Maternal and Infant Mortality Disparities May Just Be The Tip Of The Iceberg
How racism is affecting the health of Black communities in the U.S
The pervasiveness of racism in the United States is seeping into our bodies and affecting our health. Perhaps one of the biggest public health crises of our time is one that has not received enough attention. The Black-White disparity in maternal and infant mortality in the U.S is shameful and is a cornerstone for public health professionals in understanding race as a social determinant of health. Black women are 2 to 3 times more likely to die from pregnancy or childbirth than White women (1). This disparity worsens with age: Black women older than 30 years old are 4 to 5 times more likely to die as a result of pregnancy than their White counter-parts (9). This disparity persists even among mothers with a college degree or higher (9). Black moms are 2.3 times more likely than White moms to receive late or no prenatal care (10). Black babies are 2.3 times more likely to die within the first year of their life than White babies (10). Black babies are more likely to die as a result of low birthweight and Sudden Infant Death Syndrome (10). Eliminating this disparity would have saved almost 65,000 black babies between 2000 and 2013 alone (2).
A Potential Determinant: Stress
There are many possible determinants of these disparities. Many scientists have pointed to lower quality prenatal, hospital and post-natal care, often related to discrimination experienced within the health care system (11). Some have also claimed that these Black moms have lower levels of health-seeking behaviors or that lifestyle factors contribute to the disparity (11). While it seems likely that discrimination during the period of pregnancy and childbirth as well as lower access to health-promoting resources because of other societal racial disparities, these stories seem to be lacking, given how dramatic these disparities are. The lifestyle and access to resources question also does not explain why rich, educated Black women are still more likely to die because of pregnancy than poor, uneducated White women. I suggest that the primary reason for this disparity is actually stress. Extensive research has supported this idea, that Black women experience higher levels of stress and that results in poorer outcomes. Stress in pregnant women is particularly dangerous, being that pregnancy is a sensitive developmental period in which stress can have ramifications for infant mortality risk (3). Maternal psychological stress during pregnancy may exert a “programming” effect on the developing telomere biology system that is already apparent at birth, as reflected by the setting of newborn leukocyte telomere length (7). Stress‐ and/or pregnancy‐related hormones (corticotropin releasing hormone, adrenocorticotropin, prolactin, and progesterone) might interact with peripheral and local immunocompetent cells, such as certain T cell subsets, mast cells or NK cells, and result in changes of cytokine production (8). However, when we are talking about stress in this context, we are not just talking about stress while pregnant. We are talking about substantial prolonged stress that Black women are experiencing their whole lives, accumulating in their bodies, and creating negative outcomes during their pregnancies and childbirth. Not only does this stress hurt the mothers but it may be affecting their babies in-utero, making Black babies have complications and die.
Racism As A Stressor
So why are Black women more stressed over their life course than White women? Many scientists have conceptualized racism as a life-long stressor that has the potential to affect psychological and physiological functioning (4). This idea argues that, by virtue of being Black in the U.S, you are more likely to experience individual, intra-personal and systemic racism, and are therefore more likely to experience significant stress on a regular basis during all periods of life. Very few people would doubt that living in a racist society would be a stressful experience for the oppressed group. We are starting to discover the significant effect that stress, especially prolonged stress, can have on the body.
The most obvious pathway is that elevated stress, meaning sustained levels of cortisol in your blood, likely results in poorer mental health. Indirectly, stress causes poorer mental health, which in turn creates negative physical health outcomes. We are discovering that mental and physical health are intertwined and that poorer mental health can have direct consequences for physical health as well. Current evidence points to additional psychophysiological pathways linking facets of racist environments with physiological reactions that contribute to disease (6). There are also direct relationships between racism and physical health, being that Black Americans are more likely to be poor, live in a low-resource area, go to low-resource schools, have inadequate access to healthy food and exercise, live in an area with more crime, be un-insured, and have poorer access to quality health care. All of these experiences have direct implications for mental and physical health.
Health Effects Beyond Maternal and Infant Outcomes
So, if Black people are more likely to experience prolonged toxic stress, why do we only see its consequences during pregnancy and childbirth? The simple answer is that we don’t. The same toxic stress related to racism causing maternal and infant mortality disparities could be the cause of other racial disparities in the U.S. I suggest that the disparities in maternal and infant mortality, that led to these discoveries about the effect of toxic stress and racism, are so strong because pregnancy is a particularly vulnerable period in which the role of stress is more significant than in other times in life. But that doesn’t mean that toxic stress and racism is not a significant factor in all Black people’s lives at all periods of their lives. It seems likely that if Black pregnant women are experiencing the negative outcomes of toxic stress and racism, that all Black people have a similar experience that may manifest in different ways.
Stress resulting from racism may be a significant determinant in all Black-White health disparities. There is evidence that racism, largely via inequalities in power, prestige, freedom, neighborhood context, and health care, has a fundamental association with health independent of socio-economic status (5). Overall, there are significant disparities between Black and White people in the U.S, outside of maternal and infant health. Black people are still expected to live 2.5 years less than White people (12). Only 1 in 3 Black Americans who need mental health care receive it (14). Compared to White Americans, Black Americans with any mental illness have lower rates of any mental health service use including prescriptions medications and outpatient services (14). Black people are more likely to have AIDS, chronic diseases, obesity, heart disease, stroke, asthma, influenza, pneumonia, diabetes cancer and die by homicide (13, 14).
Stress As A Determinant Of All Racial Health Disparities
Toxic stress may be a common experience in the Black community, as a result of the racist society that we live in. Maybe the stress so clearly reveals itself through a vulnerable period like pregnancy but is the underlying result of many disparities that we see in Black-White outcome comparisons. It seems likely that if racism-related stress is causing more Black babies and moms to die that it may be affecting the health of the whole Black community in a way that is harder to investigate scientifically. All of the health disparities described above may be at least partially described by this phenomena.
Visual 1: This diagram depicts some of the systems and outcomes that I described above (15).