The Genetics Debate

Some researchers assume Black race is a genetic factor that places African American women at higher risk during pregnancy (e.g., Amini, Catalano, Hirsch, & Mann, 1994). Black immigrant women, however, tend to exhibit significantly better pregnancy outcomes than their American counterparts, even when stratifying by risk status (e.g., David & Collins, 1997). Given the degree of European genetic admixture in the African American population, this trend is the exact opposite of what the genetic hypothesis would predict (David & Collins). Moreover, there is evidence that the U.S.-born daughters of Black immigrant women deliver a significantly higher percentage of LBW infants than did their foreign-born mothers of the previous generation (Collins, Wu, & David, 2002). These nativity patterns suggest that the reproductive disadvantage of African American women is likely a function of their experiences in the American social system rather than an expression of genetic vulnerability.

Whether racial group classifications reflect innate biological differences that fundamentally distinguish subgroups of the human species is a highly contentious issue in medical and public health research (Fine, Ibrahim, & Thomas, 2005). On the one hand, genetic clustering of population groups by geographic origin, the existence of rare variant alleles in particular subgroups (e.g., Ashkenazi Jews), and distinctions in external phenotype (e.g., skin color) seem to support a biologic conceptualization of race (Burchard et al., 2003). On the other hand, the vast majority of genetic variation occurs within geographic populations rather than between them; predominant racial taxonomies do not adequately capture human biodiversity; and genetic disease is relatively rare and affects specific subgroups within, and sometimes across, geographic populations (Cooper, Kaufman, & Ward, 2003).

Those who view race as primarily a social construct argue that race is a marker of differential social privilege (e.g., Krieger, 2003). Race-based health disparities, then, may be understood as the “biological expression of race relations” whereby social inequality gets “embodied” through adaptational responses that negatively impact biological function and contribute to population differences in disease burden (Krieger). In this age of rapidly growing interest in genomics, purely biological conceptions of race may lead to further prejudice and discrimination against historically oppressed groups, a de-emphasis of the contextual factors that shape disease risk, and a resurgence of eugenics-based thinking (Fine et al., 2005).

Money Matters

Perhaps nowhere is race more profoundly a marker of differential privilege and social inequality than in the ways in which socioeconomic resources are distributed across the population. African Americans rank behind all major racial/ethnic groups in annual household earnings (DeNavas-Walt, Proctor, & Lee, 2005). Compared to non-Hispanic Whites, the most common referent group, African Americans also have lower levels of education (Newburger & Curry, 2000), and they are three times as likely to be poor (U.S. Bureau of the Census, 1998). Race and class are so closely aligned in the United States that many argue that racial disparities in health are primarily attributable to socioeconomic inequalities (e.g., Nazroo, 2003).

Although health improves in a stepwise fashion as socioeconomic resources increase, racial disparities persist at each rung of the socioeconomic ladder (e.g., Lin, Rogot, Johnson, Sorlie, & Arias, 2003). In the case of infant mortality, the gap actually widens as socioeconomic status (SES) improves (Williams, 2002). One explanation for the persistence of racial differences after SES has been taken into account is that specified levels of SES are not equivalent across racial groups, given historical obstacles to minority social advancement (Kaufman, Cooper, & McGee, 1997). For example, at every level of education, African Americans have lower earnings and less accumulated wealth than Whites (Oliver & Shapiro, 1995). They also face higher average costs for such basics as housing, food, and insurance, and they tend to have more people dependent on their income. Therefore, African Americans and Whites at a given level of SES may not be directly comparable.

Another important factor to consider is that middle-class status was not an attainable goal for many African Americans until the passage of the Civil Rights Act (Oliver & Shapiro, 1995). As such, they are more likely to be newly arrived into, rather than generationally established in, the middle class. A considerable number of higher SES African American women, therefore, are likely to have experienced some degree of socioeconomic deprivation as children (Williams, 2002). Achieved gains in socioeconomic position as an adult may not completely offset vulnerabilities to poor health outcomes that are carried forward from poorer childhood living conditions (Lu & Halfon, 2003). Even second-generation high SES African American mothers have been reported to have two times the rate of LBW and three times the rate of PTD as similar Whites (Foster et al., 2000). Thus, the relatively recent socioeconomic gains of the past few decades appear to be insufficient to compensate for the centuries of socioeconomic subjugation African Americans have experienced.

