New research links racism to higher premature birth rates among black women

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Two new studies add to the growing body of evidence that racism plays a key role in the persistent disparities in preterm birth that exist between black and white women in the United States.

Although there is ongoing research on the association between preterm birth and factors such as the health of pregnant women or the level of access to medical care, there is a growing body of evidence, including the two recent studies, that societal factors, including racism, also have an impact on preterm birth rates.

In an article published in September, a task force convened by the March of Dimes examines the existing literature on contributors to racial disparities in preterm births and finds racism at the root of it all.

Meanwhile, in another study also published in September, researchers at the University of Rochester picked 15 zip codes in Rochester, New York, and overlaid them with the map of the historic discriminatory practice of redlining home loans. Their results show how structural inequalities cast a shadow over today’s health outcomes.

Premature birth, that is, giving birth before 37 weeks of pregnancy, is associated with a higher risk of death and long-term health complications in babies. Researchers are interested in premature birth rates because it is an indicator of the health of a community or nation.

“Since there are a lot of things that impact preterm births, it probably captures both the issues of accessing healthcare and the resources we are able to provide to patients,” says Dr Stefanie. Hollenbach, assistant professor of obstetrics and gynecology at the University of Rochester Medical Center. “But it also captures elements of community and social structures that can be linked to health outcomes.”

Premature births are on the increase in most countries and are now the second leading cause of death in children under five, after pneumonia, according to the World Health Organization. Every year, around 15 million babies are born prematurely around the world. That’s about one in 10 births.

Premature birth rates in the United States are no better than global rates: 1 in 10 babies are born too early, according to the March of Dimes, a nonprofit maternal health education and advocacy organization and infantile. Premature birth is the second leading cause of infant death in the United States and the leading cause of death among black babies, according to the organization. Black women have the highest rate of preterm births compared to all other races and ethnicities in the United States

Below, we explain the two new studies in more detail, including interviews with some of the authors.

Associations between historically demarcated districts and racial disparities in current obstetric outcomes
Stefanie Hollenbach, Loralei Thornburg, J. Christopher Glantz and Elaine Hill. Opening of the JAMA network, September 2021

In 2016, a local Rochester newspaper, the Democrat & Chronicle, ran an article about the new redlining maps, which were digitized by a four-university effort called Mapping Inequality. Two University of Rochester researchers read the journal article and wondered if the cards could help understand how discriminatory lending practices from decades ago are associated with health outcomes today, including disparities in premature birth rates.

The practice of redlining began in the 1930s with the federal Homeowners’ Loan Company. HOLC created color-coded cards telling banks where it was “safe” to issue mortgages.

The maps had four categories or ratings: green for “best” neighborhoods, blue for “still desirable” areas, yellow for “definitely in decline” and red for “dangerous” areas. Areas marked “dangerous” mainly included low-income people, foreign-born people and, in most cases, black people.

The practice lasted for three decades, but even after the closure of HOLC and the passage by Congress of the Federal Fair Housing Act of 1968 prohibiting discrimination in housing based on race, religion and country of Originally, the negative effects of redlining persisted. Studies have shown that the practice has lasting implications, affecting not only the socio-economic status of blacks, but their health as well.

To explore their local community, the researchers examined 64,804 birth certificates dated 2005 to 2018 in 15 zip codes in Rochester, using the New York State Department of Health’s electronic birth certificate database. . They then overlaid the data with the historical redlining maps. Some postal codes had a single red card designation and others had two or more designations.

They found that preterm birth rates increased with the worst shades of HOLC color. The highest preterm birth rate – 12.38% – was in the single postcode that overlapped the area defined as “dangerous” by the HOLC card. The lowest preterm birth rate of 7.55% was found in a single zip code that overlapped an area that was historically defined as “best” or “still desirable.” The overall premature birth rate for the study population was 10.36%.

The associations persisted even after researchers controlled for the poverty and education levels and race of parents.

They also found that the odds of being diagnosed with severe maternal depression and substance use disorder were significantly higher in areas labeled as “unsafe” compared to those labeled as “better” or “still desirable. In the red cards.

“I think it is important as clinicians to recognize that there are many facets of our patients’ experiences that impact their health outcomes,” says lead author Hollenbach. “All of us in the community, including the doctors, really need to be motivated to understand that healthcare is only one part of it and that our community structures also have a real impact on the differences. “

Even through the authors controlled for race, they did not do the analysis separately for black and white women. Within the scope of the study’s limitations, they also say that the results may or may not be generalizable to other U.S. cities.

“I hope this is the start of a long series of research with my colleagues where we can reflect on how to tackle persistent poverty in the Rochester area and whether some of the historic practices might be something we can try to sort it out, ”says co-author Elaine Hill, economist and associate professor of public health sciences, economics, obstetrics and gynecology at the University of Rochester Medical Center. “I feel like we have to tackle this story. “

Explaining the disparity between blacks and whites in premature births: a consensus statement from a multidisciplinary scientific working group convened by the March of Dimes
Paula Braveman; et al. Reproductive epidemiology, September 2021.

In 2017, March of Dimes convened a multidisciplinary task force to review the existing literature on persistent racial disparities in preterm births in the United States. Reviews continued until consensus was reached, according to the document.

The team reviewed 456 peer-reviewed English articles published over the past decade. “Limited web material from scientifically reliable sources [e.g., Centers for Disease Control and Prevention (CDC) reports] were also included, ”they write.

Based on the metaphor of a river flowing from its upstream source to its downstream destination, the working group placed 30 potential factors leading to preterm birth into three categories: upstream, mid-term and downstream. , depending on the proximity of their effects to premature birth.

Downstream factors include prenatal care, substance use disorders, age, and chronic illnesses such as obesity, diabetes, and high blood pressure. Intermediate factors include stress, depression, social support, income, education, and neighborhood socioeconomic disadvantage. The only element identified as an upstream factor was racism, which could directly and indirectly explain the disparities between intermediate and downstream factors, according to the document.

“None of these downstream factors alone could explain the disparity between blacks and whites, but if you put them all together, they could,” says lead author Dr. Paula Braveman, social epidemiologist, founder and professor of family and community medicine. director of the Center for Health Equity at the University of California, San Francisco School of Medicine. “And then that raised the question: if you have so many biologically plausible things [mechanisms], is there a common source that sets them in motion? And racism was the only factor identified by one of the committee members. “

The authors also looked at studies exploring the role of genes in preterm births and found that genetic factors at most could explain a small fraction of the disparity in preterm birth rates between black and white women.

“When considering the potential role of genetic factors, it is important to note the scientific consensus that race is primarily a social construct and not a biological one,” they write in their consensus statement.

The authors say that racism explains the racial disparity in socio-economic factors. The legacy of slavery, 100 years of Jim Crow laws, residential racial segregation and continued discrimination in employment, housing, policing and sentencing “have relentlessly deprived African Americans of ‘socio-economic opportunities,’ they write.

Racial discrimination is also a powerful direct source of stress, the researchers write. Stress can lead to changes in the body’s immune pathways, leading to immune and inflammatory conditions, which are among the factors believed to be associated with preterm labor.

“What neuroscience has revealed, especially over the past 10 to 20 years, is the huge role that stress, and in particular chronic stress, plays in health through pathways that start with neuro disturbances. -endocrine that trigger movement mechanisms that produce inflammation, ”explains Courageous Man.

In short, the woman’s experience, including the stress of racism, has already caused a level of damage that will not be significantly reversed, she says.

“My hope would be that if [researchers and clinicians] read this review article, it would make them more receptive to the idea that racism kills, ”said Braveman.

Learn more about redlining

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