The Association Between Experiencing Racism and Postpartum Care: A Cross-Sectional Study of Pregnant People in the United States in 2019

Background: The United States is the only high-income country with consistently high maternal mortality (MM) and severe maternal morbidity (SMM) rates, with Black pregnant people being disproportionately impacted. Racial and ethnic disparities in MM and SMM are not completely explained by social, economic, and behavioral factors suggesting that the impact of racism should be further explored as a driving factor of MM and SMM. Healthcare visits during the postpartum period, a period during which a significant proportion of pregnancy-related complications occur, provide an opportunity for interventions to prevent MM and SMM. The primary aim of this study was to quantify the association between experiencing racism within the 12 months before delivery and postpartum follow-up visit attendance. The secondary aim of this study was to examine if this association varies by racial and ethnic subgroups. Methods: This research study was a cross-sectional secondary analysis of 2019 data from the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is coordinated by the Centers for Disease Control and Prevention (CDC). The study sample included a total of 676,047 participants with 47,832 pregnant people experiencing racism and 628,215 pregnant people not experiencing racism. The outcome was not attending a postpartum follow-up visit within 4-6 weeks of giving birth. Three logistic regression models were used to calculate prevalence ratios (PR) and 95% confidence intervals. The first regression model was the crude, unadjusted model. The second regression model adjusted for demographic factors, and the third regression model adjusted for demographic factors and pregnancy complications. To address the secondary aim, the three regression models were run within each racial and ethnic subgroup. Results: About 47,832 (7%) of participants experienced racism. The prevalence of postpartum nonattendance was 11% among participants who did experience racism, and 6.7% among participants who did not experience racism. In unadjusted and partially adjusted models, not attending postpartum follow-up visits were 67% (95% CI: 0.95, 2.92) and 51% (95% CI: 0.66, 3.48) higher among pregnant participants who did experience racism in comparison to pregnant participants who did not experience racism. However, both associations were not statistically significant. In fully adjusted models, associations were further attenuated, and postpartum nonattendance was statistically insignificant 28% (95% CI: 0.07, 5.26) higher among participants who experienced racism compared to those who did not. After adjusting for demographic factors and complicated pregnancies, although statistically insignificant, we observed stronger associations among Black and Indigenous pregnant participants, where postpartum nonattendance among Black pregnant participants who experienced racism was 87% and postpartum nonattendance among Indigenous pregnant participants was 92% higher compared to the respective referent groups of pregnant participants who did not experience racism. Conclusion: In conclusion, we found that people who experienced racism may have a higher prevalence of postpartum follow-up nonattendance, although the associations were not statistically significant. The results from this study are consistent with previous reports from quantitative and qualitative studies. We also found that this association may be stronger among Black and Indigenous pregnant participants in comparison to White Non-Hispanic pregnant participants. The results from this study highlight the need for further exploration of the impacts of pregnant people experiencing racism and other pregnancy outcomes. The field of public health must research and address these impacts to promote the health of historically excluded groups, improve health equity, and protect the quality of life of birthing people and their new infants.