Keywords
1. Racial disparities in stillbirth
2. Stillbirth incidence in the US
3. Ethnic inequities in pregnancy outcomes
4. Structural racism and perinatal health
5. Community-engaged stillbirth research
In the United States, stillbirth is a critical public health issue that devastates families each year. Over the past several decades, the nation has seen improvements in the overall rates of stillbirth, yet stark racial and ethnic disparities have persisted, highlighting an area of maternal and child health that requires urgent attention and action. A recent study published in the journal ‘Seminars in Perinatology’ sheds light on these inequities, underscoring the need for structured interventions and research that incorporate equity-focused lenses to address and mitigate the underlying determinants of these disparities.
While stillbirth remains an under-discussed topic, the study by Debbink Michelle P., Stanhope Kaitlyn K., and Hogue Carol J.R., titled “Racial and ethnic inequities in stillbirth in the US: Looking upstream to close the gap” (DOI: 10.1016/j.semperi.2023.151865), exposes the two-fold greater risk of experiencing stillbirth faced by Black and Indigenous pregnant individuals compared to their White counterparts. Noting that race is a social construct rather than a biological determinant, the researchers highlight the role of structural, institutional, and interpersonal racism in creating a landscape of differentially accessible opportunities for health that result in the inequitable distribution of stillbirth rates.
The study explains how these downstream consequences can manifest in the prevalence of chronic health conditions and structural differences in the quality of health care or availability of healthy neighborhood conditions. This holistic perspective recognizes the multifaceted challenges that contribute to such disparities and emphasizes the inadequacy of narrowly focused interventions.
Anchored in acknowledging the far-reaching impact of systemic racism on stillbirth outcomes, the research proposes an equity-oriented framework for investigating and responding to these complex issues. Community-engaged approaches are championed as a means of leveraging the experiential wisdom of those most affected, thus enabling the creation of a comprehensive understanding of the causes and consequences of stillbirth inequities.
The authors advocate for a collaborative effort in which investigators work closely with community partners, employing a synergy of qualitative, quantitative, and implementation science methods. This interdisciplinary research strategy is presented as a promising route to unravel the entrenched patterns of racial and ethnic inequities in stillbirth outcomes and to identify leverage points for transformative intervention.
The urgency and salience of investigating and addressing the disparities in stillbirth rates cannot be overstated, as this is not merely an issue of maternal and child health equity but one that deeply affects the fabric of communities. Health professionals, policymakers, and the broader society must heed the compelling evidence that highlights the necessity for system-wide change.
Recognizing the importance of this research, a detailed examination of the current landscape and potential pathways forward is warranted. This deep dive explores the epidemiological data, underlying determinants, and proposed interventions that can potentially bridge the wide chasm that racial and ethnic disparities have created in stillbirth rates within the United States.
Epidemiology of Stillbirth and Disparities by Race and Ethnicity
The Centers for Disease Control and Prevention (CDC) defines stillbirth as the loss of a baby at or after 20 weeks of pregnancy. Despite improvements in prenatal care and perinatal technologies, stillbirth continues to affect about 1 in 160 pregnancies in the United States. However, the blanket numbers belie a grim divide: According to the data presented in the study, Black and Indigenous pregnant people are disproportionately affected by stillbirths.
In unpacking the epidemiological trends, it is crucial to consider not only the prevalence of stillbirths but also the persisting racial and ethnic disparities. This persistence suggests that the root causes are systemic and deeply entrenched in the health care delivery system and broader societal structures.
Structural Determinants of Disparities in Stillbirth
A closer look at the structural determinants of health reveals numerous barriers impeding the reduction of racial and ethnic disparities in stillbirth rates. These include socioeconomic factors, access to quality healthcare, differential treatment within healthcare settings, and the cumulative stress caused by systemic discrimination, often referred to as “weathering.”
Intertwined with these are issues such as housing instability, food insecurity, and environmental hazards, which disproportionately affect communities of color. The study eloquently describes how these social determinants of health chart a course that can lead to varied pregnancy outcomes, with non-White pregnant people invariably on a trajectory fraught with higher risk for adverse events like stillbirth.
Intervention Approaches Using an Equity Lens
The study further points to a remedy through research and intervention approaches that explicitly utilize an equity lens. An equity lens compels one to look beyond immediate causes and tackle the root issues that underlie disparities. In the context of stillbirth, this translates to interventions that address social determinants and provide culturally competent and accessible prenatal and perinatal care.
Community Engagement: Key to Understanding and Intervening
A resounding theme throughout the research is the essential role of community engagement. The authors call for partnerships between investigators and those directly affected by stillbirth disparities to design and implement intervention strategies. These partnerships prioritize the voices and experiences of community members, thereby ensuring that interventions are relevant and responsive to their needs.
Moreover, engaging with communities can foster trust and cooperation, which has historically been strained due to unethical research practices and discrimination in healthcare delivery. This collaborative approach promises not just better insights but also more effective, sustainable interventions owing to community buy-in and ownership.
Qualitative and Quantitative Methodologies: Unpacking Complexity
To address the complexity of racial and ethnic disparities in stillbirth, a multifaceted research approach is needed. Qualitative methods illuminate personal experiences and cultural nuances that might influence health behaviors, while quantitative analyses provide a broader perspective on trends and target points for intervention. The incorporation of implementation science further guides the translation of research findings into real-world settings. This triangulated approach is positioned by the authors as crucial to yielding a rich, actionable understanding of stillbirth disparities.
Conclusion
The research presented in ‘Seminars in Perinatology’ highlights the need to recognize and address the structural drivers of racial and ethnic disparities in stillbirth outcomes in the United States. It underscores the importance of community-engaged research that harnesses a multifaceted approach to adequately address the complex realities of those most impacted by these disparities.
National and local health systems must heed this call to action, reorienting their focus and determining how to effectively leverage resources to dismantle the structural barriers that perpetuate inequities. Only by looking upstream to close the gap, can the enduring challenge of unequal stillbirth rates be met with the comprehensive, equity-focused response it demands.
References
1. Debbink, Michelle P., Stanhope, Kaitlyn K., and Hogue, Carol J.R. “Racial and ethnic inequities in stillbirth in the US: Looking upstream to close the gap.” Seminars in Perinatology, December 20, 2023, DOI: 10.1016/j.semperi.2023.151865.
2. Centers for Disease Control and Prevention. “Data on pregnancy mortality surveillance system – Stillbirth.” CDC, https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
3. Lu, Michael C., and Halfon, Neal. “Racial and ethnic disparities in birth outcomes: A life-course perspective.” Maternal and Child Health Journal, DOI: 10.1023/A:1022979022995.
4. Collins, James W. Jr., David, Richard J. “Differential infant mortality of blacks and whites in the United States: A study of social pathology.” Ethnicity & Disease, DOI: 10.1001/archpedi.1991.02160090029019.
5. Giscombé, Cheryl L., and Lobel, Marci. “Explaining disproportionately high rates of adverse birth outcomes among African Americans: The impact of stress, racism, and related factors in pregnancy.” Psychological Bulletin, DOI: 10.1037/0033-2909.131.5.662.