Mothers Who Experience Racism Have Worse Birth Outcomes

As I’ve written before, when it comes to infant and maternal mortality, the US is effectively two nations. According to the CDC, the U.S. infant mortality rate for whites is 5.7 per 1000, a rate comparable to Switzerland or Australia. The U.S. infant mortality rate for blacks is 14 per 1000, a rate comparable to Uruguay and Bulgaria. The differences in maternal mortality rates are even more stark – 5.5 per 100,000 for whites, compared to 23.3 per 100,000 for blacks. This means that as far as maternal mortality goes, American whites have nearly the best outcomes in the world – better than Sweden’s – while American Blacks might as well be living in Bulgaria or Saudi Arabia. (I’m using 1995 World Health Organization data, available in word format here, to make this comparison).

Bottom line: If we judge by infant and maternal deaths, African-Americans in the US effectively live in the third world, rather than in the first world. (See this post for some information about infant mortality among other demographic groups in the US.)

Now it turns out that multiple studies have found that experiences of racism are directly correlated with childbearing outcomes. From Kate Orman’s Livejournal:

…Even if you take into consideration other factors such as income, education, and genetics, the Black infant mortality rate in the US is still higher than for other groups. What’s the missing factor? The review article I summarised earlier cited four journal articles which found a link between infant mortality and Black mothers’ personal, direct experience of discrimination.

I was able to get hold of all four journal articles. Let me try my best to summarise them. Very briefly: multiple studies have found that premature birth, and low birthweight, are more likely for African American mothers who report having personally experienced high levels of discrimination.

Here’s Kate’s summary of one of the studies:1

Participants “completed a discrimination questionnaire asking them whether they had ‘ever experienced discrimination, been prevented from doing something or been hassled or made to feel inferior… because of their race or color’ in any of 7 situations: ‘at school, getting a job, at work, getting housing, getting medical care, on the street or in a public setting, and from the police or in the courts.’ Even when other factors (depression, smoking, alcohol, education, income, marital status, etc) were taken into account, for mothers who reported experiencing discrimination in at least three of these situations, premature births were 3.1 times as likely, and low birthweight was 5 times as likely.

The other three studies described seem similar in approach.

I’d be very interested in seeing similar studies conducted regarding discrimination among American Indians, Hawaiians, and Puerto Ricans, all of whom experience above-average infant mortality in the US (although less so than African-Americans).2

US Infant Mortality, among whites, blacks, Asians, Latinos, and American Indians

There’s a lot of writing about the intersection of reproductive rights and racism, but this isn’t something I’ve seen considered. The mere existence of racism is, in effect, an attack on the reproductive rights of women.

  1. Sarah Mustillo et al. Self-Reported Experiences of Racial Discrimination and Black-White Differences in Preterm and Low-Birthweight Deliveries: The CARDIA Study. American Journal of Public Health 94(12) December 2004 pp 2125-2131. (Pdf link.) []
  2. Source: pdf link. []
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15 Responses to Mothers Who Experience Racism Have Worse Birth Outcomes

  1. 1
    RandyS says:

    Amp,

    Why is the word ‘Black’ capitilized while the word ‘white’ always lowercase; in this, and most posts, at Ampersand?

  2. 2
    Kaethe says:

    I have a theory that explains some of the disparity, which by-the-bye does not hold for other racial/ethnic groups or poverty level or insurance level.

    According to the CDC

    Factors that might contribute to the disparity include racial differences in maternal medical conditions, stress, lack of social support, bacterial vaginosis, previous preterm delivery, and maternal health experiences that might be unique to black women.

    Not to discount the validity of the others, but I think bacterial vaginosis is the key. It’s very common, most women have it at some time, one in three pregnant American women have it. And in most cases, it’s asymptomatic. Now, look at the racial disparity in incidence:

    Black, non-Hispanic women had an odds of bacterial vaginosis three times that of non-Hispanic, white women after adjusting for age, education, and poverty. Similarly, the odds for Mexican-American women were slightly higher when compared with white women. The adjusted analyses confirmed associations of bacterial vaginosis with lower levels of education and living near or below the federal poverty level.

