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  • Writer's picturePre-Collegiate Global Health Review

Examining Black Maternal Mortality: Racialization and the Social Determinants of Health

By Uttara Natarajan, Saratoga High School, Saratoga, California, USA



Summary

The maternal mortality crisis in the United States disproportionately affects Black women, who are over three times more likely to die in childbirth than their White counterparts. This disparity is due to a combination of social determinants of health and the storied history of medical racism against Black women. These factors include poverty, long-term exposure to racism, living in violent neighborhoods, witnessing police brutality, and similar forms of ongoing race, class, and gender oppression. The marginalization of Black women and their health needs must be addressed in order to reduce the maternal mortality rate and ensure equitable healthcare for all women.


 

Black women are over three times more likely to die in childbirth than their white counterparts and five times more likely to die of cardiac or blood pressure disorders during or after childbirth (Petersen et al., 2019; Macdorman et al., 2021). Multiple factors explained by the biopsychosocial model of health contribute to the public health emergency that Black women in the United States face today, all of which have to do with the social determinants of health and ongoing medical racism against Black women.


Figure 1: Black women show higher rates of maternal mortality across the board (“Maternal mortality rates, by race and Hispanic origin, 2021).


The World Health Organization states, “The social determinants of health (SDH) are the non-medical factors influencing health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems” (World Health Organization, n.d.). Beyond the obvious factors such as water, housing, and air quality, indirect factors such as fear, crime, lack of heating or air, dirty streets, lack of amenities, and concentrated poverty also affect physical and mental health. The weathering hypothesis was developed by public health researcher Arline T. Geronimus to account for the glaring health disparities between Black and White women over time, proposing that “chronic exposure to social and economic disadvantage leads to accelerated decline in physical health outcomes and could partially explain racial disparities in a wide array of health conditions” (Forde et al., 2019). These long-term environmental stressors, specifically for Black women, can include poverty, long-term exposure to racism, violent neighborhoods, witnessing police brutality, and similar forms of ongoing race, class, and gender oppression. Although the weathering hypothesis originated as a sociological explanation for health disparities, it is linked to the biological mechanism of allostatic load, which refers to the cumulative burden of wear and tear on the body as an individual is subject to long-term chronic stress. The body’s regulation of homeostasis in response to stressors can often leave it in a heightened state of vulnerability until the threat subsides and normalcy is returned (McEwen, 2000). Allostatic load is exacerbated by financial stress, as it is more prevalent in individuals with low income, impoverished neighborhoods, housing instability, poor coping habits, and low education (Guidi et al., 2020). Geronimus found that the allostatic load of Black women exceeded that of both Black men and White men and women. The biological impact of weathering requires the endocrine system to constantly work “overtime” to maintain defensive homeostasis while dealing with stressors (Geronimus et al., 2006).


Figure 2: The main social determinants of health (Social Determinants of Health, 2023).


Two mechanisms are commonly blamed for these negative results. The first is chronically high stress caused by discrimination, which reduces the body’s ability to fight sickness and causes dysregulation of various physiological systems. The second is that people who are discriminated against have a more challenging time engaging with institutions that provide health-beneficial resources and using those resources to safeguard and improve their own and others’ health. Findings based on measures other than patient reports, such as chart reviews, administrative data, and clinical vignettes, generally corroborate that the quality of care delivered to patients from minority and underrepresented groups tends to be lower (Cockerham et al., 2017). These social determinants of health have been established as a fundamental cause of chronic illness and thus directly influence maternal health.


One study showed that racist experiences cause an increase in inflammation in Black Americans — the body’s physical response to these stressors that Black Americans often face in day-to-day life increases the risk of becoming chronically ill and compromises biological systems that are responsible for fighting disease (Thames et al., 2019). During the vulnerable state of pregnancy, it is plausible that the inflammatory response could cause increased risks of complications during or after birth — long-term exposure to racial oppression exacerbates the heightened prenatal, birthing, and postpartum morbidity and mortality among Black women.


