Objective-This study examined the role of psychosocial stress in racial differences in birth outcomes.Design-Maternal health, sociodemographic factors, and 3 forms of stress (general stress, pregnancy stress, and perceived racism) were assessed prospectively in a sample of 51 African American and 73 non-Hispanic White pregnant women.Main Outcome Measures-The outcomes of interest were birth weight and gestational age at delivery. Only predictive models of birth weight were tested as the groups did not differ significantly in gestational age.Results-Perceived racism and indicators of general stress were correlated with birth weight and tested in regression analyses. In the sample as a whole, lifetime and childhood indicators of perceived racism predicted birth weight and attenuated racial differences, independent of medical and sociodemographic control variables. Models within each race group showed that perceived racism was a significant predictor of birth weight in African Americans, but not in non-Hispanic Whites.Conclusions-These findings provide further evidence that racism may play an important role in birth outcome disparities, and they are among the first to indicate the significance of psychosocial factors that occur early in the life course for these specific health outcomes. Keywords stress; racism; pregnancy; birth weight; health disparities African Americans are twice as likely as non-Hispanic Whites, the most common referent group, to die before their first birthday (Mathews, Menacker, & MacDorman, 2004). In this Correspondence concerning this article should be addressed to Tyan Parker Dominguez, School of Social Work, SWC 224, University of Southern California, Los Angeles, CA 90089-0411, or Christine Dunkel-Schetter, Department of Psychology, 405 Hilgard Avenue, University of California, Los Angeles, CA 90095-1563. tyanpark@usc.edu or dunkel@psych.ucla.edu. NIH Public Access Author ManuscriptHealth Psychol. Author manuscript; available in PMC 2010 May 12. Published in final edited form as:Health Psychol. 2008 March ; 27(2): 194-203. doi:10.1037/0278-6133.27.2.194. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript country, low birth weight (LBW; <2,500 g) and preterm delivery (PTD; <37 weeks) are leading causes of infant death in the overall population, behind congenital anomalies, and the leading causes of death for African American infants (Mathews et al., 2004). Compared with White infants, African American infants have two times the rate of LBW and PTD, and three times the rate of very low birth weight (<1,500 g) and very preterm delivery (<32 weeks) (Martin et al., 2005). These poorer birth outcomes have serious implications not only for infant survival, but also for childhood growth and development (e.g., Botting, Powls, Cooke, & Marlow, 1998) and some important health outcomes in adulthood (e.g., Rich-Edwards et al, 1997). Thus, understanding and eventually eliminating racial disparities in adverse birth outcomes is a major public health priority in the United ...

This exploratory study's findings support the need for measures reflecting the complexity of childbearing African-American women's racism experiences. In addition to discrete, interpersonal experiences across multiple domains and active/passive responses, which have been measured, birth outcomes research should also measure women's childhood experiences and their potentially enduring impact, perceptions of institutionalized racism and internalized negative stereotypes, vicarious experiences related to their children, vigilance in anticipating future racism events, as well as the pervasiveness and chronicity of racism exposure, all of which could be sources of ongoing stress with potentially serious implications for birth outcomes. Measures of racism addressing these issues should be developed and formally tested.

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Socioeconomic factors play an important but complex role in PTB disparities. The absence of Black-White disparities in PTB within certain socioeconomic subgroups, alongside substantial disparities within others, suggests that social factors moderate the disparity. Further research should explore social factors suggested by the literature-including life course socioeconomic experiences and racism-related stress, and the biological pathways through which they operate-as potential contributors to PTB among Black and White women with different levels of social advantage.

ObjectivesThe causes of the large and persistent Black-White disparity in preterm birth (PTB) are unknown. It is biologically plausible that chronic stress across a woman’s life course could be a contributor. Prior research suggests that chronic worry about experiencing racial discrimination could affect PTB through neuroendocrine, vascular, or immune mechanisms involved in both responses to stress and the initiation of labor. This study aimed to examine the role of chronic worry about racial discrimination in Black-White disparities in PTB.MethodsThe data source was cross-sectional California statewide-representative surveys of 2,201 Black and 8,122 White, non-Latino, U.S.-born postpartum women with singleton live births during 2011–2014. Chronic worry about racial discrimination (chronic worry) was defined as responses of “very often” or “somewhat often” (vs. “not very often” or “never”) to the question: “Overall during your life until now, how often have you worried that you might be treated or viewed unfairly because of your race or ethnic group?” Prevalence ratios (PRs) with 95% Confidence Intervals (CI) were calculated from sequential logistic regression models, before and after adjustment for multiple social/demographic, behavioral, and medical factors, to estimate the magnitude of: (a) PTB risks associated with chronic worry among Black women and among White women; and (b) Black-White disparities in PTB, before and after adjustment for chronic worry.ResultsAmong Black and White women respectively, 36.9 (95% CI 32.9–40.9) % and 5.5 (95% CI 4.5–6.5) % reported chronic worry about racial discrimination; rates were highest among Black women of higher income and education levels. Chronic worry was significantly associated with PTB among Black women before (PR 1.73, 95% CI 1.12–2.67) and after (PR 2.00, 95% CI 1.33–3.01) adjustment for covariates. The unadjusted Black-White disparity in PTB (PR 1.59, 95%CI 1.21–2.09) appeared attenuated and became non-significant after adjustment for chronic worry (PR 1.30, 95% CI 0.93–1.81); it appeared further attenuated after adding the covariates (PR 1.17, 95% CI 0.85–1.63).ConclusionsChronic worry about racial discrimination may play an important role in Black-White disparities in PTB and may help explain the puzzling and repeatedly observed greater PTB disparities among more socioeconomically-advantaged women. Although the single measure of experiences of racial discrimination used in this study precluded examination of the role of other experiences of racial discrimination, such as overt incidents, it is likely that our findings reflect an association between one or more experiences of racial discrimination and PTB. Further research should examine a range of experiences of racial discrimination, including not only chronic worry but other psychological and emotional states and both subtle and overt incidents as well. These dramatic results from a large statewide-representative study add to a growing—but not widely known—literature linking racism-related stress with physic...

While the biologic authenticity of race remains a contentious issue, the social significance of race is indisputable. The chronic stress of racism and the social inequality it engenders may be underlying social determinants of persistent racial disparities in health, including infant mortality, preterm delivery, and low birth weight. This article describes the problem of racial disparities in adverse birth outcomes; outlines the multidimensional nature of racism and the pathways by which it may adversely affect health; and discusses the implications for clinical practice.

In 2017–2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

African Americans have the highest rates of infant mortality and adverse birth outcomes of all major racial/ethnic groups in the United States. The long-standing nature of this disparity suggests the need to shift epidemiologic focus from individual-level risk factors to the larger social forces that shape disease risk in populations. In this article, the African American reproductive disadvantage is discussed within the context of American race relations. The review of the literature focuses on racism as a social determinant of race-based disparities in adverse birth outcomes with specific attention to the viability of genetic explanations, the role of socioeconomic factors, the multidimensional nature of racism, and the stress-induced physiologic pathways by which racism may negatively affect pregnancy. Implications for social work research and practice also are discussed.