The Centers for Disease Control and Prevention define social determinants of health as “the conditions in the places where people live, learn, work, and play” that can affect health outcomes. Systemic racism is a root cause of the power and wealth imbalances that affect social determinants of health, creating disproportionate rates of comorbidities and adverse outcomes in the communities of racial and ethnic minority groups. Focusing primarily on disparities between Black and White individuals born in the United States, this document reviews the effects of social determinants of health and systemic racism on reproductive health outcomes and recommends multilevel approaches to mitigate disparities in obstetrical outcomes.
Introduction
The effect of social determinants of health (SDOH) ( Figure 1 ) and systemic racism on obstetrical healthcare and outcomes is one of the most important challenges in reproductive healthcare today. Despite individual and systematic efforts to understand social determinants of reproductive health and to dismantle the associated obstetrical health disparities, there remains a need for changing care delivery to achieve equitable and desirable health outcomes among obstetrical patients. The purpose of this document is to review the effects of SDOH and systemic racism on reproductive health outcomes ( Table 1 ) and to recommend multilevel approaches to mitigate the disparities in obstetrical outcomes ( Table 2 ).
| Outcomes | American Indian/Alaska Native | Asian | Black | Hispanic |
|---|---|---|---|---|
| Prepregnancy health | ||||
| Obesity , | > | < | > | > |
| Hypertension | n/a | < | > | < |
| Diabetes mellitus , | > | > | > | > |
| Anemia | n/a | < | > | > |
| Maternal health | ||||
| Gestational diabetes mellitus , | > | > | < | > |
| Cesarean delivery , | < | > | > | > |
| Maternal mortality | > | > | > | < |
| Severe maternal morbidity | > | > | > | > |
| Postpartum depression | > | > | > | > |
| IPV | > | < | > | < |
| Infant health | ||||
| Low birthweight | > | > | > | > |
| Preterm birth | > | < | > | < |
| Stillbirth | > | < | > | > |
| Infant mortality | > | < | > | > |
| Care delivery | ||||
| Prenatal care initiation in first trimester | < | < | < | < |
| Late or no prenatal care | > | > | > | > |
| Adequate postpartum pain assessment and treatment | n/a | < | < | < |
| Postpartum care follow-up | < | > | < | < |
| Postpartum depression screening | < | > | < | < |
| IPV screening | n/a | n/a | > | > |
| Level | Strategy |
|---|---|
| Healthcare systems and institutions |
|
| Individual |
|
| Society |
|
This document primarily focuses on disparities between Black and White individuals born in the United States. We acknowledge the presence and importance of disparities affecting other racial minority groups, particularly American Indian, Alaska Native, Southeast Asian, and Pacific Islander people, and disparities based on religion, sexual orientation, gender, economic deprivation, country of origin, and the intersection of historically marginalized identities minority statuses. The concepts and tools presented here are applicable beyond disparities between Black and White individuals and should be considered in that context, including the potential application of similar tools to address disparities in obstetrical care for marginalized groups other than Black persons.
Defining the problem
What are social determinants of health?
The Centers for Disease Control and Prevention (CDC) define SDOH as “the conditions in the places where people live, learn, work, and play” that can affect health outcomes ( Figure 1 ). SDOH include but are not limited to factors that may affect access to healthcare, such as access to stable and safe housing; access to clean water, food, other supplies, and translation services; access to education and transportation; and employment status. SDOH extend beyond sociodemographic risk factors (eg, race, socioeconomic status, education level, and marital status) and health behaviors (eg, smoking, nutrition, and prenatal care utilization), although many of those risk factors, including exposure to racism and lower socioeconomic status, are the key drivers affecting many SDOH. It is important to note these differences between SDOH and demographics because compared with demographic data sets, data sets on SDOH remain limited. As national organizations begin to emphasize the importance of screening for SDOH, more information will be available to analyze the association between SDOH and reproductive health outcomes.
What is the role of systemic racism on health outcomes?
Although race is frequently cited as an SDOH and a risk factor for adverse obstetrical outcomes, it is exposure to systemic racism that is the critical factor. Systemic racism is a root cause of the power and wealth imbalances that affect SDOH, creating disproportionate rates of comorbidities and adverse outcomes in communities of racial and ethnic minority groups ( Figure 2 ). Exposure to systemic racism encompasses socioeconomic inequalities such as access to education, healthy lifestyle opportunities, and healthcare. Experiencing discrimination has been associated with chronic stress leading to increased morbidities, higher rates of disease, and epigenetic changes.
