Michelle B. faced all kinds of stress during her latest pregnancy: she juggled school, a job and the task of single-parenting three children while pregnant with twins.
Her doctor recommended bed rest, but she had no choice but to keep working and parenting. Her twins, a boy and a girl, were born premature in June, six weeks before their due date in August.
Yet despite these stresses, she didn’t slow down. “I would deal with it,” said Michelle, who lives in Richmond and withheld her real name because she is involved in a custody case. Her motivation is her children, she said, “At the end of the day, you can’t give up.”
Like Michelle, many black mothers in Richmond and neighboring Contra Costa cities struggle with a long list of stressors while pregnant. No matter their circumstances, they all have the same goal, to have happy, healthy children. But now, a growing number of researchers say that for too long the medical community has ignored a potent stressor that lies at the root of all the other stress some women face, racism.
A growing number of scientific studies show that racism experienced by women of color, particularly black women, can affect the health of their future children in many ways. Racism can lead to an increased likelihood of preterm birth and low birth weight, these studies show, and both of these circumstances can increase the likelihood of other health problems throughout a child’s life. Moreover, some scientists believe that the racism a woman experiences can affect her newborn’s health long before the child is even conceived.
The influence of race on newborn health is apparent in Contra Costa, where 7.2 percent of white babies and 11.7 percent of African American infants are born preterm, and where an African American child is almost twice as likely as a white child not to reach her first birthday.
Advocacy groups and county officials have been taking steps to close this gap, but success so far remains out of reach. In fact, despite focused efforts, the infant mortality rate for African Americans in the county was slightly higher in 2013 (9.9 percent) than it was in 2003 (8.5 percent), according to Peristats, a statistics database produced by the March of Dimes using data from the National Center for Health Statistics. (Within that decade, the rate fluctuated up and down.)
Now, some researchers who study the black-white gap in birth outcomes say that infant health disparities like these may continue until racism is a thing of the past.
The Life Course Perspective
For decades, researchers were stumped over the cause of the racial gap in birth outcomes. Many thought it was caused by lack of access to prenatal care, which includes taking key vitamins, such as folic acid, and testing for conditions such as high blood pressure and genetic diseases.
Prenatal care boomed in the United States in the 1970s and 80s, as research showed that it reduced the likelihood of low birth weight in newborn babies. Today, prenatal care is recommended by most doctors and health organizations, from primary care providers here in Contra Costa to the national Centers for Disease Control and Prevention.
But even though experts thought that better access to prenatal care would close the gap in birth outcomes, this has not been the case, said Dr. Michael Lu, Associate Administrator at the Maternal and Child Health Bureau of the Health Resources and Services Administrations, via email.
In a 2010 paper published in the journal Ethnicity & Disease, Lu showed that even though the racial gap in prenatal access had been closing over the previous decade, the gap in poor birth outcomes had not.
By the time Lu published that paper, he and colleagues had already proposed a theory to explain the persistent racial disparity in birth outcomes. In a paper published in Maternal and Child Health Journal in 2003, they had argued that health care providers need to consider the experiences a woman has over the course of her life—not just the nine months she is pregnant—to predict her birth outcomes. They called this idea the “life course perspective.”
According to the life course perspective, experiences a woman had when she was very young can be risk factors in her future pregnancies, even decades later. In the paper, Lu and colleagues classified experiences of stress and racism in early life as risk factors that can contribute to poor birth outcomes in black women.
“Each stage of life is influenced by all the stages that precede it,” said Lu.
Since publication, the theory has gained traction with medical and public health professionals across the country.
“Life course always made sense to me,” said Tyan Parker Dominguez, Ph.D., an associate professor at the University of Southern California’s Suzanne Dworak-Peck School of Social Work. She said that she was a graduate student at UCLA when Lu’s paper was published, and “I thought, ‘Wow, I have experienced these things.’”
Parker Dominguez, whose research focuses on how racial stress perpetuates health disparities, said Lu’s work helped medical professionals and academics start thinking more broadly about how social experiences—not just medical factors—affect health.
Lu and colleagues proposed a 12-point plan to reduce racial disparities in birth outcomes. The first four recommendations were medical, and had to do with improving access to health care before, during and after pregnancy, and throughout a woman’s life. The rest of the recommendations were social and behavioral, and included closing the education gap, increasing father involvement and reducing poverty among African American families.
The last item on the list was the shortest. It said simply, “Undo racism.”
“Racism,” Lu and colleagues wrote, “may be ‘the cause of the cause’ of health disparities in the United States.”
That idea “really became the common language that people are using now” in health care settings, said Parker Dominguez.
A Life of Chronic Stress
Though racism can affect people in different ways, Amani Nuru-Jeter, Ph.D., associate professor of epidemiology at the UC Berkeley School of Public Health, said discrimination is “a chronic stressor.” And when a woman is stressed all of the time, she is less likely to have a healthy pregnancy.
The stress response, also known as “fight or flight,” is familiar to most people: fast breathing, trembling hands and a rapidly beating heart.
The physical symptoms of stress are caused by hormones released in the brain—most notably, adrenaline and cortisol. Cortisol, often called “the stress hormone,” causes more than just sweaty palms. Studies link high levels of cortisol to inflammation, weight gain, high blood pressure, mood changes and heart disease. Which means that living with a high level of constant stress is not just uncomfortable for women, said Nuru-Jeter, “it can also be very harmful to their bodies.”
