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In The Lancet, Jameela Sheikh and colleagues
contribute to this evidence base with a systematic review and individual participant data (IPD) meta-analysis. 51 studies from 20 high-income to upper-middle-income countries, from the International Prediction of Pregnancy Complications (IPPIC) Network, with at least two ethnic or racial categories (White, Black, South Asian, Hispanic, or other), were included.
Across 2 198 655 pregnancies, the outcomes studied were neonatal mortality, stillbirth, preterm birth, and small-for-gestational-age babies. A two-step random-effects IPD meta-analysis was done with confounding variables adjusted for, establishing a multivariate logistic regression model, to estimate associations between race, ethnicity, and perinatal outcomes. Subgroup analyses were done across regions.
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Similarly, the racial and ethnic categorisations used for these 2 198 655 pregnant women would have varied across context, time, and place,
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notwithstanding the conflation between race and ethnicity, as illustrated by the example of Hispanic people, who can be racially categorised in various different ways.
Calculating the risk of outcomes without associated time periods can also obscure progress or widening inequality. The ascribing of static health risk by racial group, while concluding there are no geographical variations, can be dangerous. The additional health risks borne by Black and other racially minoritised people are not immutable and individually held; they have been created and entrenched through structural and societal racial frameworks.
rather than using conglomerate groupings, can be helpful. UK data show the compound effects relating to social deprivation and ethnicity: the risk of stillbirth for Black African and Caribbean babies increases for those from the most deprived areas, whereas the lowest stillbirth rates are among White populations in the least deprived areas.
This requires understanding of two key principles. First, the association between ill health and minoritised populations is seen globally across all ages and a range of health outcomes.
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Second, these associations between racially and ethnically minoritised people and ill health can be changed, thus shifting race and ethnicity from non-modifiable to modifiable risk factors. The onus is on us all to modify this risk.
The validity of guidelines based on crude racial groupings must be questioned.
Individual approaches to treatment could be more effective, as illustrated by kidney function calculations when race is removed as a variable.
and mechanistic pathways to be elucidated.
This special issue of The Lancet provides a framework mapping pathways of discrimination to health outcomes.
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Research needs to utilise and develop such frameworks; further improve understanding of these inequities; monitor progress; and explore equitable ways of living, healing, and repairing. This healing often happens outside of health-care settings. We recommend multisectoral approaches across health, housing, and education, cultivating culturally cognisant partnerships that centre individuals within their communities, and collaborate with advocacy groups such as Five X More and Birthrights,
engendering collective empowerment, such as through Women’s Health Hubs.
Modifying these perinatal and maternal risks as clinicians includes building trust across the life course, avoiding group homogenisation, and challenging the structures undermining health for millions globally. Every interaction with a patient from a minoritised background is an opportunity for listening and sharing information and decisions, thus modifying the association between race, ethnicity, and ill health.
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