Table 1.

Summary of Individual Studies Examining Racial Discrimination and Pathways to Adverse Birth Outcomes

Authors (Year)	Design, Participants	Measure of Health Outcomes	Racism/Discrimination Measure	Results
Qualitative Studies
Bermudez-Millan (2011)22	Qualitative descriptive N = 29 Puerto Rican women	To explore how poverty, the built environment, education, working conditions, health care access, food insecurity, and perceived discrimination are experienced throughout the life course and their perceived impact on health	Open-ended question assessing perceived discrimination/racism	Perceived racial discrimination limited employment opportunities, which in turn was perceived to negatively influence maternal and child health.
Giurgescu (2013)13	Qualitative descriptive N = 22 pregnant AA women	To explore pregnant AA women’s perceptions of risk and protective factors impacting PTB	Open-ended questions related to perceptions of causes of PTB, influence of neighborhood, and woman’s feelings influencing PTB	Racism was an identified stressor that potentially leads to PTB.
Nuru-Jeter (2009)24	Qualitative descriptive N = 40 AA women with child < 15 years, including pregnant women	To explore the racism experiences of childbearing women to inform subsequent development of improved measures for birth outcomes research	Semi-structured interview guide intended to engage women in freely discussing their experiences of racism	Women reported experiencing racism 1) over the life course, with childhood experiences being particularly salient; 2) directly and vicariously, particularly with regards to their children; 3) in interpersonal, institutional, and internalized forms.
Salm Ward (2013)25	Qualitative descriptive N = 29 AA women aged ≥ 18 years with a child aged ≤ 1 year	To examine experiences of racial discrimination during prenatal care	Semi-structured interview guide focused on participants’ thoughts about the effect of race on their experiences	Experiences of perceived discrimination based on insurance or income status, race, and lifetime experiences of racial discrimination. The majority of participants described institutionalized racism, particularly in regards to PNC.
Quantitative Studies
Carty (2011)27	Cross-sectional population-based health survey N = 629 participants (n = 407 AA, n = 222 European American)	To examine how perceived racism is associated with self-rated health and birth	24 racism questions included in survey	Perceived racism predicted lower self-rated physical health. Emotional responses to racism-related experiences not significantly associated with lower-birth-weight births (P = .06).
Christian (2012)28	Prospective longitudinal N = 56 pregnant women (n = 38 AA, n = 18 white)	To examine the effects of gestational age, race, and subjective stress on Epstein-Barr virus (EBV) capsid antigen immunoglobulin G (VCA IgG)	Experiences of Discrimination Scale	AA women exhibited higher serum EBV VCA IgG antibody titers than white women (P < .001). This effect was most pronounced among AA women reporting greater racial discrimination.
Dailey (2009)29	Prospective cohort N = 108 pregnant AA women	To examine the extent to which social stressors, personal resources, and known perinatal risk factors predict newborn birth weight	Everyday Discrimination Scale	Fifty-six percent of participants reported experiences of discrimination attributed to race. In final model, tobacco use, number of prenatal care visits, and discrimination due to age and physical disability were significant predictors of birth weight (R2 = .25; P < .001).
Earnshaw (2013)30	Secondary data analysis of control group from longitudinal RCT N = 420 pregnant women who identified as black (n = 158) or Latina (n = 262)	To examine the association between maternal everyday discrimination and newborn birth weight	Modified version of the Everyday Discrimination Scale	Path analysis demonstrated that everyday discrimination was associated with lower birth weight. Depressive symptoms mediated this relationship.
Giurgescu (2012)26	Descriptive correlational comparative N = 72 AA with full term birth (n = 39) or PTB (n = 33)	To determine if neighborhood environment, racial discrimination, and psychological distress predicted PTB	Experiences of Discrimination Scale	Women who reported more experiences of racial discrimination reported higher levels of psychological distress (r = .44, P < .001). Discrimination not significantly associated with PTB (P = .39)
Mendez (2014)31	Secondary data analysis from clinic-based sample of pregnant women (N = 3462) with linked data from the 2000 US Census and Home Mortgage Disclosure Act data	To examine if reported stress, discrimination, and neighborhood quality were associated with PTB	Investigator-developed measure of experiences of discrimination	After adjustment for covariates, discrimination not significantly associated with PTB (OR, 1.0; 95% CI, 0.8–1.3)
Misra (2010)32	Hybrid retrospective and prospective cohort N = 832 AA women	To examine how social and psychosocial factors, including racism, relate to risk of PTB	Racism and Lifetime Experiences Scale (RALES) and 3 items from RALES Daily Life Experiences Scale	In adjusted and unadjusted models, exposure to racism over a women’s lifetime had no effect on PTB. However, racism scores above the median were significantly associated with an increased risk of PTB in 3 subgroups with the effect moderated by depressive symptoms and stress
Rankin (2011)33	Case-control N = 277 AA mothers of PTB LBW (n = 160 cases) and term newborns (n = 117 controls)	To determine if AA women’s coping behaviors modify the relationship between racial discrimination and PTB	Modified version of the Perceived Racism Scale	A greater percentage of AA mothers of preterm newborns had higher past-year exposure to racism than their counterparts who gave birth to term newborns (OR, 2.5; 95% CI, 1.2–5.2)
Ruiz (2014)34	Secondary analysis of Louisiana Pregnancy Risk Assessment Monitoring System Unweighted n = 1561 white mothers and n = 899 black mothers	To examine impact of perceived access to health care services and information received on birth outcomes	Investigator-developed variables used as potential proxy for perceived discrimination	In adjusted models, self-perceived access to health care was associated with PTB for black women (OR, 2.94; 95% CI, 1.1–8.3) and infant mortality for white women (OR, 340.5; 95% CI, 35.7 > 999.9)
Slaughter-Acey (2013)35	Prospective/retrospective cohort design N = 872 AA women	To examine the relationship between racism and prenatal care initiation	Investigator-developed index	Entry into PNC not significantly associated with experiences of racism (P = .33) though significantly associated with group (eg, family, friends, neighbors, other AA individuals) experiences of racism (P < .01).
Wallace (2015)36	Retrospective; electronic medical records from singleton births to white and black women (N = 121,758) linked to state-level indicators of structural racism	To examine the synergistic effects of racial and socioeconomic inequality associated with SGA birth	Investigator-developed index using indicators of structural racism including employment, incarceration, and education ratios of blacks and whites.	High levels of racial inequality and socioeconomic inequality significantly associated with SGA birth. In areas with high inequality levels, AORs ranged from 1.81 to 2.11 for the 3 structural racism indicators.

Abbreviations: AA, African American; AOR, adjusted odds ratio; CI, confidence interval; LBW, low birth weight; OR, odds ratio; PNC, prenatal care; PTB, preterm birth; RCT, randomized control trial; SGA, small for gestational age.