Why Causation Matters: Rethinking "Race" as a Risk Factor

Abstract

Although it is tempting to construe the correlation between Black "race" and higher rates of preterm birth as causal, this logic is flawed. Worse, the continued use of Black "race" as a risk factor for preterm birth is actively harmful. Using Black "race" as a risk factor suggests a causal relationship that does not exist and, critically, obscures what actually causes Black patients to be more vulnerable to poorer maternal and infant outcomes: anti-Black racism. Failing to name anti-Black racism as the root cause of Black patients' vulnerability conceals key pathways and tempts us to construe Black "race" as immutably related to higher rates of preterm birth. The result is that we overlook two highly treatable pathways-chronic stress and implicit bias-through which anti-Black racism negatively contributes to birth. Thus, clinicians may underuse important tools to reduce stress from racism and discrimination while missing opportunities to address implicit bias within their practices and institutions. Fortunately, researchers, physicians, clinicians, and medical staff can positively affect Black maternal and infant health by shifting our causal paradigm. By eliminating the use of Black "race" as a risk factor and naming anti-Black racism as the root cause of Black patients' vulnerability, we can practice anti-racist maternity care and take a critical step toward achieving birth equity.

Fig. 1.. An explanatory diagram of the implications of our current causal paradigm naming Black “race” as the risk factor vs adopting an anti-racist paradigm that names anti-Black racism as the root cause of Black maternal health disparities. This article focuses on two key, highly treatable pathways linking anti-Black racism to preterm birth disparities, chronic stress, and implicit bias, which are obscured by naming Black “race” as the risk factor. This explanatory diagram is applicable to other maternal and infant outcomes, in addition to other birthing populations in which disparities are attributed to “race.”

Fig. 2.. A visual model highlighting the importance of naming anti-Black racism, practicing anti-racist maternity care, and enriching prenatal and postnatal environments to achieve birth equity.