Similar to the issue of the biological validity of race, the question of whether racial disparities in socioeconomic resources are primarily responsible for racial disparities in health is the subject of much debate (Krieger, 2003). Though there are large racial gaps in SES and overwhelming evidence that socioeconomic factors play a central role in determining health outcomes, the social significance of race extends well beyond group differences in education and earnings. In a society that has historically, and continues to the present-day, to condone, reinforce, and perpetuate racism, explaining racial disparities in health also requires a serious consideration of the “non-economic” ramifications of living in a color-conscious society (Krieger).

The Varied Shades of Racism

Racism entails the oppression and denigration of others based on skin color or racial/ethnic group affiliation, as manifested through prejudiced beliefs and attitudes, and discriminatory behaviors, institutional practices, and structural arrangements (Clark, Anderson, Clark, & Williams, 1999). Researchers have typically conceptualized racism as an individual-level psychosocial stressor when studying its relationship to health (Williams et al., 2003). Though results are somewhat mixed, perceived racism has been related to a variety of mental and physical health outcomes, including LBW, and PTD (see reviews by Giscombe & Lobel, 2005; Williams et al.). Although institutionalized racism's impact on health is studied less frequently (Gee, 2002), societal institutions provide the infrastructure that supports and directs all social life. Therefore, the racism embedded in them at the macro-level will produce social disadvantages that threaten health quite independently of personal perceptions of unfair treatment.

Institutionalized racism may not be readily perceived as a personal threat to health because of its more hidden integration into the ways in which systems function (Meyer, 2003). For example, racist ideologies codified in zoning laws and lending policies throughout the post-Civil War era severely limited the housing choices of African Americans and shifted them into the worst residential areas (Massey & Denton, 1993). De facto housing and mortgage discrimination persists to the present day, with African Americans remaining highly segregated from Whites, even after accounting for SES and residential preferences (Acevedo-Garcia, Lochner, Osypuk, & Subramanian, 2003). Macro-level barriers to residential integration may indirectly harm health via risky living environments and restricted access to resources. Segregated communities often are characterized by more crime, greater pollution, higher population densities, more poverty, fewer and lower quality services, and restricted educational and employment opportunities (Acevedo-Garcia et al.). Empirical studies have linked residential segregation to the incidence of both infant mortality (Polednak, 1996) and LBW (Roberts, 1997).

Differential treatment in the health care system is another way in which racial bias is institutionalized at the macro-level. Racial/ethnic minorities receive less intensive and poorer-quality health care services than do Whites (Smedley, Stith, & Nelson, 2003). African American pregnant women are less likely to be given medical advice, to be informed of medical complications or risks (Kogan, Kotelchuk, Alexander, & Johnson, 1994), and to receive such prenatal therapies as tocolytics and antenatal steroids (Paul et al., 2006). Even though many factors likely contribute to the racial bias evident in the health care system, providers' conscious or unconscious prejudices and acceptance of negative racial stereotypes are thought to be central contributors (Smedley et al.).

Stress and the Physiologic Cost of Racial Inequality

A stress and health paradigm may be particularly useful in delineating potential pathways by which racism contributes to persistent disparities in health because it can accommodate the integration of socioenvironmental, psychological, and biological determinants into a multi-level explanatory model of differential health risk (Williams et al., 2003). Stress involves environmental demands that strain or overwhelm one's ability to adapt (Cohen, Kessler, & Gordon, 1995). It directly and indirectly (via emotional responses) influences physiologic function in the neuroendocrine, immune, and cardiovascular systems, which are all involved in the process of parturition (Wadhwa, Culhane, Rauh, & Barve, 2001).

Racism is not only a unique stressor with which racial/ethnic minorities must contend, it also heightens exposure to and impact of other types of stressors (Williams et al., 2003). Chronic exposure to racism and the social inequality it produces is hypothesized to prematurely age the female reproductive system via stress-induced pathways that render a woman vulnerable to an adverse birth outcome long before she ever becomes pregnant (Hogue & Bremner, 2005). Such a view is supported by evidence that African American women exhibit a steeper increase in their age-related risk for LBW than non-Hispanic White women (e.g., Rich-Edwards, Buka, Brennan, & Earls, 2003). This accelerated decline in the reproductive health status of African American women has been attributed to the cumulative effects of social disadvantage and racial discrimination (Hogue & Bremner).

