Understanding Racial Disparity in Adverse Pregnancy Outcome



Pregnancy complications are hard to diagnose and treat due to complex etiologies and pathophysiologies. Adding to this difficulty is the observation that the distribution of risk is not even across populations of different geographical ancestry. Pregnancy complications are disproportionately high in African American populations. This chapter provides an overview of various factors that can contribute to higher risk and likely racial disparity.


Preterm Birth Amniotic Fluid Racial Disparity Pregnancy Complication Preterm Labor 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Ms. Geeta Bhat for the editorial assistance and generating the figures used in this book chapter.


  1. 1.
    Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167–94.CrossRefPubMedGoogle Scholar
  2. 2.
    Dehlendorf C, Bryant AS, Huddleston HG, Jacoby VL, Fujimoto VY. Health disparities: definitions and measurements. Am J Obstet Gynecol. 2010;202:212–3.CrossRefPubMedGoogle Scholar
  3. 3.
    Stillbirth Collaborative Research Network Writing Group. Association between stillbirth and risk factors known at pregnancy confirmation. JAMA. 2011;306:2469–79.CrossRefGoogle Scholar
  4. 4.
    Maternal, pregnancy, and birth characteristics of Asians and Native Hawaiians/Pacific Islanders – King County, Washington, 2003–2008: MMWR Morb Mortal Wkly Rep 2011;60:211–3.Google Scholar
  5. 5.
    Bryant AS, Worjoloh A, Caughey AB, Washington AE. Racial/ethnic disparities in obstetric outcomes and care: prevalence and determinants. Am J Obstet Gynecol. 2010;202:335–43.CrossRefPubMedGoogle Scholar
  6. 6.
    Culhane JF, Goldenberg RL. Racial disparities in preterm birth. Semin Perinatol. 2011;35:234–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Dominguez TP. Adverse birth outcomes in African American women: the social context of persistent reproductive disadvantage. Soc Work Public Health. 2011;26:3–16.CrossRefPubMedGoogle Scholar
  8. 8.
    MacDorman MF. Race and ethnic disparities in fetal mortality, preterm birth, and infant mortality in the United States: an overview. Semin Perinatol. 2011;35:200–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Mason SM, Kaufman JS, Daniels JL, Emch ME, Hogan VK, Savitz DA. Black preterm birth risk in nonblack neighborhoods: effects of Hispanic, Asian, and non-Hispanic white ethnic densities. Ann Epidemiol. 2011;21:631–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Rowland Hogue CJ, Silver RM. Racial and ethnic disparities in United States: stillbirth rates: trends, risk factors, and research needs. Semin Perinatol. 2011;35:221–33.CrossRefPubMedGoogle Scholar
  11. 11.
    Spong CY, Reddy UM, Willinger M. Addressing the complexity of disparities in stillbirths. Lancet. 2011;377:1635–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Willinger M, Ko CW, Reddy UM. Racial disparities in stillbirth risk across gestation in the United States. Am J Obstet Gynecol. 2009;201(5):469 e1–8.Google Scholar
  13. 13.
    MacDorman MF, Kirmeyer S. The challenge of fetal mortality. NCHS Data Brief. 2009;16:1–8.Google Scholar
  14. 14.
    MacDorman MF, Kirmeyer S. Fetal and perinatal mortality, United States, 2005. Natl Vital Stat Rep. 2009;57:1–19.PubMedGoogle Scholar
  15. 15.
    Mbah AK, Alio AP, Marty PJ, Bruder K, Wilson R, Salihu HM. Recurrent versus isolated pre-eclampsia and risk of feto-infant morbidity outcomes: racial/ethnic disparity. Eur J Obstet Gynecol Reprod Biol. 2011;156:23–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Tanaka M, Jaamaa G, Kaiser M, et al. Racial disparity in hypertensive disorders of pregnancy in New York State: a 10-year longitudinal population-based study. Am J Public Health. 2007;97:163–70.CrossRefPubMedGoogle Scholar
  17. 17.
    Samadi AR, Mayberry RM, Zaidi AA, Pleasant JC, McGhee Jr N, Rice RJ. Maternal hypertension and associated pregnancy complications among African–American and other women in the United States. Obstet Gynecol. 1996;87:557–63.CrossRefPubMedGoogle Scholar
  18. 18.
    Bukowski R, Carpenter M, Conway D, Coustan D, Dudley DJ, Goldenberg RL, Hogue CJ, Koch MA, Parker CB, Pinar H, Reddy UM, Saade GR, Silver RM, Stoll BJ, Varner MW, Willinger M. Causes of death among stillbirths. JAMA. 2011;306:2459–68.Google Scholar
  19. 19.
