Racism in obstetric care linked to higher blood pressure in mothers

Mothers of color who faced racism or microaggressions during obstetric care had higher blood pressure after delivering their babies compared to people of color who did not report racism during their care, according to new research from the Perelman School of Medicine at the University of Pennsylvania. Among patients who lived in neighborhoods greatly affected by structural racism, there was a magnified correlation between racism and blood pressure. Their findings are published in Hypertension this week.

"The findings underscore not only the unacceptable prevalence of racism even within clinical spaces but also its impact on current and future health, said Elizabeth Howell, MD, MPP, chair of Obstetrics and Gynecology and the Harrison McCrea Dickson, M.D. President's Distinguished Professor at Penn. "Our work also highlights the potential role that eliminating racism could have in decreasing the high rate of poor maternal health outcomes among people of color. We found 37 percent of participants had experienced some form of racism or microaggression from their care team."

As many as one in 10 post-partum patients develop high blood pressure within a year of giving birth. Untreated high blood pressure – at any phase in life -- can cause a host of serious and life-threatening health issues including heart, vision, and kidney damage, seizures, and strokes. Since the condition can be asymptomatic – often dubbed "the silent killer" – screening is essential to identify new mothers who need treatment.

While we certainly were not surprised at the impact that racism and microaggression has on overall blood pressures postpartum, it was scary and very upsetting to see how long that period lasted after giving birth. Not only did their experiences during obstetric care impact their health immediately postpartum, but that continued for up to three months. That makes the entire impact of racism on maternal health even more nefarious. And the magnitude of these types of physiologic changes become cumulative over time and undoubtedly lead to the inequities we see in many health outcomes."

Lisa Levine, MD, MSCE, chief of the Division of Maternal Fetal Medicine at Penn

During the first 11 days postpartum, blood pressures were higher among mothers who were subjected to racism. But blood pressures were even higher from 2 weeks to 3 months after delivery, meaning the effects of racism on new moms' health lasted long after the delivery.

Roughly 22 moms die per 1,000 live births in the United States. The association between racism and maternal health inequality has been clearly identified by previous research. Last year, the Centers for Disease Control and Prevention (CDC) reported that 40 percent of Black, Hispanic, and multiracial moms face discrimination during obstetric care. Racist interactions may include dismissing a patient's pain, failing to involve them in decision-making, or neglecting to provide thorough assessments-all of which compromise quality of care. Additionally, the same report stated 45 percent of participants refrained from asking at least some questions to their obstetric care team.

"This leads to a lack of trust from patients," said Howell. "It might keep them from follow-up appointments, engaging with doctors, seeking care in the future when they are facing serious symptoms, or reporting things like postpartum depression."

Measuring the effects of racism

The study included 373 pregnant people of color (Black, Hispanic, and South Asian) who gave birth at four hospitals in New York City and Philadelphia. At delivery, patients completed a survey which included questions regarding racism and microaggressions that the authors adapted for their multiethnic participants with the help of a patient and community advisory board. The team monitored their blood pressures twice weekly for the first 10 days after delivery and then twice a week until three months after their baby's birth. During the first 10 days, the mothers who reported experiencing racism or microaggressions from their care team had systolic blood pressures (the top number) that were 1.88 points higher on average compared to their peers who didn't experience racism. After 3 months, that average was about 2.19 points higher. The blood pressures of those who faced racism and lived in neighborhoods determined to be greatly affected by structural racism were even higher: three months later, their systolic pressures were 7.55 points higher compared to the control group.

"It may appear these numbers aren't huge differences, but even small increases in blood pressure in young adulthood elevate risk of cardiovascular disease in older age," said Levine. "Blood pressure increases are often cumulative as we age."

Ending maternal-health inequity

The researchers say that along with efforts to eradicate racism and improve communication between providers and patients, studies should evaluate blood pressure management methods to help eliminate the health impacts of racism.

"At Penn, we want the brightest and most talented clinicians and staff but also those who truly care about all our patients, including patients often marginalized from our health care system," said Howell. "Along with training on systemic racism and microaggressions, we have programs in place like Heart Safe Motherhood to ensure that patients most susceptible to structural racism in the American healthcare system don't fall through the cracks." Additionally, Levine and Jennifer Lewey, MD, co-author of the study and an assistant professor of Obstetrics and Gynecology and Cardiovascular Medicine, recently received a 12.5 million dollar grant from the Patient-Centered Outcomes Research Institute (PCORI) to evaluate ways to improve postpartum blood pressure control in high risk populations, such as those included in this current study.

Additional Penn authors are Micki Burdick, Oluwadamilola Oshewa, and Maria Monterroso.

This study was funded by the National Institutes of Health's National Institute on Minority Health and Health Disparities (R01 MD016029-02SI).