    I think that black women, particularly those who have experienced racism, may be less likely to seek out prenatal and preconception care, and/or may be less likely to receive screening for BV, even though they are more likely to have it. It may well be that black women who have had prior poor birth outcomes may be even less likely to be screened, particularly if health care providers blame them in any way for the prior outcomes.

    And if doctors are willing to blame women in the NYT, I doubt if they’d balk at blaming them to their faces:

    “I think the rise is real, and it’s going to get worse,” said Dr. Bouldin Marley, an obstetrician at a private clinic in Clarksdale since 1979. “The mothers in general, black or white, are not as healthy,” Dr. Marley said, calling obesity and its complications a main culprit.

    By the way, you can guess who’s more likely to be obese, although maternal weight hasn’t be shown to cause adverse outcomes in pregnancy.

  3. 3
    Sailorman says:

    Infant mortality is the wrong statistic if you are talking about birth. Infant mortality includes all deaths in the first year of life. It is more a measure of pediatric care than of labor and delivery care. The statistic you should be using if you want to talk about birth issues is neonatal mortality, which includes deaths in the first 28 days. Those deaths are more directly attributable to natal care.

    FWIW, the racial differences for neonatal and infant mortality in the US are similar, so the thrust of your post is still correct. Black women have much higher rates of neonatal death in the US than do women of most other races, and the question of why is widely discussed.

    You are also a bit off, though, in the reference to “third world” statistics, at least as applied to neonatal death. You can see, if you look, that countries with good socialized medicine tend to have lower rates of infant mortality than we do. However, the US still does (on a nationwide scale) a decent job at neonatal mortality as measured on a worldwide scale. And thr real third world–which is to say places with very little advanced medical access–have much, much, higher rates of death than do we.

    You will also see that the phenomenon of “bad neonatal mortality for black women” appears to be at least somewhat consistent across first world countries. (this by no means argues against racism, of course) Finally, you will see that many of the countries with low death rates are countries which have small populations of nonwhites and/or which are relatively homogeneous.

    Anyway…

    The first question is whether it is in any way genetic. Obviously, there are some physical and genetic traits which are linked in some way to race. Sickle cell anemia is the obvious one to use here, as it also primarily affects blacks. Interestingly enough, just like sickle cell, a difference in birth outcomes is not an issue of inferiority but can also be balanced in effect: one could have fewer (but healthier) children, for example.

    The next question then becomes trying to figure out what proportion (and by that I include “none at all”) of the increased neonatal mortality is attributable to genetic factors, and what proportion is attributable to racism.

    The final question is identifying the causal element of racism. E.g., to the degree that racism raises neonatal death rates, do black women have a higher rate of neonatal death because the mothers suffer from racism, and therefore they are stressed, and their deliveries go south? Or do they have a higher rate of neonatal death because they are given worse care in hospitals because of their race? Or do they have a higher rate of neonatal death because they are more likely to live in an area with poor access to medical services and insurance, and therefore cannot get the necessary prenatal care?

    Those examples are all issues where racism could have a significant effect on neonatal death, but obviously the solutions are extremely different in each case.

  4. 4
    Ampersand says:

    However, the US still does (on a nationwide scale) a decent job at neonatal mortality as measured on a worldwide scale.

    That’s not true. Look at this graph, from an earlier “Alas” post:

    Graph: Infant mortality, newborn mortality, and stillbirth rate per 1,000 live births in seven wealthy countries

    Looking at deaths in the first month, the US does quite badly compared to many other nations.

  5. 5
    Robert says:

    That doesn’t counter Sailorman’s point. A first-month rate of 5 has room for improvement, but is on the (very) good end of the scale. I mean, it’s 192 in Angola. The difference between 192 and 5 is huge. The difference between 5 and 3, not so huge.

  6. 6
    Sailorman says:

    Two issues there.

    One is similar to what Robert says: we have room for improvement but we are certainly decent.

    Next is that on a population specific basis, the US does better than you may think.