    Getahun D, Nath C, Ananth CV, Chavez MR, Smulian JC. Gestational diabetes in the United States: temporal trends 1989 through 2004. Am J Obstet Gynecol. 2008;198:525.CrossRefPubMedGoogle Scholar
  20. 20.
    Kirk JK, Passmore LV, Bell RA, et al. Disparities in A1C levels between Hispanic and non-Hispanic white adults with diabetes: a meta-analysis. Diabetes Care. 2008;31:240–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Brown HL, Chireau MV, Jallah Y, Howard D. The “Hispanic paradox”: an investigation of racial disparity in pregnancy outcomes at a tertiary care medical center. Am J Obstet Gynecol. 2007;197:197.CrossRefPubMedGoogle Scholar
  22. 22.
    Kirk JK, D’Agostino Jr RB, Bell RA, et al. Disparities in HbA1c levels between African-American and non-Hispanic white adults with diabetes: a meta-analysis. Diabetes Care. 2006;29:2130–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Holcomb Jr WL, Mostello DJ, Leguizamon GF. African–American women have higher initial HbA1c levels in diabetic pregnancy. Diabetes Care. 2001;24:280–3.CrossRefPubMedGoogle Scholar
  24. 24.
    Kelley M, Rubens CE. Global report on preterm birth and stillbirth (6 of 7): ethical considerations. BMC Pregnancy Childbirth 2010;10:Suppl 1:S6.Google Scholar
  25. 25.
    Mata-Greenwood E, Chen DB. Racial differences in nitric oxide-dependent vasorelaxation. Reprod Sci. 2008;15:9–25.CrossRefPubMedGoogle Scholar
  26. 26.
    Wang Y, Chen L, Horswell R, et al. Racial differences in the association between gestational diabetes mellitus and risk of type 2 diabetes. J Womens Health (Larchmt). 2012;21:628–33.CrossRefGoogle Scholar
  27. 27.
    Bodnar LM, Simhan HN. Vitamin D may be a link to black-white disparities in adverse birth outcomes. Obstet Gynecol Surv. 2010;65:273–84.CrossRefPubMedGoogle Scholar
  28. 28.
    Kieffer EC, Alexander GR, Kogan MD, et al. Influence of diabetes during pregnancy on gestational age-specific newborn weight among US black and US white infants. Am J Epidemiol. 1998;147:1053–61.CrossRefPubMedGoogle Scholar
  29. 29.
    Chien EK, Jayakrishnan A, Dailey TL, Raker CA, Phipps MG. Racial and ethnic disparity in male preterm singleton birth. J Reprod Med. 2011;56:58–64.PubMedGoogle Scholar
  30. 30.
    Collins Jr JW, David RJ, Simon DM, Prachand NG. Preterm birth among African American and white women with a lifelong residence in high-income Chicago neighborhoods: an exploratory study. Ethn Dis. 2007;17:113–7.PubMedGoogle Scholar
  31. 31.
    Collins Jr JW, Rankin KM, David RJ. African American women’s lifetime upward economic mobility and preterm birth: the effect of fetal programming. Am J Public Health. 2011;101:714–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Kistka ZA, Palomar L, Lee KA, et al. Racial disparity in the frequency of recurrence of preterm birth. Am J Obstet Gynecol. 2007;196:131–6.PubMedGoogle Scholar
  33. 33.
    Lu MC, Kotelchuck M, Hogan V, Jones L, Wright K, Halfon N. Closing the black–white gap in birth outcomes: a life-course approach. Ethn Dis. 2010;20:S2 62–76.Google Scholar
  34. 34.
    McElrath TF. Unappreciated but not unimportant: health disparities in the risk for cervical insufficiency. Hum Reprod. 2010;25:2891–3.CrossRefPubMedGoogle Scholar
  35. 35.
    Messer LC, Kaufman JS, Mendola P, Laraia BA. Black-white preterm birth disparity: a marker of inequality. Ann Epidemiol. 2008;18:851–8.CrossRefPubMedGoogle Scholar
  36. 36.
    Schempf AH, Decker SL. Decline in the United States black preterm/low birth weight rate in the 1990s: can the economic boom explain it? Ann Epidemiol. 2010;20:862–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Spriggs AL. Racial disparities in preterm birth: the role of social determinants. Am J Obstet Gynecol. 2007;197:328–30.CrossRefPubMedGoogle Scholar
  38. 38.
