The Centers for Disease Control and Prevention, along with many other medical institutions, lists Black "race" as a risk factor for preterm birth.1 Black “race” is not a risk factor for preterm birth because “race” is not a meaningful biological variable.2 Race is a socially constructed and politically assigned category, which has changed opportunistically over time.3 Census categories are a clear example of how notions of race have evolved following varying political climates.4

Throughout this article we use the term “Black women” to highlight the multiplicative, interactional effects of interlocking systems of power and discrimination that specifically and adversely affect Black women—historically and continuing into the present day—both outside of and within medical institutions.5–8 This terminology is inclusive of all people who may birth and identify as Black (ie, cis, trans, nonbinary, queer, and gender nonconforming).9

In this article, we highlight two important pathways—chronic stress and implicit bias—that link anti-Black racism to poor birth outcomes and that, as we argue, are fully revealed only by eliminating the use of Black “race” as a risk factor. These two pathways are by no means exhaustive, and the complexity, various mechanisms, and epidemiologic underpinnings by which anti-Black racism negatively affects the health and well-being of Black women are being examined across disciplines and diverse fields of medicine.10–17 Simultaneously, the use of Black “race” as a risk factor in medicine is being challenged across various health outcomes.18–21 Accordingly, the intention of this article is to encourage a paradigm shift in our causal frameworks, one that embraces anti-racist thinking and praxis by recognizing the harm and limitedness of maintaining a race-based paradigm that labels Black “race” as the risk factor and instead names anti-Black racism as the root cause of these persistent disparities, thereby revealing important and highly treatable pathways (Fig. 1).

Fig. 1.:

An explanatory diagram of the implications of our current causal paradigm naming Black “race” as the risk factor vs adopting an anti-racist paradigm that names anti-Black racism as the root cause of Black maternal health disparities. This article focuses on two key, highly treatable pathways linking anti-Black racism to preterm birth disparities, chronic stress, and implicit bias, which are obscured by naming Black “race” as the risk factor. This explanatory diagram is applicable to other maternal and infant outcomes, in addition to other birthing populations in which disparities are attributed to “race.”

By focusing on the specific issue of preterm birth, we can see how misusing Black “race” in medical settings perpetuates disparities.22 Preterm birth disparities exist for various ethnic and socioeconomic groups, and preterm birth is but one of many disparate health outcomes. Therefore, the solutions presented here are applicable in other birthing populations, as well as other reproductive outcomes.23 In addition, despite decades-long efforts to reduce preterm birth, rates are increasing; thus, our discussion of the importance of stress mitigation in pregnancy is applicable to all birthing bodies.23 It is important to note that Black women are disproportionately affected by poorer maternal and infant outcomes, and their experience is therefore critically important for how we understand the negative effects of stress and discrimination on pregnancy.23

BLACK “RACE” IS NOT A RISK FACTOR

Black women in the United States have a distinct, traceable history of discrimination and easily identifiable stressors related to anti-Blackness.24,25 Anti-Blackness may be understood as the beliefs, actions, and practices by individuals and institutions that devalue people of or perceived to be of African descent.26 Anti-Blackness and anti-Black racism encompass not just health inequities but also inequities in education, criminal justice, science, and our built environment.27 As a result, Black women's intersectional7 position within our health care system is akin to the proverbial “canary in the coal mine,” to borrow the metaphor recently used by Heather McGhee28 and Linda Villarosa,17 thereby revealing the dangerous effects of increased stress and discrimination on all birthing people.29

Certainly, social inequalities affect biology, and in a racialized society like the United States, we can observe these inequalities correlating to social categories of “race.”30 Accordingly, we as researchers, doctors, clinicians, and health care institutions should be alert to the fact that Black women are currently more likely to give birth prematurely and appropriately identify the etiology behind this increased risk. However, by using “race” as the risk factor, we effectively pathologize “Blackness.” The result is that we erase the historical, structural, and social inequities that have led to and continue to fuel these disparities.17,31

In practice, over time, the notion of Black “race” as a risk factor—in research, clinical settings, and medical algorithms32—has come to suggest, both implicitly and explicitly, that “Blackness” is the cause of certain medical outcomes. As recently as 2018, researchers suggested that “normal-term” gestational length may be naturally shorter in women of African ancestry compared with “Caucasian European women,”33 thereby conflating association with causation. A “race-conscious” shift in health research seeks to understand how long-standing systemic and cultural biases negatively affect the health of racialized groups and accordingly actively prioritizes anti-racism, moving away from race-based medicine.34–37 Anti-racist medicine recognizes racism at the root of health disparities and actively seeks to dismantle it.38–41 Anti-racist maternity care centers Black birthing voices and experiences; strives for respectful, patient-centered care; and focuses on reproductive justice and birth equity.42,43

Recently, research convened by the March of Dimes investigated 33 hypothesized explanations for the persistent Black and White disparity in preterm birth and found racism as the only upstream factor plausibly explaining middle and downstream factors.44 Although genetic factors do play a role in preterm birth risk,45 there is no biologically meaningful way in which to categorize human groups, genetic or otherwise.46,47 It is important to note that foreign-born Black women have better birth outcomes compared with their U.S.-born counterparts,48,49 demonstrating how ancestry and genetics do little to explain persistent Black and White disparities.

