“It’s The Skin You’re In”: African-American Women Talk About Their Experiences of Racism. An Exploratory Study to Develop Measures of Racism for Birth Outcome Studies

  • Amani Nuru-Jeter
  • Tyan Parker Dominguez
  • Wizdom Powell Hammond
  • Janxin Leu
  • Marilyn Skaff
  • Susan Egerter
  • Camara P. Jones
  • Paula Braveman


Objectives Stress due to experiences of racism could contribute to African-American women’s adverse birth outcomes, but systematic efforts to measure relevant experiences among childbearing women have been limited. We explored the racism experiences of childbearing African-American women to inform subsequent development of improved measures for birth outcomes research. Methods Six focus groups were conducted with a total of 40 socioeconomically diverse African-American women of childbearing age in four northern California cities. Results Women reported experiencing racism (1) throughout the lifecourse, with childhood experiences seeming particularly salient and to have especially enduring effects (2) directly and vicariously, particularly in relation to their children; (3) in interpersonal, institutional, and internalized forms; (4) across different life domains; (5) with active and passive responses; and (6) with pervasive vigilance, anticipating threats to themselves and their children. Conclusions This exploratory study’s findings support the need for measures reflecting the complexity of childbearing African-American women’s racism experiences. In addition to discrete, interpersonal experiences across multiple domains and active/passive responses, which have been measured, birth outcomes research should also measure women’s childhood experiences and their potentially enduring impact, perceptions of institutionalized racism and internalized negative stereotypes, vicarious experiences related to their children, vigilance in anticipating future racism events, as well as the pervasiveness and chronicity of racism exposure, all of which could be sources of ongoing stress with potentially serious implications for birth outcomes. Measures of racism addressing these issues should be developed and formally tested.


Race Racism Birth outcomes African-American women 



Our thanks and appreciation also to the Measures of Racism Working Group: Vicki Alexander, MD, MPH, Lynda Dailey, PHN, and Tiffany Simpson, MHSA from the Berkeley Division of Public Health; Barbara Curry, MSW, and Cassius Lockett, PhD with the Sacramento Division of Public Health, and Twila Brown from the San Francisco Department of Public Health, who made important contributions to the design and conduct of this effort, including the content of the focus group guides. We would also like to thank Sheryl Walton, MPH for her contributions to developing the guide for the focus groups and for her support with recruitment and focus group facilitation. This project was supported by Cooperative Agreement TS-842 from the Centers for Disease Control and Prevention and a grant from the Robert Wood Johnson Health and Society Scholars Program Health Disparities Working Group (UC San Francisco).


  1. 1.
    Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Munson, M. L. (2005). Births: Final data for 2003. National Vital Statistical Report, 54, 1–116.Google Scholar
  2. 2.
    Goldenberg, R. L., Cliver, S. P., Mulvihill, F. X., Hickey, C. A., Hoffman, H. J., Klerman, L. V., & Johnson, M. J. (1996). Medical, psychosocial, and behavioral risk factors do not explain the increased risk for low birth weight among black women. American Journal of Obstetrics and Gynecology, 175, 1317–1324. doi: 10.1016/S0002-9378(96)70048-0.PubMedCrossRefGoogle Scholar
  3. 3.
    Shiono, P. H., Rauh, V. A., Park, M., Lederman, S. A., & Zuskar, D. (1997). Ethnic differences in birthweight: The role of lifestyle and other factors. American Journal of Public Health, 87, 787–793.PubMedCrossRefGoogle Scholar
  4. 4.
    Botting, N., Powls, A., Cooke, R. W., & Marlow, N. (1998). Cognitive and educational outcome of very-low-birthweight children in early adolescence. Developmental Medicine and Child Neurology, 40, 652–660.PubMedGoogle Scholar
  5. 5.
    Rich-Edwards, J. W., Colditz, G. A., Stampfer, M. J., Willett, W. C., Gillman, M. W., Hennekens, C. H., Speizer, F. E., & Manson, J. E. (1999). Birthweight and the risk for type 2 diabetes mellitus in adult women. Annals of Internal Medicine, 130, 278–284.PubMedGoogle Scholar
  6. 6.