    Tsai HJ, Hong X, Chen J, et al. Role of African ancestry and gene-environment interactions in predicting preterm birth. Obstet Gynecol. 2011;118:1081–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Xu X, Grigorescu V, Siefert KA, Lori JR, Ransom SB. Cost of racial disparity in preterm birth: evidence from Michigan. J Health Care Poor Underserved. 2009;20:729–47.CrossRefPubMedGoogle Scholar
  40. 40.
    Torloni MR, Fortunato SJ, Betran AP, et al. Ethnic disparity in spontaneous preterm birth and maternal pre-pregnancy body mass index. Arch Gynecol Obstet. 2012;285:959–66.CrossRefPubMedGoogle Scholar
  41. 41.
    Dunlop AL, Kramer MR, Hogue CJ, Menon R, Ramakrishan U. Racial disparities in preterm birth: an overview of the potential role of nutrient deficiencies. Acta Obstet Gynecol Scand. 2011;90:1332–41.CrossRefPubMedGoogle Scholar
  42. 42.
    Hogue CJ, Menon R, Dunlop AL, Kramer MR. Racial disparities in preterm birth rates and short inter-pregnancy interval: an overview. Acta Obstet Gynecol Scand. 2011;90:1317–24.CrossRefPubMedGoogle Scholar
  43. 43.
    Kramer MR, Hogue CJ, Dunlop AL, Menon R. Preconceptional stress and racial disparities in preterm birth: an overview. Acta Obstet Gynecol Scand. 2011;90:1307–16.CrossRefPubMedGoogle Scholar
  44. 44.
    Menon R. Spontaneous preterm birth, a clinical dilemma: etiologic, pathophysiologic and genetic heterogeneities and racial disparity. Acta Obstet Gynecol Scand. 2008;87:590–600.CrossRefPubMedGoogle Scholar
  45. 45.
    Menon R, Dunlop AL, Kramer MR, Fortunato SJ, Hogue CJ. An overview of racial disparities in preterm birth rates: caused by infection or inflammatory response? Acta Obstet Gynecol Scand. 2011;90:1325–31.CrossRefPubMedGoogle Scholar
  46. 46.
    Gomez R, Ghezzi F, Romero R, Munoz H, Tolosa JE, Rojas I. Premature labor and intra-amniotic infection. Clinical aspects and role of the cytokines in diagnosis and pathophysiology. Clin Perinatol. 1995;22:281–342.PubMedGoogle Scholar
  47. 47.
    Gomez R, Romero R, Edwin SS, David C. Pathogenesis of preterm labor and preterm premature rupture of membranes associated with intraamniotic infection. Infect Dis Clin North Am. 1997;11:135–76.CrossRefPubMedGoogle Scholar
  48. 48.
    Romero R, Mazor M. Infection and preterm labor. Clin Obstet Gynecol. 1988;31:553–84.CrossRefPubMedGoogle Scholar
  49. 49.
    Gibbs RS, Romero R, Hillier SL, Eschenbach DA, Sweet RL. A review of premature birth and subclinical infection. Am J Obstet Gynecol. 1992;166:1515–28.CrossRefPubMedGoogle Scholar
  50. 50.
    Goldenberg RL, Hauth JC, Andrews WW. Intrauterine infection and preterm delivery. N Engl J Med. 2000;342:1500–7.CrossRefPubMedGoogle Scholar
  51. 51.
    Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet. 2008;371:75–84.CrossRefPubMedGoogle Scholar
  52. 52.
    Menon R. Spontaneous preterm birth. Race and genetics in understanding the complexities of preterm birth. Obstet Gynecol. 2009;4:695–704.Google Scholar
  53. 53.
    Romero R, Chaiworapongsa T, Kuivaniemi H, Tromp G. Bacterial vaginosis, the inflammatory response and the risk of preterm birth: a role for genetic epidemiology in the prevention of preterm birth. Am J Obstet Gynecol. 2004;190:1509–19.CrossRefPubMedGoogle Scholar
  54. 54.
    Sadowsky DW, Adams KM, Gravett MG, Witkin SS, Novy MJ. Preterm labor is induced by intraamniotic infusions of interleukin-1beta and tumor necrosis factor-alpha but not by interleukin-6 or interleukin-8 in a nonhuman primate model. Am J Obstet Gynecol. 2006;195:1578–89.CrossRefPubMedGoogle Scholar
  55. 55.
    Steer P. The epidemiology of preterm labor–a global perspective. J Perinat Med. 2005;33:273–6.CrossRefPubMedGoogle Scholar
  56. 56.
    Stetzer BP, Mercer BM. Antibiotics and preterm labor. Clin Obstet Gynecol. 2000;43:809–17.CrossRefPubMedGoogle Scholar
  57. 57.
