We read with interest the paper by Merriam et al (May 7, 2023),[1] which investigates the risk factors for maternal morbidity in nulliparous patients. We note that in the discussion of the racial inequities, the authors mention structural racism and implicit bias; but we are concerned that they do not state clearly enough that the risk factor is Racism experienced by Black patients, and not Black race.

We believe that labeling “Black race” as the risk factor in the abstract and in the highlighted “key points” could lead to inappropriate focus on race and lack of attention to the root cause that needs to be addressed to reach health equity—Racism.[2] We note that this paper uses the word “race” 13 times, and in contrast uses the word “racism” only once.[1] It is critical for research to state explicitly that race is a social construct and that exposure to racism that is the risk factor, not race.[2] [3] [4] Finally, we are concerned that in table 1 of the article in question, the racial categories of “other” and “Asian” seem to be combined with “non-Hispanic white” as the reference group.[1] Aggregating these groups with “white” obscures inequities that other groups experience.[5]

To identify and address the barriers to health equity and to be as scientifically accurate as possible, biomedical research studies must clearly state that race is a social construct, explain what the variable is being used as a proxy for, and they should explicitly name “exposure to racism” (not race) as the risk factor for poor maternal health outcomes.[2]

Received: 19 May 2023

Accepted: 10 November 2023

Accepted Manuscript online:
11 November 2023

Article published online:
05 December 2023

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