence Statistics, 2011). This conflicts with the statistics from the study which show that white women report higher incidences of domestic violence during pregnancy (Alio, et al., 2009). If this statistic is accurate, it means that there are many Black women who are not reporting incidences of domestic violence that they are experiencing during pregnancy. This could be because of the need to protect the male in the life from institutional racism that exists within society and within the justice system. Black men are incarcerated at alarmingly high rates compared to white men, which may be part of the reason that Black women are hesitant to report domestic violence to the police ( Domestic Violence Statistics, 2011). The lack of reporting domestic violence may be seen as an act of solidarity against institutionalized racism.
"Adverse Pregnancy Outcomes: Differences Between US- and Foreign-Born Women in Major US Racial and Ethnic Groups" examines another key factor in recognizing the causes of the disparity in adverse birth outcomes among U.S.-born Black women. Studies have shown that foreign-born Black women in the United States have better birth outcome than U.S.-born Black women in the United States. According to the study, U.S.-born black women are affected by the stress caused by historical racism, discrimination, and poverty that has been experienced by U.S.-born Black Americans for generations (Singh & Yu, 1996). The stress caused by these experiences affects the health of U.S.-born Black women especially during pregnancy, in a way that foreign-born Black women are not affected, as they have not experienced the historical and prolonged discrimination that U.S.-born Black women have faced, nor have the experienced discrimination to the same degree (Singh & Yu, 1996).
Environmental factors, such as exposure to smoke during pregnancy also increase the occurrence of adverse pregnancy outcomes, and "US-born non-Hispanic White, Black, Asian, and Hispanic mothers were 1.3 to1.9 times more likely than their immigrant counterparts to be exposed to environmental tobacco smoke during pregnancy" (Singh & Yu, 1996). Other environmental factors include "lead, air pollution, mold" which are experienced at higher levels in areas of poverty (NIH, 2008).
"Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women" discusses the unique sources of stress that are experienced by Black women in the United States. According to researchers, "abuses of Black American women by the medical system and issues of power in obstetrics that disadvantage Black American women" increase a Black woman's chance of experiencing an adverse birth outcome (Rosenthal & Rosel, 2011). Another factor that increases adverse birth outcome for Black women is the stereotypes that exist within our society about Black women, sexuality, and motherhood (Rosenthal & Rosel, 2011). The findings discussed in "Adverse Pregnancy Outcomes: Differences Between US- and Foreign-Born Women in Major US Racial and Ethnic Groups"corroborate the findings discussed in "Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women".
"The unsolved mystery of racial disparities in birth outcome: Is racism-related stress a missing part of the puzzle?" presented at the NIH Summit on Health Disparities also corroborates the finding that stress related to racism and internalized racism increase the incidences of adverse pregnancy outcomes in Black women (Braveman, 2008). According to Braveman, racism-related stress includes stress related to hardship, economic insecurity, experiencing, and/or anticipating discrimination, both during pregnancy and across the course of one's lifetime (2008). These stressors can have a negative impact on a woman's overall health, especially during pregnancy. It is important to note that these stressors have more of an impact on maternal health and pregnancy outcomes than stressors that are experienced for a short amount of time or are experienced periodically. These stressors are chronic, and are experienced over long periods of time.
These studies have shown that while many things factor into the causes of higher rates of adverse birth outcomes among Black women, including maternal and fetal mortality, there is still more research that needs to be done to pinpoint exact causes and find solutions. However, it is clear from the studies that the causes of racial disparities in maternal outcomes go beyond biological or genetic factors related to race and ethnicity, to sociological factors. These sociological factors include historical and chronic racism, stress caused by historical and chronic racism (and the anticipation of such racism), social structure (support systems), and institutional racism (both in medical institutions and the judicial system).
If we want to reduce or eliminate the disparities in adverse maternal outcomes for Black women, we must work to eliminate racism in all forms, including institutionalized racism in medical establishments and the judicial systems. These factors all compound to create a crisis in health care for Black women in the United States, and their babies, and in order to remedy the situation we cannot ignore the implications of societal factors such as racism, poverty, and discrimination that these women are experiencing.
References
American Bar Association. (2012). Domestic violence statistics. Retrieved from http://www.americanbar.org/groups/domestic_violence/resources/statistics.html
Braveman, P., NIH Summit On Health Disparities, Family & Community Medicine. (2008). The unsolved mystery of racial disparities in birth outcome: Is racism- related stress a missing part of the puzzle?. San Francisco: Center on Disparities in Health.