    I hesitate to say this next part, because I have not had great success at explaining it without it seeming like I am trying to cast blame: As you note and as we both agree, there is generally but not always a much higher rate of neonatal mortality among minority populations, with blacks serving as the population most affected and asians providing a counterexample. It seems likely that there is racism implicit in this difference; it also seems possible that there is some genetic component. But be that as it may, the racial makeup of a country’s population is likely to have a significant effect on its neonatal death statistics.

    As I noted above, you will see that many of the countries with low death rates are countries which have small populations of nonwhites and/or which are relatively homogeneous. There are outliers on a worldwide scale, and it is clear in a variety of respects that the US does not provide good healthcare to all its citizens. I am neither denying the fact that black women have higher rates of delivery issues, nor the likely fact that racism is implicit in the problem. However, part of the reason that Norway has such an apparently low OVERALL rate is probably that Norway is 98% white.

    The final thing is an issue of how and whether you classify a death as neonatal as opposed to prenatal.

    Every country classifies a death as neonatal if it happens to a term baby, a day after delivery. However, there is wide variation among countries in how they treat (and therefore classify) their own deaths in terms of the more difficult questions.

    Some countries exclude premature babies, to varying degrees. Some countries tend to classify more deaths as stillbirths (thus removing them from neonatal death category.) Each of those re-classifications results in an apparent (and incorrect) change in the reported neonatal death rate.

    As these things go, the US tends to have one of the more inclusive reporting schemes, which means that it tends to report more deaths, which tends to make it have worse statistics. Obviously this makes analysis difficult. The variance in country practices is not widely understood but is an important factor to keep in mind when making comparisons based on WHO or similar statistics.

    At one point, I had data on the reporting practices of a variety of countries, which I have long since discarded. I have no idea where the countries you listed fall on the scale and this issue may not apply to them. I may be able to find it again if you are interested, but not for a few days.

    I will close by saying–just in case this was not clear–that I do not believe all those factors would add up to make the US blameless. They would certainly not eliminate the racial disparity in neonatal death.

  7. 7
    Robert says:

    This would be a good way for socialized medicine advocates to incrementally get part of what they want.

    Put together a federal package that gives gold-plated prenatal, delivery, and first-year medical care to every American citizen on the federal nickel. Present it as a pro-life, anti-racist measure: “we must not tolerate a situation where women abort their children because they cannot afford to deliver them, we must not tolerate a situation where the children of black and Hispanic women die because they cannot get the care they need”.

    I could not in good conscience vote against it. Neither could a lot of my socialized-medicine-hatin’ allies.

  8. 8
    Myca says:

    I could not in good conscience vote against it. Neither could a lot of my socialized-medicine-hatin’ allies.

    Dude, I know! What kind of a horrible person could vote against aid to pregnant teens?

    Oh wait. Oh shit.

    —Myca

  9. 9
    Decnavda says:

    The difference between 5 and 3, not so huge.

    “Huge” is both a relative and subjective term. 5 is 66.6% higher than 3. To me, subjectively, that seems like a huge difference between newborn mortality in the U.S. and the rest of the industialized world. Relative to the difference between 192 and 5, no, I guess it is not so huge.

  10. 10
    rob says:

    Should we interpret the fact that Asian-American women (as a group) have better “birth outcomes” than White women to Asian-Americans experiencing less racism than Whites? It is consistent.

  11. 11
    Elena Perez says:

    I wonder if there have been any studies on levels of intervention in Black pregnancies and births vs white pregnancies/births? There’s a lot of evidence showing that the higher the number of medical interventions, the more likely that those interventions will escalate (i.e. pitocin drip -> fetal distress -> C-section). I did a post about the medicalization of birth over at the CA NOW blog: http://www.canow.org/canoworg/2008/07/the-womanizatio.html

  12. 12
    Bjartmarr says:

    Put together a federal package that gives gold-plated prenatal, delivery, and first-year medical care to every American citizen on the federal nickel.
    [...]
    I could not in good conscience vote against it. Neither could a lot of my socialized-medicine-hatin’ allies.

