This project is sponsored by the International Center for Traditional Childbearing, the International Cesarean Awareness Network, the Midwives Alliance of North America, and Elephant Circle.
The International Center for Traditional Childbearing (ICTC) is a non-profit infant mortality prevention, breastfeeding support, and midwife training organization, comprised of women and men who want to improve birth outcomes and provide training opportunities in their communities.
The International Cesarean Awareness Network, Inc. (ICAN) is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting Vaginal Birth After Cesarean (VBAC).
The Midwives Alliance of North America (MANA) is a professional membership organization that promotes excellence in midwifery practice, endorses diversity in educational backgrounds and practice styles, and is dedicated to unifying and strengthening the profession, thereby increasing access to quality health care and improving outcomes for women, babies, families, and communities.
Elephant Circle is an innovative reproductive justice organization dedicated to circling around in support of strong people during vulnerable times. Elephant Circle practices circling with presently and historically marginalized groups, groups no one else is helping, and groups that share an intersectional reproductive justice analysis.
We would also like to acknowledge Melissa Cheyney, PhD, LM, CPM, Saraswathi Vedam, RM, FACNM, MSN, Sci. D. (h.c.), Heather Thompson, PhD, and give special thanks to Holly Horan, for their guidance and insight on this project and dedication to eliminating disparities in birth outcomes.
EXECUTIVE SUMMARY
by Shandanette Molnar, JD, MPH
“We carry our history in our bodies . . . How can we not?”
- Nancy Krieger, Unnatural Causes
Intro
Despite widespread calls to reduce the infant mortality, preterm birth, and low birthweight rates in the United States racial disparities in birth outcomes persist, with African-American infants remaining the most vulnerable. In 2013, the rate of preterm birth for African-American infants was nearly double that for white infants. Known medical, genetic, and/or sociodemographic factors alone do not account for these disparities, leading researchers to examine race and the experience of racial discrimination as independent risk factors for affecting maternal, infant, and child health.
This Executive Summary is organized as follows: First, we include statistical data to describe the racial disparities in birth outcomes, including preterm birth, low birthweight, and infant mortality. Next, we provide a summary of current research to examine the correlations between race, racism, and poor birth outcomes. Finally, we provide recommendations to policymakers and researchers so that meaningful strides can be made toward dismantling racism, a necessary strategy to improve birth outcomes and eliminate healthcare disparities in the United States.
Background: Statistics
There were just under 4 million (3,932,181) births in 2013. The rate of preterm birth, defined as birth before 37 weeks gestation, declined in 2013 to 11.39%. According to the CDC, infants who weigh less than 2500 grams (5.5 pounds) at birth are classified as low birthweight infants. Infants who weigh less than 1500 grams (3.25 pounds) at birth are classified as very low birthweight infants. In 2013, the rate of low birthweight births remained unchanged at just over 8% of births. More than one percent (1.4%) of infants were born at very low birthweights in 2013.
African-American women, defined as non-Hispanic Black women by the CDC, gave birth to 583,834 infants in 2013. More than 16% of African-American infants born in 2013 were born preterm, compared to only 10% of white infants born preterm. Black women also gave birth to low birthweight (LBW) and very low birthweight (VLBW) infants at greater rates than white women (LBW = 8.5% vs. 4.6%, VLBW = 2.8% vs. 1.06%, respectively.)
2013 was not an anomaly; African-American infants have reported higher rates of preterm birth since the CDC began comparing data in 1981. Despite efforts to improve racial disparities in birth outcomes, African-American infants are more than twice as likely as White infants to die in their first year of life.
African-American pregnant women are nearly four times more likely to die from pregnancy- related complications than are white women. African-American pregnant women are also two to three times more likely to experience preterm birth, and three times more likely to give birth to a low birthweight infant. This disparity persists even after researchers control for confounding medical and sociodemographic risk factors, such as low income, low education, and alcohol and tobacco use. In fact, research shows that the gap widens as socioeconomic levels increase. In order to explain these persistent disparities in health outcomes, researchers now theorize that racism serves as a course of chronic stress, negatively affecting the body’s hormonal levels, which can initiate physical mechanisms that may lead to preterm birth. The graph below demonstrates the disparities in birth outcomes, with Non-Hispanic Black and Native American women reporting higher rates of pre-term birth than their white, Asian, and Hispanic counterparts.
Summary of current research to examine the correlations between race, racism, and poor birth outcomes
“[S]tress and racism are constant factors in African-American women’s lives and are inseparable from their pregnancy experiences.”
Source: Barnes GL. Perspectives of African-American women on infant mortality. Soc Work Health Care. 2008;47(3):293-305.
Hormones play an integral role in pregnancy and childbirth, including initiating the physiological process of labor. Researchers have identified relationships between elevated stress hormone levels and chronic exposures (i.e., throughout the life-course) to stress. Such research suggests that those who experience chronic stress, such as racism and discrimination, have measurably higher levels of stress hormones. Increased hormone levels cause the body to remain “chronically activated” because it is unable to return to its normal state following a stressful event. This creates a “wear and tear” effect on the body, which researchers identify as the primary cause of malfunctions in “allostatic load” or “allostatsis.” Thus, a chronically activated maternal stress response may initiate pre-term labor. Based on the findings in the existing scientific literature, prenatal stress, including racism, is associated with an increased risk of poor birth outcomes, including preterm birth and low birthweight.
Research indicates that African-American women experience more chronic stress in their lives than white women, in part due to the effects of lifetime exposure to interpersonal racism. Researchers have also found that African-American women who delivered very low birthweight infants were more likely to report incidences of interpersonal racism than those who delivered higher weight infants at term. Another study found that African-American women who reported frequent discrimination in the form of interpersonal racism were more likely to give birth to very low birthweight infants and/or deliver preterm. Researchers also found that African-American participants who reported high levels of racial discrimination were at 3.1 times the risk of preterm delivery and almost five times more likely to deliver low birthweight infants.