    Rich-Edwards, J. W., Stampfer, M. J., Manson, J. E., Rosner, B., Hankinson, S. E., Colditz, G. A., Willett, W. C., & Hennekens, C. H. (1997). Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. BMJ, 315, 396–400.PubMedGoogle Scholar
  7. 7.
    Fiscella, K. (2004). Racial disparity in infant and maternal mortality: Confluence of infection, and microvascular dysfunction. Maternal and Child Health Journal, 8, 45–54. doi: 10.1023/B:MACI.0000025726.53515.65.PubMedCrossRefGoogle Scholar
  8. 8.
    Institute of Medicine. (2006). Committee on understanding premature birth and assuring healthy outcomes, and board on health sciences policy. Preterm birth: Causes, consequences, and prevention. Washington, DC: The National Academies Press.Google Scholar
  9. 9.
    Cabral, H., Fried, L. E., Levenson, S., Amaro, H., & Zuckerman, B. (1990). Foreign-born and US-born black women: Differences in health behaviors and birth outcomes. American Journal of Public Health, 80, 70–72.PubMedGoogle Scholar
  10. 10.
    Pallotto, E. K., Collins, J. W. Jr., & David, R. J. (2000). Enigma of maternal race and infant birth weight: A population-based study of US-born Black and Caribbean-born Black women. American Journal of Epidemiology, 151, 1080–1085.PubMedGoogle Scholar
  11. 11.
    Hogan, V. K., & Ferre, C. D. (2001). The social context of pregnancy for African American women: Implications for the study and prevention of adverse perinatal outcomes. Maternal and Child Health Journal, 5, 67–69. doi: 10.1023/A:1011360813893.PubMedCrossRefGoogle Scholar
  12. 12.
    Collins, J. W. Jr., David, R. J., Handler, A., Wall, S., & Andes, S. (2004). Very low birthweight in African American infants: The role of maternal exposure to interpersonal racial discrimination. American Journal of Public Health, 94, 2132–2138.PubMedCrossRefGoogle Scholar
  13. 13.
    Collins, J. W. Jr., David, R. J., Symons, R., Handler, A., Wall, S. N., & Dwyer, L. (2000). Low-income African-American mothers’ perception of exposure to racial discrimination and infant birth weight. Epidemiology, 11, 337–339. doi: 10.1097/00001648-200005000-00019.PubMedCrossRefGoogle Scholar
  14. 14.
    Dole, N., Savitz, D. A., Hertz-Picciotto, I., Siega-Riz, A. M., McMahon, M. J., & Buekens, P. (2003). Maternal stress and preterm birth. American Journal Epidemiology, 157, 14–24. doi: 10.1093/aje/kwf176.CrossRefGoogle Scholar
  15. 15.
    Dole, N., Savitz, D. A., Siega-Riz, A. M., Hertz-Picciotto, I., McMahon, M. J., & Buekens, P. (2004). Psychosocial factors and preterm birth among African American and White women in central North Carolina. American Journal of Public Health, 94, 1358–1365.PubMedCrossRefGoogle Scholar
  16. 16.
    Jackson, F. M., Phillips, M. T., Hogue, C. J., & Curry-Owens, T. Y. (2001). Examining the burdens of gendered racism: Implications for pregnancy outcomes among college-educated African American women. Maternal and Child Health Journal, 5, 95–107. doi: 10.1023/A:1011349115711.PubMedCrossRefGoogle Scholar
  17. 17.
    Lespinasse, A. A., David, R. J., Collins, J. W., Handler, A. S., & Wall, S. N. (2004). Maternal support in the delivery room and birthweight among African-American women. Journal of the National Medical Association, 96, 187–195.PubMedGoogle Scholar
  18. 18.
    Murrell, N. L. (1996). Stress, self-esteem, and racism: Relationships with low birth weight and preterm delivery in African American women. Journal of National Black Nurses’ Association, 8, 45–53.PubMedGoogle Scholar
  19. 19.