Because “we live in a culture that is racist and does not treat everyone equally,” said Cheri Pies, Dr.PH, principal researcher at Best Babies Zone in Oakland and former Director of the Contra Costa Health Services Family, Maternal and Child Health Department, “people of color tend to have higher cortisol levels all the time.”
And women who have high levels of stress and high levels of cortisol tend to have babies that are born low birth weight or preterm, she said.
When Nuru-Jeter and colleagues convened focus groups of Bay Area women to discuss their experiences of racial discrimination, they were surprised at how long the women had been holding on to such memories, she said.
“We found that the majority of women talked about their very first experience of racial discrimination occurring in middle childhood,” said Nuru-Jeter. The conversations were often painful, she said, and evoked “very intense emotional reactions, even during adulthood.”
The stress didn’t start and end when the women were faced with direct acts of racial discrimination, said Nuru-Jeter. Instead, it is a burden they carry all the time.
“They talked about having their armor on,” she said. And just being prepared for potential discrimination, said Nuru-Jeter, is enough to start the biological stress response.
In women who live with this source of stress, said Dr. Francine Jolton, Chair of the Department of Pediatrics for the Contra Costa County regional medical centers, “their system is on this kind of revved up cycle.” That means that they are constantly experiencing the fight or flight response, including the cortisol levels—and increased risk of health issues—that go with them.
For some women living in Richmond, local stressors compound the stress of racial discrimination: financial challenges, an uptick in homicides this year, and the closing of a major medical center, which means women in labor must plan to travel to the county health center in Martinez, a 30-minute drive from central Richmond without traffic, or to the Alta Bates Medical Center in Berkeley—which has also recently announced plans to close.
Natalie Berbick, Infant Health Programs Manager for the Contra Costa Health Services Department, said that one woman who attended the county’s Black Infant Health (BIH) program said she wanted to leave the city because over the course of her pregnancy this year, two people were murdered near her home.
“She did not want to raise her child on that block,” said Berbick, “She doesn’t want to be somewhere where bullets are flying around her.”
“It Changes in a Split Second”
According to a report released by the March of Dimes last month, the health of infants in the United States took a step backwards in 2016 for the first time in eight years.
Across the country, preterm birth rates worsened from 9.57 to 9.63 percent of births between 2015 and 2016. The U.S.’s preterm birth rate is lower than that of most other high-resource countries, including those in Canada and Western Europe, according to the report. In 2010, the most recent year for which international data are available, the U.S. had the 54th highest rate of preterm births, out of 184 countries around the globe, based on a separate 2012 report.
Babies born prematurely or underweight are also more likely to die during birth or shortly after. That’s because preterm infants face an increased risk of severe complications after birth, including difficulty breathing, bleeding in the brain, heart issues and an underdeveloped immune system.
The death of an infant, no matter how old, can be extremely traumatic, said Erica Alexander, Central Valley Program Director at the March of Dimes.
“You have hopes and dreams for your children,” she said, “not having any idea that it changes in a split second.”
Even if they survive infancy, preterm babies are more likely to have a host of chronic health problems later in life, including diabetes, heart disease, high blood pressure, and neurological problems.
Moreover, said Jolton, if a woman has one preterm birth, she’s “definitely more likely to have a second.”
The End of Racism
Racial disparities in health are “not naturally occurring differences,” said Parker Dominguez. “These are things that we created” by excluding people of color from facets of American society, she said.
Completely eliminating racism from American society seems like a lofty goal—if not an impossible one in the current political climate. But does this mean that the gap in birth disparities will indefinitely persist?
“The short answer is yes,” said Parker Dominguez.
In the meantime, she, Nuru-Jeter and others advocate community-based interventions as a step in the right direction. In Contra Costa, these include the services offered by several programs dedicated to helping expecting and new mothers.
The Family, Maternal and Child Health department of the Contra Costa Health Services supports more than ten county programs, including the Black Infant Health program, the Nurse-Family Partnership and the Women, Infants and Children (WIC) program. There are also state-funded programs, such as First 5 Contra Costa, that provide parenting classes, home visits, and support for teenage parents.
Tracey Weston of El Sobrante, a single mother of two, attended the Black Infant Health program during both of her pregnancies. The program, which is free and open to African American women in Contra Costa County who are less than 36 weeks pregnant, currently has about 100 participants.
Women in the program learn about everything from breastfeeding to safe sleeping to car seats. But, said Weston, “what I like the most is just being able to sit down with other women such as myself.”
“It’s a good resource for the women who are afraid to ask for help, because I know there’s a lot of women out there who feel like they’re alone.”
Berbick said when people ask her why it is necessary to have a program specifically for African American women, she refers them back to the statistics.
“This is not a preferential treatment,” she said. “The data shows that this population is having the worst outcomes.”
In fact, other women of color in Contra Costa, including Latina and Asian women, have preterm birth rates and infant mortality rates that are only slightly above those of white babies—while black rates are 1.7 times higher, according to Peristats.
Racism, said Nuru-Jeter, is the “root cause” of poor birth outcomes—meaning that while there may be other factors related to poor birth outcomes, such as access to health care, education, and poverty, all of these issues can be traced back to living in a racist society.
Other experts, however, warn against placing too much emphasis on one cause.
“There is so much that is still unknown because everybody’s experience is very different,” said Alexander of the March of Dimes.
For Lu, whatever the cause, the solution is to care about the health of girls and women at all times.
“If we are serious as a nation about improving birth outcomes and reducing disparities,” he said, “we have to start taking care of women not only during pregnancy, but before pregnancy and between pregnancies and indeed, across the entire life course of women and families.”