Am J Perinatol
DOI: 10.1055/a-2209-4568
Letter to the Editor

The Risk Factor for Maternal Morbidity is Racism, not Race

1   Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
Sudarshan Krishnamurthy
2   Wake Forest School of Medicine, Winston-Salem, North Carolina
Himali Weerahandi
3   Department of Medicine, UCSF School of Medicine, San Francisco, California
› Author Affiliations
Funding None.

We read with interest the paper by Merriam et al (May 7, 2023),[1] which investigates the risk factors for maternal morbidity in nulliparous patients. We note that in the discussion of the racial inequities, the authors mention structural racism and implicit bias; but we are concerned that they do not state clearly enough that the risk factor is Racism experienced by Black patients, and not Black race.

We believe that labeling “Black race” as the risk factor in the abstract and in the highlighted “key points” could lead to inappropriate focus on race and lack of attention to the root cause that needs to be addressed to reach health equity—Racism.[2] We note that this paper uses the word “race” 13 times, and in contrast uses the word “racism” only once.[1] It is critical for research to state explicitly that race is a social construct and that exposure to racism that is the risk factor, not race.[2] [3] [4] Finally, we are concerned that in table 1 of the article in question, the racial categories of “other” and “Asian” seem to be combined with “non-Hispanic white” as the reference group.[1] Aggregating these groups with “white” obscures inequities that other groups experience.[5]

To identify and address the barriers to health equity and to be as scientifically accurate as possible, biomedical research studies must clearly state that race is a social construct, explain what the variable is being used as a proxy for, and they should explicitly name “exposure to racism” (not race) as the risk factor for poor maternal health outcomes.[2]

Publication History

Received: 19 May 2023

Accepted: 10 November 2023

Accepted Manuscript online:
11 November 2023

Article published online:
05 December 2023

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  • References

  • 1 Merriam AA, Metz TD, Allshouse AA. et al; +nuMoM2b Investigators. Maternal morbidity risk factors in nulliparas. Am J Perinatol 2023; DOI: 10.1055/a-2088-2586.
  • 2 Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and structural determinants of health inequities in maternal health. J Womens Health (Larchmt) 2021; 30 (02) 230-235
  • 3 Kaufman JS, Cooper RS, McGee DL. Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race. Epidemiology 1997; 8 (06) 621-628
  • 4 Breathett K, Spatz ES, Kramer DB. et al. The groundwater of racial and ethnic disparities research: A Statement From Circulation: Cardiovascular Quality and Outcomes . Circ Cardiovasc Qual Outcomes 2021; 14 (02) e007868
  • 5 Kauh TJ, Read JG, Scheitler AJ. The critical role of racial/ethnic data disaggregation for health equity. Popul Res Policy Rev 2021; 40 (01) 1-7