Prather and colleagues present a socioecological model to demonstrate the role of racism on the sexual and reproductive health outcomes among Black people and provide health considerations that promote equity. This model describes institutional, personally mediated, and internalized racism, all of which play key roles in the trajectory of sexual and reproductive health experiences and outcomes through discrimination, substandard medical care, and unnecessary surgeries that are independent of socioeconomic status, insurance coverage, and access to care. Only recently has institutionalized racism been recognized and identified as a fundamental cause of health inequities and was rarely explicitly highlighted before 2015. Although extensive research demonstrates racial disparities in health outcomes, research documenting the negative influence of racism on Black individuals’ reproductive and overall health remains sparse. Continued study of causal influences and conceptual models that drive equity efforts through institutional and systemic change is needed. One such model is the critical race framework of Hardeman and colleagues that proposes that disparities in birth outcomes experienced by Black individuals are driven by historic and structural racism and injustices that can only be remedied through a shift in power dynamics between the system and the community.
How do social determinants of health influence prepregnancy health, and what is allostatic load?
In addition to the effects of SDOH and systemic racism on reproductive health outcomes, there has been increasing evidence to support early health deterioration among Black individuals when compared with White individuals. This disparity is known as allostatic load, which represents increased “weathering” or “wear and tear” caused by the high effort required to cope with acute and chronic stressors over the life course. Increased allostatic load is associated with an increased risk for chronic disease and comorbidities, including hypertension, abdominal obesity, and cardiovascular disease. This weathering is not explained by racial differences in poverty and appears to affect Black individuals more negatively than their White counterparts.
Black women experience race-related discrimination that affects all Black individuals, in addition to gender discrimination, sexual harassment, and sexism, suggesting that the accumulation of stress over the life course may be intersectional. Of all the demographic groups, Black women have the highest documented allostatic load. This disparity reflects the cumulative physiological effects of stress over the life course as a consequence of experiencing social, structural, and environmental stressors that are frequently the product of racism. , The concept of allostatic load has guided the exploration of how chronic stress before pregnancy may contribute to birth outcome disparities. This hypothesis proposes that the cumulative effects of racism, economic disadvantage, and the associated stress throughout a Black woman’s lifetime erode her health and put her at higher risk for poor obstetrical outcomes with increasing age. Biologically, Black women are 7.5 years older than White women of the same chronological age as measured by telomere length, with perceived stress and poverty accounting for 27% of this difference. A recent study measuring allostatic load biomarkers at a maximum of 4 months before pregnancy found that each unit of increase in allostatic load was associated with increased odds of preeclampsia (62%), preterm birth (44%), and low birthweight (39%).
In addition to higher allostatic load, disparate community conditions and experiencing discrimination negatively affect prepregnancy health. Systemic racism is associated with housing discrimination and food deserts as a consequence of historic housing polices known as redlining and a lack of availability of grocery stores. Racial residential segregation among Black persons has also been independently associated with adverse pregnancy outcomes. One study of 4770 non-Hispanic Black persons using census tracts data demonstrated a higher level of preterm birth in high residential segregation areas compared with low segregation areas (15.5% vs 10.7%; P <.001).
Which perinatal outcomes have the greatest association with social determinants of health and systemic racism?
Multiple studies have shown that increases in specific obstetrical-related morbidities and mortality are associated with SDOH and exposure to racism. This section focuses on the different perinatal outcomes associated with SDOH and systemic racism.
Maternal mortality and severe maternal morbidity
Black women are more than 4 times more likely to die from pregnancy-related complications, , and almost 2 times more likely to die in the hospital than White women. The pregnancy-related mortality ratio for Black women aged 40 years or older in one cohort approached 150 maternal deaths per 100,000 live births vs 40 per 100,000 live births among White women in the same age group.
The adjusted risk for severe maternal morbidity (SMM) in California between 1997 and 2014 was higher for non-Hispanic Black women than for non-Hispanic White women. Comorbidities, cesarean delivery, and other factors including educational attainment did not fully explain these disparities in SMM, which remained persistent over time. Instead, evidence for the persistence of SMM disparities among Black individuals after comorbidity risk adjustment indicates that factors other than comorbidities (eg, lower-quality healthcare and social factors) are likely to be additional contributors to disparities. Black individuals with chronic medical conditions experienced higher rates of adverse outcomes in pregnancy than White individuals with similar conditions. In racial and ethnic minorities, being overweight and obese and having hypertension, diabetes, and anemia are more frequently seen before pregnancy, and these conditions are associated with several pregnancy complications, including preterm birth, stillbirth, macrosomia, gestational diabetes, and cesarean delivery. Racism and SDOH contribute to the Black-White disparities in the prevalence of these preexisting conditions that increase a pregnant person’s risk for maternal morbidity and mortality. ,
Obstetrical outcomes and infant mortality
Non-Hispanic Black women experience a 1.5- to 2-fold higher rate of preterm birth than non-Hispanic White women. , The overall rate of preterm birth in the United States in 2019 was 10.23%. Black (14.39%), American Indian or Alaska Native (11.59%), and Native Hawaiian or Other Pacific Islander (11.15%) women have the highest risk for preterm delivery as opposed to non-Hispanic White (9.26%), Asian (8.72%), and Hispanic women (9.97%). Inequities in preterm birth persist after controlling for risk factors such as smoking, birthing parent’s education, and socioeconomic status. Self-reported experiences of discrimination are associated with both higher rates of preterm birth and low birthweight. A March of Dimes scientific workgroup concluded that exposure to racism is “a highly plausible, major upstream contributor to the Black-White disparity in PTB [preterm birth] through multiple pathways and biologic mechanisms.”
