Study Traces Origins of Pregnancy-Related Morbidity and Mortality in Black Women Back to the Womb

ALBANY, N.Y. (October 6, 2022) – Many researchers have made attempts to understand why Black women in the U.S. face disproportionately high rates of pregnancy-related morbidity and mortality. Most studies have focused on risk factors occurring during pregnancy, but a recent paper from Betty Lin and Allison Appleton argues that we should be looking much farther back, to intrauterine and early life development, in order to understand the complete picture.

In the U.S., Black women are 1.5 to 4 times more likely to die within a year of giving birth compared to other racial groups. Black infants are also 2-3 times more likely be born prematurely, have low birth weight, and to die within their first year of life than their non-Black peers. Lin and Appleton share that these numbers do not capture the full impact, and these health disparities have serious implications for longevity and well-being of future generations of women.

Pregnancy-related morbidity and mortality often manifests in the form of complications such as hypertension, cardiomyopathy, preeclampsia, and gestational diabetes. Since many of these conditions are disproportionately prevalent in the wider Black population, the researchers believe they may share common origins. Their hypothesis is based on a framework called the Developmental Origins of Health and Disease (DOHaD) model, which posits that adult health and disease can often be traced back to environmental exposures that occur during the very earliest stages of life – and even before birth. These might include things like maternal malnutrition, exposure to toxins, or even psychological stress.

If the authors are correct, it would also help to explain why disparities are most pronounced in Black women of high socio-economic status. The stories of Black celebrities, like Serena Williams and Beyoncé, facing life-threatening pregnancy complications despite receiving top quality medical care has drawn the public’s attention to broader issues of racial disparities and pregnancy. In an essay she wrote for Elle magazine, Williams says of her ordeal with severe blood clotting after her emergency c-section that “being heard and appropriately treated was the difference between life or death for me.” She was initially dismissed by her medical staff when she indicated that she had a history of blood clots and believed she was experiencing a pulmonary embolism. Ultimately, Williams required four successive surgeries to save her life.

While much scholarship has focused on the ways in which the social and material impacts of structural racism can impact maternal health during pregnancy, there is also some indication of a biological mechanism through which maternal intrauterine socio-economic status (i.e., women’s mother’s socioeconomic status when women were in-utero) might increase the risk for future pregnancy-related morbidity and mortality. The proposed hypothesis for this phenomenon is that intrauterine exposure to maternal stress—including stressors tied to structural racism and discrimination, such as psychosocial stress, poverty, lack of access to health care, poor nutrition, exposure to environmental contaminants—during fetal development may prompt enduring neurobiological, metabolic, and epigenetic changes that could affect gene expression, predisposing the fetus to future reproductive health issues. If this is true, they argue, then risk for pregnancy related morbidity and mortality can be traced to stress exposures that occurred well before pregnancy, and can be passed from one generation to the next.

Ultimately, Lin and Appleton argue that more research is needed to test whether the Developmental Origins of Health and Disease model can indeed help explain racial disparities in pregnancy-related morbidity and mortality.

However, Lin and Appleton also caution readers that risk processes are not the be all end all when it comes to health. Specifically, they emphasize that even though Black women and infants are disproportionately affected by pregnancy-related morbidity and mortality, the vast majority of Black women have healthy pregnancies despite those risks. To this end, they argue that it is just as important for researchers to study factors that contribute to resiliency as well as those that lead to negative outcomes.

The full report can be found in Frontiers in Public Health.