Race and Research
One goal of clinical research is to determine how likely a group of people is to experience a certain health outcome, such as preterm birth, low birth rate, or pelvic floor dysfunction. In an attempt to answer this question, demographic information is collected in order to analyze whether an individual is representative of a larger target population. Race is often included in demographic information within research.
Racial groups are a common distinguishing characteristic to trace health outcomes epidemiologically. Unfortunately, researchers have continued to equate race with an underlying genetic sameness in order to intentionally or unintentionally reduce or ignore the societal, political, and structural reasons that may contribute to poor health outcomes (Williams et al., 1994).
“Black maternal health outcomes are not influenced solely by education, income, health care access, or health behaviors. Racism, racial discrimination, systemic inequalities, and social determinants of health contribute to poor maternal health outcomes in the Black community” (Muse et al., 2018, p.4).
I identify as black or african american
Research shows that certain qualities predispose someone to be more at risk for developing urinary incontinence and pelvic floor dysfunction during pregnancy and the postpartum period. Some of these qualities, like race, depression, lack of social support, and less education, suggest links to regular distressing experiences that impact health. Research has yet to fully clarify why some of these qualities are risk factors.
People of color experience negative health outcomes more often, including before, during, and after pregnancy, because of complex and interdependent daily experiences that are influenced and impacted by the unequal racialized conditions of the United States (Muse et al., 2018). Race is not a biological inevitability leading to pelvic floor dysfunction, but rather an indication that an individual is likely experiencing forms of systemic oppression that affect health.
Racial Disparities
A racial disparity is when the prevalence of a health outcome between two racial groups is not proportional to the racial makeup of the general population. For example, in the United States, black infants are twice as more likely to die within their first year of life compared to white infants (Lu et al., 2010).
Often maternity care researchers leave the cause of racial disparities unexplained or they attribute maternity outcomes to causes only in pregnancy - infection, less exercise, not using routine prenatal care, etc. (Lu et al., 2010, Braveman et al., 2015; Williams et al., 1994). However, new research expands the idea of causality beyond the 40 weeks of pregnancy and demonstrates that there are deeper, more complex causes of racial disparities.
Braveman et al. shows that Black parents are statistically more disadvantaged in every socioeconomic factor (education, employment, access and use of private health insurance) compared to White parents in the same income bracket (2015). These socioeconomic factors can contribute to a negative cumulative effect leading to poorer health outcomes for people of color. Lu et al. (2010) presents a compelling “life course perspective” that explains the differences in maternity outcomes between Black and White mothers and babies as a “consequence of both differential exposures during pregnancy and differential developmental trajectories across the life span” (Lu et al., 2010, p.2). Lu et al. explains that a Black mother is more likely to have a depressed and compromised immune system that leads to poorer health outcomes because she is more likely to have been exposed to high stress levels and health-compromising events during pregnancy and while she was a developing fetus, in early childhood, in adolescence, and in adulthood.
The cause of this repeated stress for people of color has been linked to the persistent, systematic, and institutionalized racism that dominates culture, politics, and economics in the United States.
“Institutionalized racism manifests itself both in material conditions and in access to power. With regard to material conditions, examples include differential access to quality education, sound housing, gainful employment, appropriate medical facilities, and a clean environment. With regard to access to power, examples include differential access to information (including one’s own history), resources (including wealth and organizational infrastructure), and voice (including voting rights, representation in government, and control of the media). It is important to note that the association between socioeconomic status and race in the United States has its origins in discrete historical events but persists because of contemporary structural factors that perpetuate those historical injustices.”
Race and Pelvic Health
The impact of racism is an important aspect to understand when considering the current research about pelvic floor disorders and stress urinary incontinence.
The current and included research about PFD/SUI categorize research participants into different demographic categories, including race. De Oliveira et al. included three “ethnicity” groups, “White,” “Black,” and “Asian” (2013). This particular study concluded that participants who were designated as Black were 2.32 times more likely to experience urinary incontinence in the perinatal period compared to White individuals.
This analysis is problematic in several ways. First, ethnicity is not equivalent to race and falsely equates similar physical characteristics (White or Black) with a shared cultural tradition. In other words, not all people who identify as Black are culturally homogenous. Definitions of both race and ethnicity have changed through time and there are indeed many examples of racial self-identity that are very similar to that of an ethnic self-identity (Adelman, 2003). However, the important consideration to remember when analyzing research based on race or ethnicity is the way in which race, much more than ethnicity, is a social construction used to impose hierarchical power and control over a particular group of people which results in profound, concrete consequences for access to resources, protections, and opportunities (Adelman, 2003; Williams et al.,1994).
Second, tracking differences between races is more a study of socioeconomic and psychosocial patterns rather than a study of innate biological differences. The inclusion of race-based research is worthwhile, but needs to be more transparent and self-critical about the reasons and causes of White-Black gaps in health outcomes. “Research that viewed racial differences in health as primarily biological in origin diverted attention from the social origins of disease, reinforced societal norms of racial inferiority, and provided a so-called scientific rationale for the exploitation of Blacks” (Williams et al., 1994). The research community has manifested this scientific exploitation into “historical experimentation on Black women’s bodies, forced sterilization, discriminatory health policies, the removal of tradition birth practices in Black communities, and other coercive reproductive practices“ (Muse et al., 2018, p.5).
Third, the research included does not specify if the participants self-identified as a particular race/ethnicity or if that category was given to them by the researcher. Additionally, there was no discussion of how many race/ethnicities a participant could select. Typically, someone is one race, but may identify as many ethnicities.
For the purpose of this project, the racial category of “Black” was included because it was a statistically significant prognostic variable. The variable could be rephrased as “I feel the stress and impact of institutionalized racism.” I decided it was in the best interest of the audience to give a more full and dynamic explanation of this prognostic variable due to the weight and consequence of racism in the United States.
In the broader context of race-based research, Lu et al. describes the hurtle before the healthcare industry, “we cannot eliminate racial disparities…without addressing racial disparities in education, healthcare, housing, employment, the criminal justice system, and built environment” (2010, p.16). It is my hope that this project will help maternity providers take one small step in the direction of acknolwedgment and change. Please see the Black Mamas Matter Alliance Black Paper, Setting the Standard for Holistic Care of and for Black Women (2018) for expert evidence and leadership for how to best care for people of color in the perinatal period.
References
Adelman, L. (2003). Race: The power of an illusion. Video. Produced by California Newsreel in association with the Independent Television Service.
Braveman, P. A., Heck, K., Egerter, S., Marchi, K. S., Dominguez, T. P., Cubbin, C., … Curtis, M. (2015). The role of socioeconomic factors in Black-White disparities in preterm birth. American Journal of Public Health, 105(4), 694–702. https://doi.org/10.2105/AJPH.2014.302008
Jones, C. P. (2000). Levels of racism: a theoretic framework and a gardener's tale. American journal of public health, 90(8), 1212-1215.
Lu, M. C., Kotelchuck, M., Hogan, V., Jones, L., Wright, K., & Halfon, N. (2010). Closing the Black-White gap in birth outcomes: A life-course approach. Ethnicity & Disease, 20(1 Suppl 2), 1–26.
Muse, S. et al., (2018). Setting the standard of holistic care of and for Black women. Black Mamas Matter Alliance. http://blackmamasmatter.org/wp-content/uploads/2018/04/BMMA_BlackPaper_April-2018.pdf
Williams, D. R., Lavizzo-Mourey, R., & Warren, R. C. (1994). The concept of race and health status in America. Public Health Reports, 109(1), 26–41.