Inaccuracies in Infant Race and Ethnicity Classifications: Implications for Vital Statistics Data.

Abstract

Identity is one of the most important human characteristics. It defines how we interact with the world around us and how the world interacts with us. Although in America we prize individualism and personal identity, there is also a strong desire to categorize and group people, such as by race, ethnicity, gender, and social status. Racial classification is based on a social construct, not a biological one. Unfortunately, racial groupings enforce “superior” and “inferior” groups. In the United States, “hypodescent” laws classify multiracial individuals on the basis of the inferior group.1,2 For example, a white mother can have a Black child, but the reverse is impossible.In 1985, the hypodescent law was applied to the case of Jane Doe v. State of Louisiana.3 Susie Phipps, a white woman (the great-great-great-great-granddaughter of an interracial affair), was denied a US passport because of discrepancy in how she identified herself and what was recorded on her birth certificate. She looked and identified herself as white, but her birth certificate stated that she was “colored.”3 Her appeal eventually went to the Supreme Court, where it was dismissed, demonstrating that what is documented in the birth certificate has lifelong social consequences. These laws enforce systemic racism.Racial and ethnic minority groups have poorer health and disease outcomes than their white counterparts in the United States. Racial and ethnic minority infants in the United States are more likely to be born prematurely, have low birth weight, and die in early childhood.4–6 We assume that the demographic data in these reports are accurate. However, how valid is the information regarding racial classification?In this issue of Pediatrics,7 Weikel et al conducted a systematic review to examine the methods used to record infant race and ethnicity, and highlight the inconsistencies.7 The authors queried online databases for articles that addressed methods of collecting demographic data and population trends, limiting their inclusion criteria to studies that compared 2 or more methods of assessing race and ethnicity data of infants in the United States. They identified 12 studies published between 1980 and 2021 documenting significant discrepancies in the race and/or ethnicity assigned to some infants at birth. Linked birth–death certificates had significant risk of misclassification of race and ethnicity that was more substantial among infants of multiracial couples.This analysis calls into question the accuracy of decades of data regarding infant health outcomes. Classifying racial and ethnic minority children as white on their death certificates erroneously inflates white infant mortality figures and reduces the infant mortality figures among racial and ethnic minority populations. The practical implication is that infant mortality rates are worse than we think they are among racial and ethnic minority populations and may be lower than are commonly reported for white infants. This inaccuracy could lead to spending limited resources on groups who are at low risk, instead of focusing those resources toward racial and ethnic minority and marginalized populations.Each state is required to report data, including race and ethnicity, on births and infant deaths to the National Vital Statistics System, which uses the data widely in health reports.8 However, there are no national standards for how this is done, and methods of birth reporting vary by state and county.8,9The authors found nonresolvable differences in how race and ethnicity were defined in the 12 studies they analyzed, including differences in terminology and how multiracial infants were categorized. The collection guidelines for the National Vital Statistics System state that the race and ethnicity of both parents should be recorded; however, the infant is sometimes assigned the race and ethnicity of the birthing parent only.7,10At a systematic level, racial and ethnic minority children are not being accurately counted. The lack of standardization between how states, regions, institutions, and individuals classify and report race and ethnicity at birth leaves a significant gap for bias and inaccuracies. A comprehensive system for collecting these data would need to account for multiracial families, nonbirthing biological parents, surrogacy, and donor-conceived children. The highlighted inaccuracies also lead to a larger call to increase cultural effectiveness and humility among health professionals, both in their care and recording data for minoritized children.The reality is that race and ethnic groupings are based on ever-changing cultural norms. We must all acknowledge that we live in a racialized society. Whether the discordance between birth certificate, death certificate, survey data, and administrative data observed in the studies highlighted in the present review were the result of human errors, or an effect of systemic racism, the epidemiologic consequences are the same. The social reality is that what race or ethnicity parents assigned to their child matters little; it is the way the society views the child that is critical. Perhaps we need a new census question: “How will society see your child?” Unfortunately, this external classification is the most consequential in a racialized society like ours.