Decades-Old Policy Fuel Black Maternal Health Disparities

Despite coming to an end in the 1960s, institutionally racist policies like redlining still rears its ugly head, manifesting itself in poor health outcomes and Black maternal health disparities in present times, according to research published in JAMA Network Open.

This comes as the US sees starker maternal health disparities than any other developed nation. In a seminal September 2019 report, the Centers for Disease Control & Prevention (CDC) stated that Black, American Indian, and Alaska Native women are between two and three times as likely to die from pregnancy-related causes as White women. That gulf continues when looking at birthing complications.

And although the literature confirms that those disparities remain even after controlling for nearly every sociodemographic factor, racist policies like redlining nevertheless don’t help.

A relic of the 1930s, redlining was a discriminatory practice in which the US Home Owners’ Loan Corporation (HOLC) designated thousands of areas as “unsafe” for issuing a homeowner’s loan. “Unsafe” usually meant there was a higher proportion of Black people living in a given neighborhood, creating a system of divestment that made it harder for Black people to own a home.

“This structure of disinvestment, which formally stretched forward into the 1960s, has far reaching impacts,” the researchers explained. “Owing to a range of sequelae of community disinvestment, as well as the critical role of home ownership in intergenerational wealth-building, the legacy of historic redline racial discrimination correlates with modern social and health inequities.”

Particularly, redlining has had negative consequences for maternal health equity, an assessment of about 65,000 live birth certificates from 2005 to 2018, revealed. The researchers measured health outcomes—pre-term birth and obstetric and medical complications—and analyzed data by zip code.

The researchers found that poor outcomes happening today were largely concentrated in areas that in the 1940s had been deemed “hazardous” for homeowner’s loans by the HOLC. In other words, the racist policymaking of the mid-20th century is still having negative health equity impacts today.

Occurrence of pre-term birth decreased as HOLC designation became more favorable, the analysis showed. For example, in areas designated “Best” or “Still Desirable,” the researchers observed a 7.55 percent pre-term birth rate. But in areas designated “Hazardous” in the 1940s, the researchers saw a present-day pre-term birth rate of 12.38 percent.

Notably, these trends continued even after factoring in characteristics like community income levels, poverty levels, and educational attainment.

“The persistence of the association of any preterm birth with increasing ‘Hazard’ designation by the HOLC, even when accounting for contemporary community income levels, poverty levels, and educational attainment, suggests that current community resource distribution alone does not explain these disparities in outcome,” the researchers explained.

“Potentially, the overarching influence of a system of profound structural inequity ripples forward in time with impacts that extend beyond measurable socioeconomic inequity.”

When looking at severe pre-term birth, these neighborhood disparities became statistically insignificant, the researchers pointed out. Factors like income, access to insurance, and life stressors could be at play with these more serious episodes, the team posited.

The data showed similar trends with obstetric and medical complications; there were significantly higher rates of complications in places deemed “Hazardous” by HOLC in 1940 and lower rates in places deemed “Best” or “Still Desirable.”

Trends were most salient for severe maternal depression and a diagnosed substance use disorder. Birthing people living in “Hazardous” designated zip codes were also less likely to be exclusively breastfeeding upon hospital discharge.

In related invited commentary, Aaron B. Caughey, MD, MPP, MPH, PhD, acknowledged that much of this data points to neighborhood, not race, as a driving factor in maternal health disparities.

“While certainly, some of these differences are due to persistent socioeconomic differences that are marked by neighborhoods or districts, essentially, that is the point,” Caughey wrote. “Denying Black people access to home loans generations ago impeded the ability of these families to develop intergenerational wealth, making it more difficult for social mobility to occur. While such social mobility does not diminish all health inequities, it can reduce them.”

Said otherwise, this data adds to the literature about Black maternal mortality. In addition to the systemic racism that has since caused neighborhood-level disparities, Black people often experience implicit bias and life stressors related to race and racism that impact maternal mortality.

By understanding this and other interpersonal- and policy-level factors related to racial health disparities, healthcare leaders can begin to reshape their thinking.