Implications for Social Work

With social justice as a key tenet of the profession, social workers are uniquely positioned to lead efforts to investigate, expose, and ameliorate the racism and social inequality that contribute to persistent racial disparities in reproductive health. Results of recent large-scale surveys indicate that there is a considerable lack of knowledge about racial health disparities among physicians and the general public (e.g., Lillie-Blanton, Brodie, Rowland, Altman, & McIntosh, 2000). Social workers in health care and community settings can coordinate health disparities presentations during staff meetings, lunch breaks, and grand rounds by partnering with hospital and clinic administrators, local public health officials, researchers, and grass-roots organizations to ensure that the information presented is current, accurate, pertinent to the setting, and highlights local efforts to address the problem. Town hall meetings may also be effective in bringing together the lay public and community and political leaders to learn about and discuss the relevant issues.

A key aim of these educational efforts should be to frame racial health disparities as a problem for all Americans, not just the minority populations who suffer from them, by highlighting the implications for society at large. For example, there are exorbitant costs associated with caring for preterm and LBW infants. Mean inpatient charges for these infants, who remain hospitalized an average of 22 days, is $50,000, with Medicaid covering nearly one-third of this total (Elixhauser, Yu, Steiner, & Bierman, 2000). The March of Dimes estimates the total societal cost of PTD, which includes medical and educational costs, and costs associated with lost productivity, to be at least $26 billion a year (March of Dimes, 2006).

Though it is imperative that the lay public, the medical community, and political leaders are educated about the problem of racial disparities in adverse birth outcomes to cultivate support from multiple constituencies, education alone is not sufficient for addressing the social determinants of this public health problem. Social workers must actively engage in advocacy efforts designed to promote health equity. Improving access to health care should be a foremost priority. The United States is the only industrialized country without a universal system of health care (Vladeck, 2003). The National Center for Health Statistics (2005) reports 42 million people were uninsured in 2003, a disproportionate percentage of whom were African American. A recent study of ecological contributors to racial differences in LBW found that African American women who were uninsured were significantly more likely to deliver a LBW infant than those with health insurance (Jaffee & Perloff, 2003).

Intervention and advocacy efforts should also be directed toward improving the responsiveness, fairness, and effectiveness of the health care system for those who do have access to it. African Americans are significantly less likely than non-Hispanic Whites to trust their medical providers to do what is best for them, especially if they receive their care in health centers, outpatient clinics, or emergency rooms (Halbert, Armstrong, Gandy, & Shaker, 2006), and they are less satisfied with the services they do receive (Smedley et al., 2003). One factor that is particularly important for promoting trust is the relationship with the provider (Hall, Dugan, Zheng, & Mishra, 2001). Social workers can encourage better patient-provider communication in their role as patient advocates. Outside of their involvement in direct medical encounters, social workers can organize workshops that focus on cultural competence, partnership building, and effective communication skills.

Advocacy efforts should not be geared just toward the health care system itself. Promoting health equity also requires attention to the ways in which policies and practices that are seemingly unrelated to health nevertheless impact it. Social workers must challenge business, community, and political leaders to consider the health ramifications of economic, environmental, and educational initiatives. Helping to organize vulnerable communities to exercise their voting rights so that policy makers take them seriously as political stakeholders is vitally important to advancing a health and social equity agenda. Furthermore, social workers can be instrumental in launching a national dialogue on race and racism. Recent efforts to gauge racial attitudes indicate that most White Americans believe racism is a thing of the past (e.g., Bobo, 2001); however, studies of racism and health consistently show that a majority of African Americans report unfair treatment owing to race (see studies reviewed in Williams et al., 2003). The prevailing culture of political correctness often stifles any meaningful conversation about American race relations, but a national conversation is in order (Jones, 2000).

Social work researchers play a vital role in addressing racial disparities in adverse birth outcomes as well. Our understanding of this public health problem can be considerably enhanced by attending to certain methodological issues. Though the literature on racism and health is growing, very few researchers have incorporated measures of interpersonal and institutional racism, although both have been shown to independently affect health outcomes when studied concurrently (e.g., Gee, 2002). Testing multi-level models may shed much-needed light on the relative contribution of individual and socioenviromental risk factors to persistent racial disparities in adverse birth outcomes. In addition, testing interactive effects of race and SES may provide new insight into the role of socioeconomic factors in perpetuating race-based health disparities (see Kaufman et al., 1997). Taking a multigenerational, life course approach, which considers childhood socioeconomic factors, changes in SES across the lifetime, and length of time in social position, also could help to explain seeming paradoxes and capture important socioeconomic distinctions that contribute to racial variations in health (Lu & Halfon, 2003). The knowledge gained from studies employing stronger and more complex methodologies can inform the development of innovative intervention strategies designed to promote the health of African American mothers and babies.