    Wadhwa PD, Culhane JF, Rauh V, et al. Stress, infection and preterm birth: a biobehavioural perspective. Paediatr Perinat Epidemiol. 2001;15 Suppl 2:17–29.CrossRefPubMedGoogle Scholar
  58. 58.
    Romero R, Espinoza J, Kusanovic JP, et al. The preterm parturition syndrome. BJOG. 2006;113 Suppl 3:17–42.CrossRefPubMedGoogle Scholar
  59. 59.
    Gomez R, Romero R, Ghezzi F, Yoon BH, Mazor M, Berry SM. The fetal inflammatory response syndrome. Am J Obstet Gynecol. 1998;179:194–202.CrossRefPubMedGoogle Scholar
  60. 60.
    Mazor M, Chaim W, Horowitz S, Romero R, Glezerman M. The biomolecular mechanisms of preterm labor in women with intrauterine infection. Isr J Med Sci. 1994;30:317–22.PubMedGoogle Scholar
  61. 61.
    Romero R, Mazor M, Wu YK, et al. Infection in the pathogenesis of preterm labor. Semin Perinatol. 1988;12:262–79.PubMedGoogle Scholar
  62. 62.
    Andrews WW, Hauth JC, Goldenberg RL. Infection and preterm birth. Am J Perinatol. 2000;17:357–65.CrossRefPubMedGoogle Scholar
  63. 63.
    Goldenberg RL, Andrews WW, Hauth JC. Choriodecidual infection and preterm birth. Nutr Rev. 2002;60:S19–25.CrossRefPubMedGoogle Scholar
  64. 64.
    Goepfert AR, Goldenberg RL, Andrews WW, et al. The preterm prediction study: association between cervical interleukin 6 concentration and spontaneous preterm birth. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol. 2001;184:483–8.CrossRefPubMedGoogle Scholar
  65. 65.
    Challis JR. Molecular aspects of preterm labor. Bull Mem Acad R Med Belg. 1998;153:263–70.PubMedGoogle Scholar
  66. 66.
    Snegovskikh VV, Schatz F, Arcuri F, et al. Intra-amniotic infection upregulates decidual cell vascular endothelial growth factor (VEGF) and neuropilin-1 and -2 expression: implications for infection-related preterm birth. Reprod Sci. 2009;16:767–80.CrossRefPubMedGoogle Scholar
  67. 67.
    Park JS, Park CW, Lockwood CJ, Norwitz ER. Role of cytokines in preterm labor and birth. Minerva Ginecol. 2005;57:349–66.PubMedGoogle Scholar
  68. 68.
    Brou L, Almli L, Drobek C, Bhat G, Pearce B, Fortunato SJ et al. Dysregulated biomarkers induce distinct pathways in preterm birth. BJOG. 2012;119:458–73.Google Scholar
  69. 69.
    Burgner D, Jamieson SE, Blackwell JM. Genetic susceptibility to infectious diseases: big is beautiful, but will bigger be even better? Lancet Infect Dis. 2006;6:653–63.CrossRefPubMedGoogle Scholar
  70. 70.
    Menon R, Fortunato SJ, Thorsen P, Williams S. Genetic associations in preterm birth: a primer of marker selection, study design, and data analysis. J Soc Gynecol Investig. 2006;13:531–41.CrossRefPubMedGoogle Scholar
  71. 71.
    Menon R, Merialdi M, Betran AP, et al. Analysis of association between maternal tumor necrosis factor-alpha promoter polymorphism (-308), tumor necrosis factor concentration, and preterm birth. Am J Obstet Gynecol. 2006;195:1240–8.CrossRefPubMedGoogle Scholar
  72. 72.
    Menon R, Velez DR, Thorsen P, et al. Ethnic differences in key candidate genes for spontaneous preterm birth: TNF-alpha and its receptors. Hum Hered. 2006;62:107–18.CrossRefPubMedGoogle Scholar
  73. 73.
    Menon R, Velez DR, Simhan H, et al. Multilocus interactions at maternal tumor necrosis factor-alpha, tumor necrosis factor receptors, interleukin-6 and interleukin-6 receptor genes predict spontaneous preterm labor in European–American women. Am J Obstet Gynecol. 2006;194:1616–24.CrossRefPubMedGoogle Scholar
  74. 74.
    Velez DR, Fortunato SJ, Thorsen P, Lombardi SJ, Williams SM, Menon R. Preterm birth in Caucasians is associated with coagulation and inflammation pathway gene variants. PLoS One. 2008;3:e3283.CrossRefPubMedGoogle Scholar
  75. 75.