    Mustillo, S., Krieger, N., Gunderson, E. P., Sidney, S., McCreath, H., & Kiefe, C. I. (2004). Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries: The CARDIA Study. American Journal of Public Health, 94, 2125–2131.PubMedCrossRefGoogle Scholar
  20. 20.
    Rosenberg, L., Palmer, J. R., Wise, L. A., Horton, N. J., & Corwin, M. J. (2002). Perceptions of racial discrimination and the risk of preterm birth. Epidemiology, 13, 646–652. doi: 10.1097/00001648-200211000-00008.PubMedCrossRefGoogle Scholar
  21. 21.
    Stancil, T. R., Hertz-Picciotto, I., Schramm, M., & Watt-Morse, M. (2000). Stress and pregnancy among African-American women. Paediatric and Perinatal Epidemiology, 14, 127–135. doi: 10.1046/j.1365-3016.2000.00257.x.PubMedCrossRefGoogle Scholar
  22. 22.
    Rich-Edwards, J., Krieger, N., Majzoub, J., Zierler, S., Lieberman, E., & Gillman, M. (2001). Maternal experiences of racism and violence as predictors of preterm birth: Rationale and study design. Paediatric and Perinatal Epidemiology, 15(Suppl 2), 124–135. doi: 10.1046/j.1365-3016.2001.00013.x.PubMedCrossRefGoogle Scholar
  23. 23.
    Bhopal, R. (2001). Racism in medicine. BMJ, 322, 1503–1504. doi: 10.1136/bmj.322.7301.1503.PubMedCrossRefGoogle Scholar
  24. 24.
    Clark, R., Anderson, N. B., Clark, V. R., & Williams, D. R. (1999). Racism as a stressor for African Americans. A biopsychosocial model. American Psychology, 54, 805–816. doi: 10.1037/0003-066X.54.10.805.CrossRefGoogle Scholar
  25. 25.
    Jones, C. P. (2000). Levels of racism: A theoretic framework and a gardener’s tale. American Journal of Public Health, 90, 1212–1215.PubMedCrossRefGoogle Scholar
  26. 26.
    Krieger, N., Rowley, D. L., Herman, A. A., Avery, B., & Phillips, M. T. (1993). Racism, sexism, and social class: Implications for studies of health, disease, and well-being. American Journal of Preventive Medicine, 9, 82–122.PubMedGoogle Scholar
  27. 27.
    Landrine, H., & Klonoff, E. A. (1996). The schedule of racist events: A measure of racial discrimination and a study of its negative physical and mental health consequences. Journal of Black Psychology, 22, 144–168. doi: 10.1177/00957984960222002.CrossRefGoogle Scholar
  28. 28.
    Giscombe, C. L., & Lobel, M. (2005). Explaining disproportionately high rates of adverse birth outcomes among African Americans: The impact of stress, racism, and related factors in pregnancy. Psychological Bulletin, 131, 662–683. doi: 10.1037/0033-2909.131.5.662.PubMedCrossRefGoogle Scholar
  29. 29.
    Parker Dominguez, T., Dunkel Schetter, C., Glynn, L., Hobel, C., & Sandman, C. (2008). Racial differences in birth outcomes: The role of general, pregnancy, and racism stress. Health Psychology, 27(2), 194–203.Google Scholar
  30. 30.
    Williams, D. R., Neighbors, H. W., & Jackson, J. S. (2003). Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health, 93, 200–208.PubMedCrossRefGoogle Scholar
  31. 31.
    Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.Google Scholar
  32. 32.
    McEwen, B. S. (1998). Stress, adaptation, and disease. Allostasis and allostatic load. Annals of New York Academy of Sciences, 840, 33–44. doi: 10.1111/j.1749-6632.1998.tb09546.x.CrossRefGoogle Scholar
  33. 33.
    Geronimus, A. T., Bound, J., & Waidmann, T. A. (1999). Health inequality and population variation in fertility-timing. Social Science and Medicine, 49, 1623–1636. doi: 10.1016/S0277-9536(99)00246-4.PubMedCrossRefGoogle Scholar
  34. 34.