Although the infant mortality rate in the United States has decreased substantially over time, the decline has not been uniform across the population. The Black infant mortality rate persistently remained 2.2 times higher than the rate for non-Hispanic White infants, whereas the non-Hispanic White infant mortality decreased during the same time period. Black pregnant individuals are also more likely to experience a stillbirth than non-Hispanic White pregnant individuals. In 2004, the overall fetal death rate (death at 20 weeks of gestation or later) was 6.2 deaths per 1000 live births and fetal deaths; the rate for Black infants (11.3 per 1000) was more than twice that of non-Hispanic White infants (5.0 per 1000). Black women are also more likely to experience fetal growth restriction, a significant contributor to neonatal morbidity and mortality, than women of other races and ethnicities.
Socioeconomic and educational disparities have a complex and variable relationship with these highlighted disparities in outcomes. Although higher levels of education are associated with a decreased risk for infant mortality, at lower levels of educational attainment, the risk for infant mortality remains higher for non-Hispanic Black women when compared with non-Hispanic White women. When compared with data on educational attainment, the relationship between the preterm birth disparity and socioeconomic status appears paradoxical. A large population-based survey of more than 10,000 women who gave birth within a 7-year period demonstrated that, in the most disadvantaged subgroups, Black and White women are at a similar risk for preterm birth; however, among the more socioeconomically advantaged subgroups, Black individuals are at higher risk for preterm birth than White individuals.
Which disparities are seen in the receipt and quality of obstetrical care?
Prenatal care
There are 3 major categories of delays in care that affect maternal outcomes worldwide: delay in seeking care, delay in arrival, and delay in the provision of adequate healthcare. , SDOH and racism play a role in causing delay at each level. Although early initiation of prenatal care has been associated with improved obstetrical outcomes, racism and discrimination create barriers to accessing care in a timely fashion and to optimizing system engagement. , As a result, these barriers prevent Black women from equitably initiating and receiving adequate prenatal care by the end of pregnancy when compared to White women, with 9.6% of Black women and 13.0% of American Indian or Alaska Native women receiving late (starting in the third trimester) or no prenatal care compared with only 4.5% of White women in a 2019 study. Racism and discrimination continue to play roles in the care experienced during pregnancy after prenatal intake, further reducing the chances of receiving optimal care. , More than 40% of women reported communication problems in prenatal care, with Black and Hispanic women having higher odds of perceived discrimination owing to race or ethnicity than White women. In the prenatal setting, Black women reported perceptions that their healthcare provider made negative stereotypical assumptions about their status regarding insurance, marriage, and substance use, leading to unfair treatment.
Delivery, postpartum, and neonatal care
Many Black and Hispanic women perceive discrimination during their hospitalization for birth. Cesarean delivery is more common among Black women than among White women (odds ratio, 1.12; 95% confidence interval, 1.12–1.13). Johnson et al showed that severe postoperative pain (score of 7/10 or greater) was more likely among Black (28%) and Hispanic (22%) women than among those who identified as White (20%) or Asian (15%). The study also showed that non-Hispanic White women were more likely to have their pain assessed and received more narcotic medications within the first 24 hours after cesarean delivery than Black, Asian, and Hispanic women.
A recent publication examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggested that racial concordance between the newborn and physician is associated with a significant reduction in mortality for Black infants. In the care of White physicians, Black newborns have a 3-fold higher in-hospital mortality rate when compared with White infants.
