Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review

Abstract

Purpose: Black women in the United States face poor outcomes across reproductive health measures—from pregnancy outcomes to gynecologic cancers. Racial health inequities are attributable to systemic racism, but few population studies of reproductive health outcomes integrate upstream measures of systemic racism, and those who do are limited to maternal and infant health outcomes. Advances in understanding and intervening on the pathway from racism to reproductive health outcomes are limited by a paucity of methodological guidance toward this end. We aim to fill this gap by identifying quantitative measures of systemic racism that are salient across reproductive health outcomes. Methods: We conducted a review of literature from 2000 to 2019 to identify studies that use quantitative measures of exposure to systemic racism in population reproductive health studies. We analyzed the catalog of literature to identify cohesive domains and measures that integrate data across domains. For each domain, we contextualize its use within population health research, describe metrics currently in use, and present opportunities for their application to reproductive health research. Results: We identified four domains of systemic racism that may affect reproductive health outcomes: (1) civil rights laws and legal racial discrimination, (2) residential segregation and housing discrimination, (3) police violence, and (4) mass incarceration. Multiple quantitative measures are available for each domain. In addition, a multidimensional measure exists and additional domains of systemic racism are salient for future development into distinct measures. Conclusion: There are quantitative measures of systemic racism available for incorporation into population studies of reproductive health that investigate hypotheses, including and beyond those related to maternal and infant health. There are also promising areas for future measure development, such as the child welfare system and intersectionality. Incorporating such measures is critical for appropriate assessment of and intervention in racial inequities in reproductive health outcomes.

Racialized economic segregation and health outcomes: A systematic review of studies that use the Index of Concentration at the Extremes for race, income, and their interaction

“…Our findings resonate strongly with those of other reviews on this topic which have reported similar connections between racialized segregation a broad range of health outcomes, including vascular diseases, cancer, pregnancy and birth complications, cancer, and lifestyle [9,10,[48][49][50][51]. The present paper, however, advances current knowledge by highlighting poverty as a key pathway through which segregation produces negative health outcomes in racial and ethnic minority populations.…”

Considerations for the Use of Race in Research in Obstetrics and Gynecology

“…61 Alson and colleagues and Chambers and colleagues have offered potential measures of structural racism that may be incorporated into OBGYN research, including but not limited to legislation and policies, access to care, discrimination, deprivation, geography and place, opportunities, and financial stability. 61,62…”

“…Researchers who include race in their studies to elucidate health inequities should also consider incorporating measures of structural racism into their study design, and seek the expertise of researchers from other fields who have interrogated these ideas for decades 61. Alson and colleagues and Chambers and colleagues have offered potential measures of structural racism that may be incorporated into OBGYN research, including but not limited to legislation and policies, access to care, discrimination, deprivation, geography and place, opportunities, and financial stability 61,62…”

Multidimensional structural racism predicts birth outcomes for Black and White Minnesotans

“…[3][4][5][6] In the past decade, scholars and policymakers have increasingly sought to understand the upstream (systemic and structural) factors that have contributed to the disproportionate risk Black pregnant people experience during pregnancy and childbirth. 7 Structural racism-carefully designed "macro-level systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups" 8 that are present in all facets of our lives-has been identified as a critical determinant of adverse birth outcomes for Black pregnant people. 7 Historically, as a fundamental cause of health inequities, 9 structural racism is not only killing Black men and women; it is also killing their infants.…”