    Hogue, C. J., & Bremner, J. D. (2005). Stress model for research into preterm delivery among black women. American Journal of Obstetrics and Gynecology, 192, S47–S55. doi: 10.1016/j.ajog.2005.01.073.PubMedCrossRefGoogle Scholar
  35. 35.
    Rich-Edwards, J. W., Buka, S. L., Brennan, R. T., & Earls, F. (2003). Diverging associations of maternal age with low birthweight for black and white mothers. International Journal of Epidemiology, 32, 83–90. doi: 10.1093/ije/dyg008.PubMedCrossRefGoogle Scholar
  36. 36.
    Geronimus, A. T., Hicken, M., Keene, D., & Bound, J. (2006). “Weathering” and age patterns of allostatic load scores among blacks and whites in the United States. American Journal of Public Health, 96(5), 826–833. doi: 10.2105/AJPH.2004.060749.PubMedCrossRefGoogle Scholar
  37. 37.
    Harrell, J. P., Hall, S., & Taliaferro, J. (2003). Physiological responses to racism and discrimination: An assessment of the evidence. American Journal of Public Health, 93, 243–248.PubMedCrossRefGoogle Scholar
  38. 38.
    McCubbin, J. A., Lawson, E. J., Cox, S., Sherman, J. J., Norton, J. A., & Read, J. A. (1996). Prenatal maternal blood pressure response to stress predicts birth weight and gestational age: A preliminary study. American Journal of Obstetrics and Gynecology, 175, 706–712. doi: 10.1053/ob.1996.v175.a74286.PubMedCrossRefGoogle Scholar
  39. 39.
    Samadi, A. R., & Mayberry, R. M. (1998). Maternal hypertension and spontaneous preterm births among black women. Obstetrics and Gynecology, 91, 899–904. doi: 10.1016/S0029-7844(98)00087-8.PubMedCrossRefGoogle Scholar
  40. 40.
    Goldenberg, R. L., Klebanoff, M. A., Nugent, R., Krohn, M. A., Hillier, S., & Andrews, W. W. (1996). Bacterial colonization of the vagina during pregnancy in four ethnic groups. Vaginal infections and prematurity study group. American Journal of Obstetrics and Gynecology, 174, 1618–1621. doi: 10.1016/S0002-9378(96)70617-8.PubMedCrossRefGoogle Scholar
  41. 41.
    Romero, R., Gomez, R., Ghezzi, F., Yoon, B. H., Mazor, M., Edwin, S. S., & Berry, S. M. (1998). A fetal systemic inflammatory response is followed by the spontaneous onset of preterm parturition. American Journal of Obstetrics and Gynecology, 179, 186–193. doi: 10.1016/S0002-9378(98)70271-6.PubMedCrossRefGoogle Scholar
  42. 42.
    Culhane, J. F., Rauh, V., McCollum, K. F., Hogan, V. K., Agnew, K., & Wadhwa, P. D. (2001). Maternal stress is associated with bacterial vaginosis in human pregnancy. Maternal and Child Health Journal, 5, 127–134. doi: 10.1023/A:1011305300690.PubMedCrossRefGoogle Scholar
  43. 43.
    Landrine, H., & Klonoff, E. A. (2000). Racial discrimination and cigarette smoking among Blacks: Findings from two studies. Ethnicity & Disease, 10, 195–202.Google Scholar
  44. 44.
    Yen, I. H., Ragland, D. R., Grenier, B.A., & Fisher, J. M. (1999). Workplace discrimination and alcohol consumption: Findings from the San Francisco Muni Health and Safety Study. Ethnicity & Disease, 9, 70–80.Google Scholar
  45. 45.
    McNeilly, M. D., Anderson, N. B., Armstead, C. A., Clark, R., Corbett, M., Robinson, E. L., Pieper, C. F., & Lepisto, E. M. (1996). The perceived racism scale: A multidimensional assessment of the experience of white racism among African Americans. Ethnicity & Disease, 6, 154–166.Google Scholar
  46. 46.
