Reply: The Risk Factor for Maternal Morbidity is Racism, Not Race.

Abstract

We agree with Drs. Rollin, Krishnamurthy and Weerahandi1 that race is a social construct and has been used in medicine and research to explain differences in outcomes that are more appropriately attributed to inequities in health care and social determinants of health due to systemic racism. In our paper we explicitly state in the discussion that our findings of increased maternal morbidity for individuals who identify as non-Hispanic Black reflect "implicit bias, structural racism, and quality of care in obstetrics". We appreciate the authors' point that references to race earlier and elsewhere in the paper could have been replaced by 'exposure to racism'. Our approach was to report results based on the data directly measured by us (self-reported race) and introduce in the Discussion the most likely underlying reason (racism) for the effect of race in the analysis. We welcome this discussion about better approaches to address this critical concern in research publications. Lastly, we understand the concerns raised about Table 1 in the original paper where "Other" and "Asian" reported races were combined with "White." This collapsing of racial categories was performed for analysis due to insufficient sample size of patients self-reporting "Other" or "Asian" as their race, which precluded independent analysis. We appreciate that combining those groups with White participants into a single reference category could potentially bias the results towards the null, as individuals in these racial groups also experience worse maternal health outcomes compared with White birthing persons.4 We agree that exposure to racism is related to poorer obstetric outcomes and future efforts need to focus on preventing structural racism in order to reduce the observed disparities in maternal morbidity and mortality by race.