Structural Racism and Black Maternal-Infant Birth Outcomes

Abstract

The United States is currently in a perinatal health crisis. Among high-income countries, the United States has one of the highest rates of maternal morbidity—a range of conditions that can cause short- and long-term consequences for birthing people and include some “near misses” of maternal deaths. There are 100 cases of maternal morbidity for each case of maternal mortality. And racial disparities persist. Black people are twice as likely to experience maternal morbidity or infant mortality than their white counterparts. There is increasing awareness regarding the role of structural racism in driving these disparities, but there is no consensus on how this occurs. This project describes how Black birthing people experience structural racism, in their own words, and measures how structural factors and structural racism may contribute to adverse Black maternal and infant birth outcomes.This dissertation first describes how Black birthing people in the Midwest experience structural racism, especially as it relates to their reproductive health and birthing experiences. Then it examines the relationship between the Maternal Vulnerability Index (MVI; a county-level aggregate measure of determinants of maternal health) and adverse birth outcomes for Black pregnant people and their infants. Finally, this dissertation describes Black-white disparities in adverse birth outcomes at the intersection of one hospital structural factor (hospital birth volume) and race. The first study summarizes how 20 Black women in the Midwest experience structural racism, primarily related to their reproductive healthcare and neighborhood experiences, and outlines their recommendations to address the impacts of racism in their lives. Identified themes included structural racism in law enforcement, healthcare, housing, education, and immigration. Participant recommendations to address racism in healthcare included recruiting, retaining, and better-paying Black providers, reviewing, addressing, and eliminating racist practices, and centering Black women in care. In the second study we found that among term, singleton births without pre-existing conditions (lower-risk births) in urban areas of South Carolina, the odds of SMM were higher among Black people with a high (top quintile) MVI compared to those with a low (bottom quartile) MVI. The same relationship was not observed for white individuals nor an infant outcome (Unexpected Newborn Complications). In the third study, we examined the association between hospital volume and maternal-infant birth outcomes among Black and white low-risk pregnant people. Among lower-risk births, we found that Black and white infants have higher odds of UNC at low-volume hospitals than high-volume hospitals. In this same population, white pregnant people had greater odds of SMM when delivering in low volume hospitals compared to high volume hospitals, but the same was not true for Black pregnant people.