Interpregnancy, prepregnancy, and contraception care
Non-White race is a negative predictor of postpartum primary care follow-ups for people with pregnancy conditions that confer lifetime health risks, including diabetes or gestational diabetes and hypertensive disorders of pregnancy. A California-based study of deliveries among 200,000 Medicaid recipients found that, compared with White women, Black women attended postpartum visits less often and were less likely to receive any contraception. Self-reported rates of experiencing discrimination are negatively associated with contraception use and partially mitigated by eliminating financial and structural barriers to contraception access. Regarding prepregnancy care, although Black women are more likely to have chronic conditions that might benefit from optimization and counseling before becoming pregnant, they are less likely than other women to receive prepregnancy counseling.
Addressing the Problem
It is well established that SDOH and systemic racism have deleterious effects on reproductive health outcomes. To date, as cited in the previous sections, substantially more published evidence has been accrued for defining the problem and delineating the inequities than for resolving them. This lack of evidence is likely because of the multifactorial nature of any solutions, making the assessment of evidence and the development of concrete mitigation strategies difficult. In the next section, established strategies that can start to eliminate the disparities in obstetrical outcomes when possible, along with promising emerging strategies that will need to be continually evaluated for their efficacy over time, are presented. Suggestions for multilevel approaches to systems assessment and care delivery are summarized in Table 2 and can be considered when creating an “Equity Bundle.”
What can healthcare systems and institutions do?
Conduct internal assessments of the barriers against and facilitators of providing equitable care
Systematically conducting internal assessments will facilitate understandable and actionable comparisons between and within systems over time, which can be used to drive change.
Several frameworks have been proposed for healthcare system modification and healthcare worker training to reduce the risk for racism-based adverse outcomes. In 2018, Howell and colleagues published the Reduction of Peripartum Racial and Ethnic Disparities Patient Safety Bundle, which includes several strategies related to conducting internal evaluations. Domains in which there are opportunities to improve include readiness, reporting and systems learning, recognition, and response. This information was reemphasized in 2019 with a proposed 8- step plan that healthcare systems can follow to reduce racial and ethnic disparities in care. Among these are strategies that should be adopted by health care institutions to assess how they are performing in terms of disparities in prenatal care utilization and in-hospital disparities, including:
- •
Assessment of language needs and cultural barriers to receiving information
- •
Implementation of a disparities dashboard
- •
Performance of enhanced maternal mortality and SMM reviews
- •
Evaluation of opportunities for standardization of care through checklists and bundles
- •
Care utilization tracking
- •
Evaluation of the institutional culture––is it a culture of equity and of safe reporting? This strategy must include an assessment of the engagement level of key stakeholders.
- •
Evaluation of opportunities for new models of care that may eliminate disparities
- •
Group prenatal care models; case management and patient navigation programs and virtual care pathways
Another framework that can be used to identify root causes and to eliminate disparities is an equity impact assessment tool. A Racial Equity Impact Assessment (REIA) is a systematic examination of how different racial and ethnic groups will likely be affected by a proposed action or decision. REIAs are used to minimize unanticipated adverse consequences in a variety of contexts, including the analysis of proposed policies, institutional practices, programs, plans and budgetary decisions.
Create and support a culture of safety, centralized reporting, and institutional response to identify and address instances of racism or bias
It is incumbent on healthcare systems to create a reporting structure that prioritizes the identification of systemic and individual acts of racism or bias as potential root causes of adverse health outcomes. A fair and just culture supports robust reporting systems because well-intentioned employees can feel confident that the contents of the report will remain confidential and will lead to reflective system improvements instead of reflexive punishment.
As part of the quality and safety strategy proposed by the Institute for Perinatal Quality Improvement, another element of eliminating “strong but wrong routines” is to change a culture that may perpetuate disrespect and differences in care. The SPEAK UP for Black Women campaign ( Box 1 ) encourages healthcare professionals to speak up against racism whenever they see racist behaviors or hear racial slurs.
| SPEAK UP actions | |
| Set limits | Allow only racially respectful speech and action in your workspace |
| P ractice and p repare | Plan how to act and to disrupt conversations and behaviors that are disrespectful, racist, or dehumanizing |
| Express your concerns | Be bold, clear, and straightforward. Discuss why you are concerned |
| A pologize | Say you are sorry, change your behavior, and ensure reconciliation if you said or did something that perpetuates racism |
| K eep improving | Be courageous. Become aware of your implicit and explicit biases. Seek feedback and collect data so you can keep learning and improving |
| U ncover and learn | Be curious, mindful, and open to new perspectives as you deepen your understanding of racism and its harmful effects |
| P ersuade others | Spread the word and encourage others to speak up against racism |
Create a data infrastructure to improve health equity
Systems must prioritize the reporting of adverse outcomes with anonymized, multidisciplinary reviews that address the potential for racism or biases as a standard item. In 2016, the Institute for Healthcare Improvement (IHI) published “Achieving Health Equity: A Guide for Health Care Organizations,” which presents a 5-component framework to guide health systems in their efforts to improve health equity. One of these strategies involves building an infrastructure to support health equity work. To improve health equity, organizations first need to understand where the disparities exist. Identifying disparities requires the accurate collection of race, ethnicity, and language (REaL) data, based on patient self-reporting, and the resources to analyze these data. Registration and admission staff are key to collecting accurate data. Research and field work have shown that registration staff and patients benefit when staff are partners in the process and when they receive training on the reasons for collecting this information and to develop the skills required to do so.