Disterhoft, J. (2011, May 20). [Web log message]. Retrieved from http:// blog.amnestyusa.org/women/maternal-health-key-to-empowering-women/
Fang, J., Madhaven, S., & Alderman, M. H. (1999). Low birth weight: Race and maternal nativity- impact of community income. Pediatrics: Official Journal of the Academy of Pediatrics, 103(1), 5-10.
Howard, D. L., Marshall, S. S., Kaufman, J. S., & Savitz, D. A. (2006). Variations in low birth weight and preterm delivery among blacks in relation to ancestry and nativity: New york city, 1998-2002.Pediatrics: Official Journal of the Academy of Pediatrics, 11(5), 1399-1405.
Kistka, Z. A., Palomar, L., Lee, K. A., Boslaugh, S. E., Wnagler, M. F., Cole, F. S., DeBaun, M. R., & Muglia, L. J. (2007). Racial disparity in the frequency of recurrence of preterm birth. American Journal of Obstetrics & Gynecology, 196(2), 131-137
Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life- course perspective. Maternal and Child Health Journal, 7(1), 13-30.
Rosenthal, L., & Lobel, M. (2011). Explaining racial disparities in adverse birth outcomes: Unique sources of stress for black american women. Social Science & Medicine, 72(6), 977-983.
Shen, J. J., Tymkow, C., & MacMullen, N. (2005). Disparities in maternal outcomes among four ethnic populations. Ethnicity & Disease, 15, 492-497.
Singh , G. K., & Yu, S. M. (1996). Adverse pregnancy outcomes: Differences between us- and foreign-born women in major us racial and ethnic groups. American Journal of Public Health,86`(6), 837-843.
U.S. Department of Health & Human Services, The Office of Minority Health. (2011). Infant mortality and african americans. Rockville: U.S. Department of Health & Human Services.
Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial disparities in health: Evidence and needed research. Journal of behavioral medicine, 22(1), 20-47. doi: 10.1007/s10865-008-9185-0
Introduction
The United States has the higher spending on health care than any other country, yet the maternal mortality rate in the United States is dismal. According to the Amnesty International report "Deadly Delivery, The Maternal Health Crisis in the USA", maternal mortality in the United States has risen. In 2010, the United States has fallen from 41st in the world to 50th in the world in regards to maternal mortality (Amnesty International, 2011). In fact, in the United States two to three women die every day as the result of pregnancy- and birth-related complications (Amnesty International, 2011). The statistics are even more dire for Black women in the United States.
The rate of maternal mortality for Black women in the United States is "at least three times higher than among white women", and higher then that of any other racial or ethnic group (Medical News Today, 2007). In addition, Black infants have 2.4 times higher infant mortality rates than white infants, and are "four times as likely to die as infants due to complications related to low birth weight" (The Office of Minority Health, 2011). This remains true even when controlling for factors such as income, education, unemployment, and medical risk. Are there other factors leading to these statistics that are not being taken into account? If so, what are they and how can we rectify these racial disparities in maternal outcomes?
Literature Review
According to the 2007 study "Racial Disparity in the Frequency of Recurrence of Preterm Birth" racial disparitites in preterm birth and low birth weight infants is the result of genetics (Kistka, Palomar, Lee, Boslaugh, Wnagler, Cole, DeBaun & Muglia, 2007). Black women in the United States have higher rates of preterm birth and low birth weight infants than any other racial group in the United States. This study concluded that the disparities in birth outcomes was due to genetic factors "must be caused by an underlying genetic factor because of the observed regularity in timing of repeat preterm births" (Kistka, et al., 2007).
While Kistka, et al. claimed to have controlled for factors such as socioeconomic status, the only qualifying factor they used to determine socioeconomic status was whether the study participant was receiving public assistance, such as Medi-Caid, Food Stamps (now known as SNAP), or WIC (Women, Infants & Children). This is not an adequate measure of socioeconomic status, as not everyone living in poverty is receiving public assistance. The study also failed to take into account the length of time the participant had lived in the United States and the education level of the participant.
Due to the failure to take these and other sociological factors into consideration, this study did not yield results that others in the same field of research consider valid, as seen in the letter "Racial Disparities in Preterm Birth: The Role of Social Determinants" written to the editor of the American Journal of Obstetrics & Gynecology written by Aubrey L. Spriggs, MA (2007). In the letter Spriggs points out the flaws in the study stating that "the authors overstated the adequacy of their adjustment for socioeconomic status" and "other aspects of socioeconomic status not included in their analysis are also important independent determinants of preterm birth", and that for this reason "the authors could not rule out the contribution of socioeconomic status" to the disparities in birth outcomes noted in the study (2007).
