Systemic racism is ubiquitous in U.S. labor and delivery rooms and contributing to a sharp rise in medically questionable inductions that could be harming Black and Latina mothers and babies, according to new CU Boulder research.
The study of 46 million births across nearly three decades is among the first to provide population-level statistical evidence of “obstetric racism,” a term coined recently to describe a concerning pattern of maltreatment of non-white pregnant women, including a disregard for their birthing wishes.
The findings come amid rising concerns about high maternal mortality rates among Black mothers, who are nearly three times more likely to die of pregnancy-related causes than white mothers, and their infants, who are twice as likely to die in their first year.
“We found that obstetric care in the United States is not being centered on the needs of the Black and Latina childbearing population, but instead is responding to the needs and preferences of white women,” said senior author Ryan Masters, an associate professor of sociology who studies health and mortality trends.
The research, published April 26 in the Journal of Health and Social Behavior, shows that medical induction of labor nearly tripled between 1990 and 2017 in the U.S., growing from 12.5% of births in 1990 to 34.4% in 2017.
That trend alone is concerning because, as the authors’ previous research has shown, early induction can lead to low birthweight babies and a host of associated problems later in life.
While the increase in inductions among white women can largely be explained by an increase in higher-risk pregnancies among the white childbearing population, the same cannot be said for Black and Latina women, the study found. Instead, decisions about their care are being based on trends in the white population.
“The U.S. medical system has a long history of centering care on the needs of dominant or majority populations, i.e. white patients, rather than considering the specific needs of marginalized populations,” said Tilstra, who earned her PhD in sociology from CU Boulder and is now a postdoctoral researcher at the Luverhulme Centre for Demographic Science at Oxford University in the United Kingdom. “Our results show systemic racism is also shaping U.S. obstetric care.”
Centering care on white women
The study builds on the groundbreaking work of medical anthropologist Dána-Ain Davis who first coined the phrase “obstetric racism” in 2018 after spending years interviewing Black women about their birthing experiences.
Her ethnographies described clinicians neglecting, dismissing or disrespecting laboring women of color, coercing them to undergo procedures they did not want or performing procedures without their consent.
“When Black women express wanting to have control over their births, some nurses and doctors … punish Black moms. It is like they don’t deserve to have the kind of birth they want,” expressed one Black mother Davis interviewed.
Subsequent studies have shown that Black women are also more likely to have their pain minimized or ignored, in part due to long-held and false assumptions that Black people have a higher tolerance for pain, and are more likely to report mistreatment during childbirth.
To explore whether obstetric racism is happening at the population level, the researchers used state-level data from the National Vital Statistics Systems to analyze single-child first-births among 26.4 million white women, 6.2 million Black women and 8.4 million Latina women, looking at whether induction occurred and at the health of the mother.
Maternal high blood pressure, obesity, diabetes, advanced age and a history of smoking can all boost the risk of problems during labor and, at times, justifiably warrant an induction.
“Labor induction can be a very important tool,” stressed Tilstra.
Among white women, increases in the rates of induction of labor were strongly associated with changes in such risk factors over time. In Black and Latina women, however, there was no such association. The trend appears to be medically unexplainable.
While the study does not explicitly show that increased induction rates are contributing to high maternal mortality rates among women of color, the authors suggest this link should be further explored.
In previous work, they showed that not only is induction of labor increasing, but it is occurring earlier in pregnancy, shortening the average U.S. pregnancy by about a week and, concerningly, driving birthweights down.
“We've completely shifted when births occur and how births occur and that can have dramatic implications on birth weight and the subsequent health of the child,” said Masters.
A systemic problem
The authors stress that they generally do not intend to blame individual clinicians for obstetric racism, but instead view the problem as a result of a systemic lack of training in medical school, a continued lack of attention to the healthcare needs of women of color and a need for everyone, including clinicians, to look closely at their own implicit biases.
They hope their work will encourage policymakers and clinicians to do more to address those biases and realize that even brief micro-interactions in the labor and delivery room can add up, leading to differences in care between different racial and ethnic populations.
“Pregnancy and childbirth are an incredibly vulnerable and difficult time in one's life,” said Tilstra. “Everyone deserves to have equal access to good care.”
This research was funded by a grant from the Eunice Kennedy Shriver Institute of Child Health and Human Development. Kate Coleman-Minahan, an assistant professor at the University of Colorado College of Nursing at CU Anschutz, and Daniel Simon, a PhD candidate in the Department of Sociology, are co-authors.