Increasingly, research suggests that chronic maternal stress affects fetal programming and lifelong health, highlighting the importance of implementing a life-course approach in healthcare delivery and research. The “fetal programming” hypothesis suggests that stimuli during critical periods of embryonic and fetal development may alter such development and influence lifelong health. In general, when humans encounter a stressor, the body responds with a quick increase then decrease of glucocorticoids, mainly the stress hormone cortisol. This physiological process is mediated by the hypothalamic-pituitary-adrenocortical axis (HPA-axis). Abnormal activity of the HPA axis, particularly quick increase or slow decrease, is associated with an increased risk of depression later in life. Thus, it is important to note that chronic stress, such as racial discrimination, may negative affect maternal, infant, and child health, underscoring the importance of supporting the mother-child dyad.
Currently, researchers are unclear of the exact mechanism by which maternal stress affects fetal programming and development, but there are various hypotheses posed by researchers. First, an excess of active maternal cortisol may pass the placental barrier, affecting the development and function of the fetal HPA-axis. Data suggests that the disruption of the hypothalamic-pituitary-adrenocortical axis (HPA-axis) may negatively affect fetal programming. Alternatively, the maternal HPA-axis may stimulate the production of corticotrophin releasing hormone (CRH) through the placenta, which has been found to increase the risk of preterm birth threefold. Finally, an increase of cortisol in the maternal bloodstream may reduce the flow of blood through the placenta and to the uterus, potentially slowing fetal growth.
The association between racism, chronic stress, and preterm birth may be explained by the fact that persistent psychological stress increases levels of stress hormones. Researchers have found that women at highest risk for preterm birth had higher levels of stress hormones, including CRH, adrenocorticotropin-releasing hormone (ACTH), and cortisol. Data suggests that women who report frequent discrimination report higher levels of cortisol and are more likely to give birth to infants with higher cortisol reactivity. High levels of fetal cortisol can affect the fetus’s ability to grow in utero and may predispose the fetus to diseases later in life. Elevated levels of cortisol also increase the likelihood of elevated levels of CRH, which increases the risk of preterm birth.
Current research supports the theory that chronic maternal stress affects fetal programming, with some research finding a link between racism-related maternal stress, stress hormones, and infant and child health outcomes. From such findings, researchers conclude that lifelong experiences of interpersonal racism serve as an independent risk factor for preterm birth. Thus, racism can influence maternal, infant, and child health trajectories prior to conception, as evidenced by data showing correlations between exposure to racism during childhood and increased likelihood of birthing a low birthweight infant.
Nonetheless, much remains unknown about the relationship between racism and poor birth outcomes, and more research is needed. For instance, research methodologies must account for the pervasive, chronic, and multidimensional experiences of interpersonal and structural racism throughout the life-course. Additionally, it is unclear how or why other racial minorities escape the outcome disparities that African-Americans experience. Future research must therefore implement a life course health development framework in order to examine the intergenerational affects of racism, weathering, and birth outcomes.
Recommendations
“[The] life-course framework...clearly illustrates that we will never eliminate disparities in birth outcomes if we only focus on the 9 months of pregnancy.”
Source: Rohan AM, Onheiber PM, Hale LJ, et al. Turning the ship: making the shift to a life-course framework. Matern Child Health J. 2013;18(2):423-30.
Racial discrimination serves as a major source of stress for African-American women, and data suggests that the physiological responses to chronic stress may explain the persistent racial disparities in birth outcomes. Maternal stress affects fetal development and is associated with preterm birth and low birthweight, which increases the risk of disease, disability, and early death over the life-course. Thus, programs to reduce maternal stress during pregnancy must also include efforts to understand and improve the lived experiences of African-American women and women of color by employing strategies to reduce stress caused by racial discrimination.
Efforts to improve birth outcomes for African-Americans must implement a life-course perspective, which strives to understand and improve population health by acknowledging that health is influenced by more than individual biology and personal choices, but also the environment, social determinants of health, and health equity. The research referenced throughout this Executive Summary demonstrates that birth outcomes are influenced by events and experiences that occur prior to pregnancy. Thus, efforts to reduce racial disparities and improve birth outcomes must shift away from a mere focus on pregnancy care and instead implement a whole-person, life-course perspective, which prioritizes primary and preventive care throughout one’s life.
Perhaps most importantly, implementing a life-course perspective requires the acknowledgement and elimination of racism. Meaningful efforts must be made to dismantle the various ways that racism pervades our society, including interpersonal and structural racism, which inhibits access to health care and utilization of social support services. Given institutional mistrust and inequities in healthcare access, policymakers and key stakeholders must increase the accessibility of healthcare to populations of color and other marginalized groups. This includes expanding access to Medicaid-approved providers, as well as addressing factors that discourage healthcare use, including inability to locate a provider, the availability of culturally competent providers in low-income communities, bolstering health care infrastructure to reduce wait times and appointment scheduling, providing additional social services for low-income or single-parent families and child care services, etc.
Additionally, “Trust . . . is the basis of quality clinical care,”28 and careful attention must be paid to improve provider-patient relationships, repair institutional mistrust, and focus on patient- or client-centered care. Recent research released by Childbirth Connection names disrespectful maternity care as a source of stress during pregnancy. This factor combined with the insidious nature of internalized racism negatively affects healthcare delivery29 and demonstrates the need for improving access to safe, respectful, supportive, and evidence-based maternity care.
for full article including references and research summaries, view the attached document.