In contrast, "Low Birth Weight: Race and Maternal Nativity- Impact of Community Income" looks at which sociological factors may cause the high number of preterm and low birth weight babies born to Black women in the United States. According to the study, while the United States spends more money on health care than any other industrialized nation, low birth weight remains a significant problem and "non-US-born black mothers tend to have more favorable birth outcomes than do their US-born counterparts" (Fang, Madhaven & Alderman, 1999). This suggests that reasons other than race/ethnicity are factors in the higher number of low birth weight babies born to Black women.
Also noted in the study was the fact that low birth weight is a "major determinant of infant mortality" (Fang, Madhaven & Alderman, 1999). The study showed that African-born Black women and Caribbean-born Black women had lower incidences of low birth weight babies than American-born Black women, and that after controlling for socioeconomic status, African-born Black women and Caribbean-born Black women had similar outcomes to those of white mothers (Fang, et al., 1999). In poor communities, African-born Black mothers and Caribbean-born Black women had better birth outcomes than white women (Fang, et al., 1999).
The study "Variations in Low Birth Weight and Preterm Delivery Among Blacks in Relation to Ancestry and Nativity: New York City, 1998-2002" produced similar results, showing that there "was substantial variation in risks of preterm birth and low birth weight among the black subgroups", and that American-born Black women had significantly higher numbers of adverse birth outcomes and of low birth weight and preterm babies than other subgroups of Black women (Howard, Marshall, Kaufman & Savitz, 2006). This study showed that American-born Black women had higher numbers of adverse birth outcomes even after controlling for income, education, employment, and medical risk factors (Howard, et al., 2006). In fact, according to "Discrimination and racial disparities in health: evidence and needed research", "African American women with a college degree or more education have a higher rate of infant mortality than white, Hispanic (or Latino), and Asian and Pacific Islander women who have not completed high school" (Williams & Mohammed, 2008).
The results of these studies lead to the question, "If race and ethnicity do not account for the disparities in maternal outcomes among American-born Black women, then what is leading to these disparities?". According to "An Ecological Approach to Understanding Black–White Disparities in Perinatal Mortality" there is a correlation between poverty, stresses related to poverty, internalized racism, and intimate partner violence and adverse birth outcomes among Black women (Alio, Richman, Clayton, Jeffers, Wathington & Salihu, 2009). The study stated that "While the reported incidence of violence during pregnancy is higher among White women, Black abused mothers are more likely to die from abuse" and that "physical abuse during pregnancy has also been linked to both fetal and neonatal death" (Alio, et al., 2009). This is a sociological issue that none of the other studies touched on, and one of importance.
According to The American Bar Association, "Black females experience[d] intimate partner violence at a rate 35% higher than that of white females" (Domestic Violence Statistics, 2011). This conflicts with the statistics from the study which show that white women report higher incidences of domestic violence during pregnancy (Alio, et al., 2009). If this statistic is accurate, it means that there are many Black women who are not reporting incidences of domestic violence that they are experiencing during pregnancy. This could be because of the need to protect the male in the life from institutional racism that exists within society and within the justice system. Black men are incarcerated at alarmingly high rates compared to white men, which may be part of the reason that Black women are hesitant to report domestic violence to the police ( Domestic Violence Statistics, 2011). The lack of reporting domestic violence may be seen as an act of solidarity against institutionalized racism.
"Adverse Pregnancy Outcomes: Differences Between US- and Foreign-Born Women in Major US Racial and Ethnic Groups" examines another key factor in recognizing the causes of the disparity in adverse birth outcomes among U.S.-born Black women. Studies have shown that foreign-born Black women in the United States have better birth outcome than U.S.-born Black women in the United States. According to the study, U.S.-born black women are affected by the stress caused by historical racism, discrimination, and poverty that has been experienced by U.S.-born Black Americans for generations (Singh & Yu, 1996). The stress caused by these experiences affects the health of U.S.-born Black women especially during pregnancy, in a way that foreign-born Black women are not affected, as they have not experienced the historical and prolonged discrimination that U.S.-born Black women have faced, nor have the experienced discrimination to the same degree (Singh & Yu, 1996).
Environmental factors, such as exposure to smoke during pregnancy also increase the occurrence of adverse pregnancy outcomes, and "US-born non-Hispanic White, Black, Asian, and Hispanic mothers were 1.3 to1.9 times more likely than their immigrant counterparts to be exposed to environmental tobacco smoke during pregnancy" (Singh & Yu, 1996). Other environmental factors include "lead, air pollution, mold" which are experienced at higher levels in areas of poverty (NIH, 2008).
"Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women" discusses the unique sources of stress that are experienced by Black women in the United States. According to researchers, "abuses of Black American women by the medical system and issues of power in obstetrics that disadvantage Black American women" increase a Black woman's chance of experiencing an adverse birth outcome (Rosenthal & Rosel, 2011). Another factor that increases adverse birth outcome for Black women is the stereotypes that exist within our society about Black women, sexuality, and motherhood (Rosenthal & Rosel, 2011). The findings discussed in "Adverse Pregnancy Outcomes: Differences Between US- and Foreign-Born Women in Major US Racial and Ethnic Groups"corroborate the findings discussed in "Explaining racial disparities in adverse birth outcomes: Unique sources of stress for Black American women".
"The unsolved mystery of racial disparities in birth outcome: Is racism-related stress a missing part of the puzzle?" presented at the NIH Summit on Health Disparities also corroborates the finding that stress related to racism and internalized racism increase the incidences of adverse pregnancy outcomes in Black women (Braveman, 2008). According to Braveman, racism-related stress includes stress related to hardship, economic insecurity, experiencing, and/or anticipating discrimination, both during pregnancy and across the course of one's lifetime (2008). These stressors can have a negative impact on a woman's overall health, especially during pregnancy. It is important to note that these stressors have more of an impact on maternal health and pregnancy outcomes than stressors that are experienced for a short amount of time or are experienced periodically. These stressors are chronic, and are experienced over long periods of time.
These studies have shown that while many things factor into the causes of higher rates of adverse birth outcomes among Black women, including maternal and fetal mortality, there is still more research that needs to be done to pinpoint exact causes and find solutions. However, it is clear from the studies that the causes of racial disparities in maternal outcomes go beyond biological or genetic factors related to race and ethnicity, to sociological factors. These sociological factors include historical and chronic racism, stress caused by historical and chronic racism (and the anticipation of such racism), social structure (support systems), and institutional racism (both in medical institutions and the judicial system).
If we want to reduce or eliminate the disparities in adverse maternal outcomes for Black women, we must work to eliminate racism in all forms, including institutionalized racism in medical establishments and the judicial systems. These factors all compound to create a crisis in health care for Black women in the United States, and their babies, and in order to remedy the situation we cannot ignore the implications of societal factors such as racism, poverty, and discrimination that these women are experiencing.
References
American Bar Association. (2012). Domestic violence statistics. Retrieved from http://www.americanbar.org/groups/domestic_violence/resources/statistics.html
Braveman, P., NIH Summit On Health Disparities, Family & Community Medicine. (2008). The unsolved mystery of racial disparities in birth outcome: Is racism- related stress a missing part of the puzzle?. San Francisco: Center on Disparities in Health.
Disterhoft, J. (2011, May 20). [Web log message]. Retrieved from http:// blog.amnestyusa.org/women/maternal-health-key-to-empowering-women/
Fang, J., Madhaven, S., & Alderman, M. H. (1999). Low birth weight: Race and maternal nativity- impact of community income. Pediatrics: Official Journal of the Academy of Pediatrics, 103(1), 5-10.
Howard, D. L., Marshall, S. S., Kaufman, J. S., & Savitz, D. A. (2006). Variations in low birth weight and preterm delivery among blacks in relation to ancestry and nativity: New york city, 1998-2002.Pediatrics: Official Journal of the Academy of Pediatrics, 11(5), 1399-1405.
Kistka, Z. A., Palomar, L., Lee, K. A., Boslaugh, S. E., Wnagler, M. F., Cole, F. S., DeBaun, M. R., & Muglia, L. J. (2007). Racial disparity in the frequency of recurrence of preterm birth. American Journal of Obstetrics & Gynecology, 196(2), 131-137
Lu, M. C., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life- course perspective. Maternal and Child Health Journal, 7(1), 13-30.
Rosenthal, L., & Lobel, M. (2011). Explaining racial disparities in adverse birth outcomes: Unique sources of stress for black american women. Social Science & Medicine, 72(6), 977-983.
Shen, J. J., Tymkow, C., & MacMullen, N. (2005). Disparities in maternal outcomes among four ethnic populations. Ethnicity & Disease, 15, 492-497.
Singh , G. K., & Yu, S. M. (1996). Adverse pregnancy outcomes: Differences between us- and foreign-born women in major us racial and ethnic groups. American Journal of Public Health,86`(6), 837-843.
U.S. Department of Health & Human Services, The Office of Minority Health. (2011). Infant mortality and african americans. Rockville: U.S. Department of Health & Human Services.
Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial disparities in health: Evidence and needed research. Journal of behavioral medicine, 22(1), 20-47. doi: 10.1007/s10865-008-9185-0