ANTI-BLACK RACISM LEADS TO HIGHER RATES OF PRETERM BIRTH IN TWO IMPORTANT WAYS Anti-Black Racism Is a Chronic Stressor, and Stress Affects the Timing of Birth

First, anti-Black racism, in its many forms (structural or systemic, institutional, and individual),50 is a chronic stressor.51 Stress can accelerate the timing of birth, and this is a highly conserved strategy seen across diverse species: mammals, amphibians, birds, and reptiles.52 In other words, organisms have been adjusting the timing of birth, hatching, or metamorphosis on the basis of changes in stress levels since the first vertebrates more than 500 million years ago.53

Variation in the timing of birth is an adaptive, reproductive strategy in all people who give birth, allowing them to respond to their unique environmental stressors, a concept understood as stress-induced developmental plasticity.54 Viewed from this ancient relationship between stress and the timing of birth, it is no surprise that birthing individuals experiencing disproportionate stressors, as Black women do, would also experience disproportionate rates of preterm birth. Understanding this relationship reveals a critical pathway that is highly treatable, yet seldom treated, as a target pathway: maternal stress.54 Simple, nontechnical interventions that increase support for pregnant patients and actively reduce or buffer stress can positively affect birth outcomes and specifically preterm birth. (The article by Mayne et al54 provides a suggested patient handout to aid busy clinicians in helping pregnant patients mitigate excessive stress.)

This revelation is crucial to all people who give birth because stress, regardless of the source, may affect when birth occurs. We observed this in real time. In 2021, as pandemic effects set in, the Centers for Disease Control and Prevention's birth data revealed that preterm birth rates rose the most since 2007 in all individuals and further exacerbated disparities.23 Individuals with Asian ancestry experienced the greatest increase, and this was coupled with an unprecedented rise in anti-Asian sentiments.55

Anti-Black Racism Negatively Affects the Care and Treatment of Black Patients

Second, anti-Black racism negatively affects the way in which pregnant Black patients are treated within the medical system, which affects birth outcomes generally and preterm birth specifically. To be clear, many Black women have healthy, empowered births; however, research consistently identifies unique stressors experienced by Black women: feeling devalued, not listened to, disrespected, and negatively stereotyped by medical staff.56–59 These stressful experiences, referred to as “obstetric racism,”60 can lead to catastrophic repercussions in the hospital setting. Stories like that of Serena Williams, and the tragic deaths of Kira Johnson and those seen in the documentary Aftershock, including Shamony Gibson and Amber Rose Isaac, highlight the many ways that racism negatively affects birth, regardless of how healthy or wealthy a person is. The interplay among implicit biases in health care professionals, social determinants of health in Black birthing populations, and institutional racism plays a role in the disparities observed. Importantly, labeling Black “race” as the risk factor obscures the role of implicit bias in health care settings: It leads clinicians and medical staff to perceive Black women as carrying an inherent risk into the medical setting, and it prevents clinicians from seeing how their own implicit bias may contribute to that risk.

MOVING AWAY FROM RACE-BASED MEDICINE AND TOWARD ANTI-RACIST MEDICINE

We cannot afford to settle for the tempting correlation between “race” and birth outcomes because causation matters. By blaming preterm birth disparities on “race” while ignoring the root cause of anti-Black racism, we are effectively saying that our hands are tied to make a difference, and that is not true.

We can make a difference because, although increased stress from anti-Black racism can cause increased rates of preterm birth, decreased stress can reduce those rates. The ancient system of stress-induced developmental plasticity works in both directions. When the stressors related to racism are removed or buffered—through patient advocates such as doulas61–63 and models of care and community collaborations that prioritize equity64–66—all outcomes improve, and rates of preterm birth are reduced.

We can improve birth outcomes by addressing implicit bias in medical settings (including medical school and training) and working to reduce and buffer stress from racism and discrimination. In short, we can and should strive to teach and practice anti-racist maternity care.42 In addition, institutional racism outside the health care system, including the criminal justice, housing, banking, and educational systems, must also be addressed to improve the well-being of Black birthing communities and ultimately to improve birth outcomes. The process of naming anti-Black racism as the root cause of Black and White disparities and targeting obstetric racism and chronic stress from discrimination is the practice of anti-racist maternity care and is a critical first step toward birth equity (Fig. 2).38

Fig. 2.: A visual model highlighting the importance of naming anti-Black racism, practicing anti-racist maternity care,42 and enriching prenatal and postnatal environments to achieve birth equity.

As legal scholar and anti-racist activist Dorothy E. Roberts states, “Race medicine is bad medicine,”67 so let's practice good medicine. Eliminating the use of Black “race” as a risk factor and naming anti-Black racism as the root cause of Black women's vulnerability is the first step.

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