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Invited Commentary
Obstetrics and Gynecology
September 30, 2021

What Is the Long-term Impact of Racist Social Policies on Perinatal Outcomes?

Author Affiliations
  • 1Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
JAMA Netw Open. 2021;4(9):e2127956. doi:10.1001/jamanetworkopen.2021.27956

There are persistent racial and ethnic disparities in obstetric and neonatal outcomes in the United States. These increased risks include a wide of range of outcomes, such as higher rates of preeclampsia, stillbirth, preterm birth, fetal growth restriction, and maternal morbidity and mortality in Black women compared with White women.1 While there are disparities seen for other racial and ethnic groups, the differences between Black and White people are stark, persistent, and likely have a basis in systemic racism that goes back hundreds of years. Some of these health inequities are inculcated into how actual health care is provided. For example, a 2020 study by Vyas et al2 pointed out that the calculator commonly used to counsel women about undergoing a trial of labor after having previously undergone cesarean delivery uses race in the risk calculation in such a way as to potentially perpetuate racial and ethnic inequities in cesarean deliveries, leading the authors to call to cease use of the calculator.

However, many of the racial and ethnic differences seen in health outcomes likely stem from lifelong personal experiences of racism and structural racism throughout an individual’s experiences outside of health care as well. An association between experienced racism and risk of preterm birth was reported in a 2002 study.3 Additionally, these experiences of racism and their impact may be intergenerational and have persisted for decades, if not centuries. The study by Hollenbach et al4 explored obstetric outcomes associated with historical redlining, a federal housing policy beginning in the 1930s that was used to deny home loans to members of racial and ethnic minority groups, particularly Black people, and that in some ways persists today. Hollenbach et al4 combined information about how such districts were described in the 1940 Home Owner’s Loan Corporation map in Rochester, New York, with data from the 21st century to see how these designations were associated with birth outcomes 70 years later. While some of the boundaries of the districts have changed, the study found a persistent and reproducible increased risk of preterm and periviable birth among women who lived in districts that were historically classified as “Hazardous.” At first blush, one might point out that these historical districts are likely associated with the distribution of Black people then and now and that is the driver of these findings. However, when Hollenbach et al4 controlled for parental race, while the odds ratios diminished, they remained positive and statistically significant. Thus, some of these differences appear associated with race in general, but there was an association more specifically with one’s neighborhood as well. These findings were robust and similar to those of another similar study from California.5

While certainly, some of these differences are due to persistent socioeconomic differences that are marked by neighborhoods or districts, essentially, that is the point. Denying Black people access to home loans generations ago impeded the ability of these families to develop intergenerational wealth, making it more difficult for social mobility to occur. While such social mobility does not diminish all health inequities, it can reduce them. For example, a 2011 study6 found that pregnant Black women who lived in a zip code with a higher socioeconomic status than the one they grew up in had a decreased risk of preterm birth.

When we consider a study such as that of Hollenbach et al,4 it is not one that presents an easy target for intervention. Rather, this is an opportunity to begin to understand how health inequities were and are created and allowed to persist. It also provides insights about how systemic racism in other realms of life leads to health inequities. While we, as clinicians, may not be responsible for these sources of health inequity, it is incumbent on each of us to recognize the systemic racism our patients have experienced and seek out how to reduce the health inequities they incur. In 2021, a year after the murder of George Floyd and subsequent protests, and the 100th anniversary of the Tulsa massacres that destroyed billions of dollars of potential Black intergenerational wealth, we have much to learn as a society to reduce the longstanding impact of racism.

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Article Information

Published: September 30, 2021. doi:10.1001/jamanetworkopen.2021.27956

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Caughey AB. JAMA Network Open.

Corresponding Author: Aaron B. Caughey, MD, MPP, MPH, PhD, Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97219 (caughey@ohsu.edu).

Conflict of Interest Disclosures: None reported.

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