Modern obstetric racism can occur in diagnostic lapses, neglect, dismissiveness or disrespect, intentionally causing pain, and reproductive coercion (Scott et al., 2021). Black people are more likely to have their pain dismissed and be undermedicated by physicians. A study shows that Black people were less likely to be prescribed analgesics for conditions requiring subjective or self-reported pain levels (Tamayo-Sarver et al., 2003). This is perpetuated in maternal care, where pain-based symptoms of further complications can be ignored or dismissed by physicians because of the implicitly biased assumption that Black women are less sensitive to pain. Consequently, symptoms of urgent conditions such as preeclampsia may be ignored until they escalate to emergencies.


The maternal health crisis for Black women in the United States is a severely overlooked epidemic, which is unwarranted given the massive innovations in healthcare technology and therapeutics. The problem therein lies in the broken system of public health policy and the lack of healthcare access that accompanies systemic racism and poverty, which Black mothers face disproportionately. The treatment of Black women in obstetrics and gynecology reflects more extensive social and historical indicators of their perceived status as second-class members of American society; therefore, it is imperative to center the needs of Black women to reduce these disparities moving forward.


References

Cockerham, W. C., Hamby, B. W., & Oates, G. R. (2017). The social determinants of chronic disease. American Journal of Preventive Medicine, 52(1), S5-S12. https://doi.org/10.1016%2Fj.amepre.2016.09.010

 

Forde, A. T., Crookes, D. M., Suglia, S. F., & Demmer, R. T. (2019). The weathering hypothesis as an explanation for racial disparities in health: A systematic review. Annals of Epidemiology, 33, 1-18.e3. https://doi.org/10.1016/j.annepidem.2019.02.011

 

Fortunato, W. (2021, January 3). [Cute black baby with young mother sleeping on bed]. Pexels. https://www.pexels.com/photo/cute-black-baby-with-young-mother-sleeping-on-bed-6393340/

 

Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006). "Weathering" and age patterns of allostatic load scores among blacks and whites in the United States. American Journal of Public Health, 96(5), 826-833. https://doi.org/10.2105/AJPH.2004.060749

 

Guidi, J., Lucente, M., Sonino, N., & Fava, G. (2020). Allostatic load and its impact on health: A systematic review. Psychotherapy and Psychosomatics, 90(1), 11-27. https://doi.org/10.1159/000510696

 

Hoyert, D. (2021). Maternal mortality rates, by race and Hispanic origin: United States, 2018–2021 [Chart]. The Center for Disease Control. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021

 

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. https://health.gov/healthypeople/objectives-and-data/social-determinants-health

 

Macdorman, M. F., Thoma, M., Declcerq, E., & Howell, E. A. (2021). Racial and ethnic disparities in maternal mortality in the United states using enhanced vital records, 2016‒2017. American Journal of Public Health, 111(9), 1673-1681. https://doi.org/10.2105/AJPH.2021.306375

 

McEwen, B. (2000). Allostasis and allostatic load implications for neuropsychopharmacology. Neuropsychopharmacology, 22(2), 108-124. https://doi.org/10.1016/S0893-133X(99)00129-3

 

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Syverson, C., Seed, K., Shapiro-mendoza, C., Callaghan, W. M., & Barfield, W. (2019). Racial/Ethnic disparities in pregnancy-related deaths — United States, 2007–2016. MMWR. Morbidity and Mortality Weekly Report, 68(35), 762-765. http://doi.org/10.15585/mmwr.mm6835a3

 

Scott, K. A., & Davis, D. (2021). Obstetric racism: Naming and identifying a way out of black women's adverse medical experiences. American Anthropologist, 123(3), 681-684. https://doi.org/10.1111/aman.13559

 

Tamayo-Sarver, J. H., Hinze, S. W., Cydulka, R. K., & Baker, D. W. (2003). Racial and ethnic disparities in emergency department analgesic prescription. American Journal of Public Health, 93(12), 2067-2073. https://doi.org/10.2105/AJPH.93.12.2067

 

Thames, A. D., Irwin, M. R., Breen, E. C., & Cole, S. W. (2019). Experienced discrimination and racial differences in leukocyte gene expression. Psychoneuroendocrinology, 106, 277-283. https://doi.org/10.1016/j.psyneuen.2019.04.016

 

World Health Organization (Ed.). (n.d.). Social determinants of health. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health


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