    Velez DR, Fortunato S, Thorsen P, Lombardi SJ, Williams SM, Menon R. Spontaneous preterm birth in African Americans is associated with infection and inflammatory response gene variants. Am J Obstet Gynecol. 2009;200:209–27.CrossRefPubMedGoogle Scholar
  76. 76.
    Velez DR, Fortunato SJ, Morgan N, et al. Patterns of cytokine profiles differ with pregnancy outcome and ethnicity. Hum Reprod. 2008;23:1902–9.CrossRefPubMedGoogle Scholar
  77. 77.
    Menon R, Velez DR, Morgan N, Lombardi SJ, Fortunato SJ, Williams SM. Genetic regulation of amniotic fluid TNF-alpha and soluble TNF receptor concentrations affected by race and preterm birth. Hum Genet. 2008;124:243–53.CrossRefPubMedGoogle Scholar
  78. 78.
    Menon R, Fortunato SJ, Edwards DR, Williams SM. Association of genetic variants, ethnicity and preterm birth with amniotic fluid cytokine concentrations. Ann Hum Genet. 2010;74:165–83.CrossRefPubMedGoogle Scholar
  79. 79.
    Velez DR, Fortunato SJ, Williams SM, Menon R. Interleukin-6 (IL-6) and receptor (IL6-R) gene haplotypes associate with amniotic fluid protein concentrations in preterm birth. Hum Mol Genet. 2008;17:1619–30.CrossRefPubMedGoogle Scholar
  80. 80.
    Menon R, Pearce B, Velez DR, et al. Racial disparity in pathophysiologic pathways of preterm birth based on genetic variants. Reprod Biol Endocrinol. 2009;7:62.CrossRefPubMedGoogle Scholar
  81. 81.
    Menon R, Merialdi M, Lombardi SJ, Fortunato SJ. Differences in the placental membrane cytokine response: a possible explanation for the racial disparity in preterm birth. Am J Reprod Immunol. 2006;56:112–8.CrossRefPubMedGoogle Scholar
  82. 82.
    Menon R, Camargo MC, Thorsen P, Lombardi SJ, Fortunato SJ. Amniotic fluid interleukin-6 increase is an indicator of spontaneous preterm birth in white but not black Americans. Am J Obstet Gynecol. 2008;198:77.PubMedGoogle Scholar
  83. 83.
    Menon R, Thorsen P, Vogel I, et al. Racial disparity in amniotic fluid concentrations of tumor necrosis factor (TNF)-alpha and soluble TNF receptors in spontaneous preterm birth. Am J Obstet Gynecol. 2008;198:533–10.PubMedGoogle Scholar
  84. 84.
    Menon R, Peltier MR, Eckardt J, Fortunato SJ. Diversity in cytokine response to bacteria associated with preterm birth by fetal membranes. Am J Obstet Gynecol. 2009;201:306.CrossRefPubMedGoogle Scholar
  85. 85.
    Menon R, Arora CP, Hobel CJ, Fortunato SJ. Corticotrophin-releasing hormone in lipopolysaccharide-stimulated term fetal membranes and amniotic fluid from term and preterm birth in African Americans and Caucasians. Reprod Sci. 2008;15:477–83.CrossRefPubMedGoogle Scholar
  86. 86.
    Parra EJ, Kittles RA, Argyropoulos G, et al. Ancestral proportions and admixture dynamics in geographically defined African Americans living in South Carolina. Am J Phys Anthropol. 2001;114:18–29.CrossRefPubMedGoogle Scholar
  87. 87.
    Phillips C, Fondevila M, Lareau MV. A 34-plex autosomal SNP single base extension assay for ancestry investigations. Methods Mol Biol. 2012;830:109–26.CrossRefPubMedGoogle Scholar
  88. 88.
    Enoch MA, Shen PH, Xu K, Hodgkinson C, Goldman D. Using ancestry-informative markers to define populations and detect population stratification. J Psychopharmacol. 2006;20:19–26.CrossRefPubMedGoogle Scholar
  89. 89.
    McKeigue PM. Prospects for admixture mapping of complex traits. Am J Hum Genet. 2005;76:1–7.CrossRefPubMedGoogle Scholar
  90. 90.
    Fernandez JR, Shiver MD. Using genetic admixture to study the biology of obesity traits and to map genes in admixed populations. Nutr Rev. 2004;62:S69–74.CrossRefPubMedGoogle Scholar
  91. 91.
    Tian C, Gregersen PK, Seldin MF. Accounting for ancestry: population substructure and genome-wide association studies. Hum Mol Genet. 2008;17:R143–50.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Division of Maternal–Fetal Medicine Perinatal Research, Department of Obstetrics and GynecologyThe University of Texas Medical Branch at GalvestonGalvestonUSA

Personalised recommendations