    But once they turn a year old, they’ve gotta fend for themselves?

    You’re starting to get the right idea, though: you seem to understand that our current byzantine patchwork of obscure, underfunded programs and red tape don’t really qualify as good medical care. Perhaps you even understand that the acid test is whether people are actually healthy (not whether the programs exist on paper in Washington).

    So, can you explain why you think our current system is good enough for one-year-olds, but not good enough for younger children and pregnant women?

  13. 13
    Sailorman says:

    Elena Perez Writes:
    September 3rd, 2008 at 2:36 pm

    I wonder if there have been any studies on levels of intervention in Black pregnancies and births vs white pregnancies/births? There’s a lot of evidence showing that the higher the number of medical interventions, the more likely that those interventions will escalate (i.e. pitocin drip -> fetal distress -> C-section). I did a post about the medicalization of birth over at the CA NOW blog: http://www.canow.org/canoworg/2008/07/the-womanizatio.html

    It is probably the opposite. The interventions that you reference (with the added implication that “intervening is bad”) are part of what allow first world countries to have such incredibly low, non-natural, neonatal and maternal death rates.(*1)

    It is far more likely that black women are being denied interventions than it is that they are being given too many interventions. Your (incorrect) link between interventions and neonatal death notwithstanding, the reality is that giving a c section to every single black mother would probably result in a significant drop in the neonatal death rate.(*2)

    Not incidentally, this tracks IIRC the results of some other studies that showed MDs prescribing beneficial treatment or drugs with less frequency when the patient was black. I believe that this has been studied for statins (heart attack medicine,) for pain relief, and for certain surgical procedures. I am not aware of a similar study on prenatal procedures but I would be unsurprised if the effect were similar.

    (*1) Let’s agree not to side track this into a debate about whether medical interventions are overused, OK? Whether you think they are good or bad on a moral level, they are not what is causing this.

    (*2) I am basing that assumption on the studies I discuss which found an increase in Type II error (failing to treat) for blacks. In the world of obstetrics and neonatology, Type II error tends to be much more costly than Type 1 error. A relatively small increase in “failure to treat” can have a significant effect on death rates.

  14. 14
    Thene says:

    Robert – what Bjartmarr said, but, I think that’s an interesting line of thought simply because it gives me the feeling that the pro-life camp isn’t a natural fit for the right-wing at all. You seem to be saying that pro-life beliefs lead to a demand for government-provided healthcare; that’s really conservative, right? Pro-life is also tied in knots when it comes to individualism; it says pharmacists should have the ‘freedom of conscience’ to not provide Plan B (which prevents abortion) but that women should not have the freedom of conscience to decide for themselves whether they need an abortion.

    I honestly can’t see a connection between the right in general and pro-life, except maybe the distaste for women’s rights, yet it sounds like you’d happily toss away your anti-public-healthcare beliefs for your pro-life ones. Why is that?

  15. 15
    KK says:

    Until we are presented with more in-depth information about the medical history and socioeconomic statuses of these women, I am going to remain skeptical of this study.

    -How old are they?

    -Do these women have a history of smoking, excessive drinking, drug abuse?

    -Do they have health issues such as anemia, fluctuating obsesity or malnourishment?

    -Did they take any forms of medication consistently? If so, what medicines did they take?

    -Did their economic status allow them to seek prenatal care?

    -What kind of support (spousal, familial or otherwise) did they have during the term periods? Was the support consistent and low-stress?

    -Did they have high-stress jobs or were they working long hours?

    -What kind of environment did they live in? What kind of water were they drinking, what kind of food were they eating?

    -What kind of health care was available to them in the area? Are we looking at inner-city mothers, rural mothers or suburban mothers?

    -How much sleep were they getting, on average?

    -Are these first-time mothers?

    I’m not trying to dismiss the racial theory. In fact, if the hypothesis stands up to these questions, it should only strengthen its case. However, I honestly feel we are not being given enough information about these mothers. What’s with the mysterious statement: “Even when other factors (depression, smoking, alcohol, education, income, marital status, etc) were taken into account”? Release the information to allow for further assessment!