Establish a patient quality and safety infrastructure that monitors and evaluates for disparities in the outcomes
Once REaL data are being collected accurately, the next strategy for building data infrastructure to support health equity is to display the stratified data. The only way to make progress in reducing disparities is to measure them. For example, a disparities dashboard stratifies quality metrics by the social constructs of race and ethnicity. Implementation of this useful tool allows hospitals and healthcare systems to become aware of the disparities and to monitor their performance among groups with higher risks for poor outcomes by using quality metrics.
Another approach proposed by the IHI is to stratify REaL data for one strategic measure to build intention and interest among leaders and clinicians. Quickly deploying stratified data for one strategic measure instead of waiting for the development of an entire dashboard allows the organization to learn about and understand aspects of equity in practice. This approach supports the IHI’s current recommendation that organizations should gain experience in improving equity by first applying an “equity lens” to existing improvement projects aligned with strategic priorities rather than by chartering new projects with the specific focus to improve equity.
Main and colleagues demonstrated the ability to eliminate disparities through quality improvement (QI) work by retrospectively looking at their outcomes after implementation of the hemorrhage patient safety bundle. The group performed a cross-sectional study among patients affected by obstetrical hemorrhage in 99 hospitals participating in a QI collaborative. The group highlighted the “marked improvement” in the rates of SMM caused by hemorrhage among Black individuals and reducing Black-White disparities for this outcome. These important findings suggest that QI efforts can improve maternal outcomes and reduce inequities in care delivery for a specific medical condition. This group further concluded that the data demonstrated that there are opportunities for reducing Black-White disparities for the most common maternity complication, hemorrhage, by implementing national safety bundles for the prevention of and response to obstetrical hemorrhage. We propose approaching each QI effort with a health equity focus from the beginning of a project to allow for a more targeted approach by implementing interventions most likely to eliminate disparities.
In addition, as part of quality and safety case reviews and debriefs, SDOH and disparities should be evaluated routinely. Using a framework developed by the Council on Patient Safety in Women’s Healthcare, the SMM review form can be used to conduct an enhanced review by a multidisciplinary team to identify potential system-, provider-, and patient-level factors that may have altered the outcome. Patient-level factors include a focus on the influence of SDOH, such as how food and housing insecurity, lack of transportation, and lack of health insurance may have affected the outcome. Reviewing these potential contributing factors can assist with hospital QI plans that target upstream contributors to health outcomes, such as the use of social services to assist during prenatal care, so that adverse outcomes around the time of delivery may be averted.
Once disparities have been identified, use a systematic approach to eliminate them
The Institute for Perinatal Quality Improvement proposes the following 5 quality and safety strategies to guide national-, state-, and hospital-based efforts to eliminate disparities in perinatal outcomes and to ensure equity for all people and newborns:
- 1.
Apply a systems approach based on the socioecological model
- 2.
Identify root causes of disparities
- 3.
Identify and eliminate strong but wrong routines
- 4.
Use improvement and implementation science methods and tools
- 5.
Use data to guide the plan and track progress
The key insight of the first strategy is that a person’s health is directly related to SDOH. Ishikawa cause-and-effect (fishbone) diagrams are used to understand the key components in a system that led to a failure or contributed to a poor outcome. The Institute for Perinatal Quality Improvement used the Ishikawa diagram format and the socioecological model to develop the Socio-Ecological Perinatal Disparities Ishikawa Diagram, which outlines numerous modifiable, system-level factors that can contribute to perinatal disparities ( Figure 3 ). This tool is recommended to support the second strategy, which aims to determine the root causes of disparities. The third strategy emphasizes scrutinizing and improving all routines to ensure that suboptimal processes are not propagated simply because they have become ingrained in clinical care. The fourth and fifth strategies stress the importance of sustaining QI efforts, even as new and competing initiatives are introduced. QI efforts can be sustained through continual surveillance of structure, process, and outcome data measures. The analysis should be done in a manner that easily identifies outcomes by race and ethnicity and allows comparison within a hospital and across hospitals, communities, regions, and nationally.