    Meyer, I. H. (2003). Prejudice as stress: Conceptual and measurement problems. American Journal of Public Health, 93, 262–265.PubMedCrossRefGoogle Scholar
  47. 47.
    Anderson, L. M., Shinn, C., Fullilove, M. T., Scrimshaw, S. C., Fielding, J. E., Normand, J., & Carande-Kulis, V. G. (2003). The effectiveness of early childhood development programs. A systematic review. American Journal of Preventive Medicne, 24, 32–46. doi: 10.1016/S0749-3797(02)00655-4.CrossRefGoogle Scholar
  48. 48.
    Berlin, L. J., Brooks-Gunn, J., McCarton, C., & McCormick, M. C. (1998). The effectiveness of early intervention: Examining risk factors and pathways to enhanced development. Preventive Medicien, 27, 238–245. doi: 10.1006/pmed.1998.0282.CrossRefGoogle Scholar
  49. 49.
    Blane, D., Hart, C. L., Smith, G. D., Gillis, C. R., Hole, D. J., & Hawthorne, V. M. (1996). Association of cardiovascular disease risk factors with socioeconomic position during childhood and during adulthood. BMJ, 313, 1434–1438.PubMedGoogle Scholar
  50. 50.
    Cohen, S., Doyle, W. J., Turner, R. B., Alper, C. M., & Skoner, D. P. (2004). Childhood socioeconomic status and host resistance to infectious illness in adulthood. Psychosomatic Medicine, 66, 553–558. doi: 10.1097/01.psy.0000126200.05189.d3.PubMedCrossRefGoogle Scholar
  51. 51.
    Davey-Smith, G., Hart, C., Blane, D., & Hole, D. (1998). Adverse socioeconomic conditions in childhood and cause specific adult mortality: Prospective observational study. BMJ, 316, 1631–1635.Google Scholar
  52. 52.
    Evans, G. W., & English, K. (2002). The environment of poverty: Multiple stressor exposure, psychophysiological stress, and socioemotional adjustment. Child Development, 73, 1238–1248. doi: 10.1111/1467-8624.00469.PubMedCrossRefGoogle Scholar
  53. 53.
    Hillis, S. D., Anda, R. F., Dube, S. R., Felitti, V. J., Marchbanks, P. A., & Marks, J. S. (2004). The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics, 113, 320–327. doi: 10.1542/peds.113.2.320.PubMedCrossRefGoogle Scholar
  54. 54.
    Miller, J. E., & Korenman, S. (1994). Poverty and children’s nutritional status in the United States. American Journal of Epidemiology, 140, 233–243.PubMedGoogle Scholar
  55. 55.
    Sepa, A., Frodi, A., & Ludvigsson, J. (2005). Mothers’ experiences of serious life events increase the risk of diabetes-related autoimmunity in their children. Diabetes Care, 28, 2394–2399. doi: 10.2337/diacare.28.10.2394.PubMedCrossRefGoogle Scholar
  56. 56.
    Wickrama, K. A., Conger, R. D., & Abraham, W. T. (2005). Early adversity and later health: The intergenerational transmission of adversity through mental disorder and physical illness. The Journal of Gerontology. Series B, Psychological Sciecnes and Social Sciences, 60(Spec No 2), 125–129.Google Scholar
  57. 57.
    Charmaz, K. (2003). Grounded theory. In J. Smith (Ed.), Qualitative psychology: A practical guide to research methods. London: Sage.Google Scholar
  58. 58.
    Strauss, A., & Corbin, J. (1997). Grounded theory in practice. Thousand Oaks: Sage.Google Scholar
  59. 59.
    Steward, D., & Shamdasani, P. (1994). Focus groups: Theory and practice. Newbury Park: Sage.Google Scholar
  60. 60.
    Morgan, D. L., & Krueger, R. A. (1993). When to use focus groups and why. In D. L. Morgan (Ed.), Successful focus groups: Advancing the state of the art. Newbury Park, CA: Sage Publications.Google Scholar
  61. 61.
