Adverse Pregnancy Outcomes Associated with Systemic Racism
Data on Black-White Disparities in the US
If a picture is worth a thousand words, data is sometimes worth exponentially more. Research has shown that Black Americans have higher mortality rates, lower life expectancy and higher burden of disease. More shocking is the research showing that maternal mortality, a critical marker of public health, is 3-4 times more likely to occur in the Black population, with higher incidence of severe maternal morbidity also experienced by Black pregnant patients.
While these disparities have been a fact of life for Black patients in the United States for quite some time, only relatively recently have disparities received more attention in the press and, in turn, from researchers. "Disparities" in this context is defined as "…racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention." (Institute of Medicine 2003 Report "Unequal Treatment").
Disparities Research to Date – Its Aims and Changing Findings
Researchers have been investigating many aspects of Black-White disparities in pregnancy outcomes, two of the most fundamental of which are why it is occurring and why it is so widespread. Findings indicating a correlation between where one lives, where one receives care, even one's educational level, were significant and contributory, but not the underlying factor.
A turning point in defining and understanding the reasons for these disparities came with the acceptance that race is a social and not a biological concept and as such not a proxy for genetic differences. (See Ukoha et al. "Toward the Elimination of Race-Based Medicine: Replace Race with Racism as Preeclampsia Risk Factor," AJOG 2022)
The determination that race in itself cannot be used to evaluate risks for certain outcomes started a reexamination of treatment protocols in obstetrics, particularly since race-based criteria was shown to have negative outcome effects. One example, later rectified by the American College of Obstetricians and Gynecologists in a revised Practice Bulletin, was the threshold for treating pregnancy iron-deficiency anemia which led to a higher risk for Black women having lower hemoglobin levels at time of delivery admission.
Dr. Ramos's Research – the Role of Systemic Racism in Obstetric and Neonatal Outcomes
MIRI Associate PI Dr. Sebastian Ramos, a maternal-fetal medicine physician in Obstetrics & Gynecology, like other researchers, notes that "It is not race, but rather exposure to Systemic Racism, which causes the risk of those conditions and outcomes." This research framework drives and defines his work.
Dr. Ramos is doing research in Black-White disparities in adverse pregnancy outcomes. Funded by a NIH K12 Building Interdisciplinary Careers in Women's Health (BIRCWH) grant, his study will investigate the "Contribution of Systemic Racism to Disparities in Obstetric and Neonatal Outcomes." His research builds on the work of Dr. Michael Siegel, an epidemiologist at TUSM Department of Public Health and Community Medicine, whose team created an index using US Census Data to quantify Systemic Racism in the United States using five parameters to quantify Black-White disparities at the state level.
Disparities Research is important, Dr. Ramos notes, not merely for the moral and ethical imperative of redressing the societal imbalances caused by Systemic Racism, but because of the economic cost of perpetuating it, and conversely, the economic benefits of addressing it. The US economy could be $8 billion larger by 2050, with $135 billion per year gained if healthcare inequities were resolved. More than one quarter growth in productivity from 1960-2008 was associated with decreased occupational barriers for Black people and women.
The hypothesis of Dr. Ramos's study is that increased risk of adverse pregnancy outcomes will be associated with higher Systemic Racism Index (SRI) values even after adjusting for differences in race, ethnicity, and socioeconomic status. To test his hypothesis, Dr. Ramos will compare rates of obstetric complications known to have significant racial/ethnicity socioeconomic inequity with the highest vs. the lowest quartile of the Systemic Racism Index. Thus, using the SRI, Dr. Ramos will map correlations between racism and adverse pregnancy outcomes in the United States, a novel use of the SRI that will add to the data in disparities research.
The study has a qualitative aspect as well that will examine the barriers that Black patients may express to equal care. Dr. Ramos will work with the Center for Black Maternal Health and Reproductive Justice to conduct surveys on physician trust and adherence to evidence based recommendations for Black pregnant patients, as data shows they have lower rates of acceptance of and adherence to evidence-based recommendations, like low dose aspirin for prevention of preeclampsia.
During the two years that the study is funded for, Dr. Ramos is looking forward to gathering and analyzing data to publish in the literature on disparities research, as a contribution to addressing this critical societal and medical issue in the United States.