    Crosby, F. J. (1984). The denial of personal discrimination. American Behavioral Scientist, 27, 371–386. doi: 10.1177/000276484027003008.CrossRefGoogle Scholar
  62. 62.
    Hughes, D., & Dumont, K. (1993). Using focus groups to facilitate culturally anchored research. American Journal of Community Psychology, 21, 775–806. doi: 10.1007/BF00942247.CrossRefGoogle Scholar
  63. 63.
    Kodel, J. (1993). The design and analysis of focus group studies: A practical approach. In D. L. Morgan (Ed.), Successful focus groups: Advancing the state of the art. Newbury Park, CA: Sage Publications.Google Scholar
  64. 64.
    Krueger, R. A., & Casey, M. A. (2000). Focus groups: A practical guide for applied research. Newbury Park: Sage.Google Scholar
  65. 65.
    Patton, M. (1990). Qualitative evaluation and research methods. Newbury Park: Sage.Google Scholar
  66. 66.
    ATLAS.ti Scientific Software 5.0.Google Scholar
  67. 67.
    Repetti, R. L., Taylor, S. E., & Seeman, T. E. (2002). Risky families: Family social environments and the mental and physical health of offspring. Psychological Bulletin, 128, 330–366. doi: 10.1037/0033-2909.128.2.330.PubMedCrossRefGoogle Scholar
  68. 68.
    Sellers, R. M., Caldwell, C. H., Schmeelk-Cone, K. H., & Zimmerman, M. A. (2003). Racial identity, racial discrimination, perceived stress, and psychological distress among African American young adults. Journal of Health and Social Behaviour, 44, 302–317. doi: 10.2307/1519781.CrossRefGoogle Scholar
  69. 69.
    Cohen, S., Kessler, R. C., & Gordon, L. U. (Eds.) (1995). Measuring stress: A guide for health and social scientists. New York, NY: Oxford University Press, Inc.Google Scholar
  70. 70.
    Geronimus, A. T. (1992). The weathering hypothesis and the health of African-American women and infants: Evidence and speculations. Ethnicity & Disease, 2, 207–221.Google Scholar
  71. 71.
    McLeod, J. D., & Kessler, R. C. (1990). Socioeconomic status differences in vulnerability to undesirable life events. Journal of Health and Social Behavior, 31, 162–172. doi: 10.2307/2137170.PubMedCrossRefGoogle Scholar
  72. 72.
    Ruggiero, K. M., & Taylor, D. M. (1995). Coping with discrimination: How disadvantaged group members perceived the discrimination that confronts them. Journal of Personality and Personal Psychology, 68, 826–838. doi: 10.1037/0022-3514.68.5.826.CrossRefGoogle Scholar
  73. 73.
    Crocker, J., Voelkl, K., Testa, M., & Major, B. (1991). Social stigma: The affective consequences of attributional ambiguity. Journal of Personality and Social Psychology, 60, 218–228. doi: 10.1037/0022-3514.60.2.218.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Amani Nuru-Jeter
    • 1
  • Tyan Parker Dominguez
    • 2
  • Wizdom Powell Hammond
    • 3
  • Janxin Leu
    • 4
  • Marilyn Skaff
    • 5
  • Susan Egerter
    • 6
  • Camara P. Jones
    • 7
  • Paula Braveman
    • 6
  1. 1.Divisions of Community Health and Human Development; and Epidemiology, School of Public HealthUniversity of CaliforniaBerkeleyUSA
  2. 2.School of Social Work, SWC 224University of Southern CaliforniaLos AngelesUSA
  3. 3.School of Public HealthUniversity of North CarolinaChapel HillUSA
  4. 4.Department of PsychologyUniversity of WashingtonSeattleUSA
  5. 5.Department of Family and Community MedicineUniversity of California, San FranciscoSan FranciscoUSA
  6. 6.Department of Family and Community Medicine and Center on Social Disparities in HealthUniversity of California, San FranciscoSan FranciscoUSA
  7. 7.Social Determinants of Health, Division of Adult and Community HealthNational Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and PreventionAtlantaUSA

Personalised recommendations