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Perceived Racial Discrimination in the Pregnant African American Population

A Concept Analysis

Mileski, Megan R. MSN, RN; Shirey, Maria R. PhD, MBA, MS, RN, NEA-BC, ANEF, FACHE, FNAP, FAAN; Patrician, Patricia A. PhD, RN, FAAN; Childs, Gwendolyn PhD, RN, FAAN

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doi: 10.1097/ANS.0000000000000392
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IN THE UNITED STATES, infant mortality is a serious public health issue, particularly for the African American population. In 2018, the national infant mortality rate (IMR) of 5.7 (calculated per 1000 live births) was higher than 27 other developed countries in the world. In addition, the national African American IMR was 10.8 compared with the IMR of 4.6 for non-Hispanic White infants.1 These statistics inform us that for every 1 non-Hispanic White infant who dies before their first birthday, 2 African American infants will die. This health disparity has persisted and even increased over time, suggesting that not all racial and ethnic groups have benefited equally from social and medical advances.2,3 Although infant mortality has declined over time for both African American and non-Hispanic Whites, the relative gap between the races is much wider today than it was in 1950.4 While the IMR is only one marker of birth outcomes, it is regarded as one of the most important indicators of the health of a nation as it encompasses several indicators such as maternal health, access to health care, and public health practices. Recent studies have found that racial and ethnic minority women experience higher lifetime exposure to chronic stressors, such as perceived racial discrimination, which may increase their risk for poor pregnancy outcomes.2,5–9


In the United States, racial disparities exist in preterm birth (PTB) rates (<37 weeks' gestation). PTB is the leading cause of racial disparity in the IMR in the United States. African American mothers have more than twice the rate of PTB than non-Hispanic White mothers.1 Approximately $26.2 billion is spent annually on health care for infants born prematurely, as PTB leads to high infant mortality, morbidity, and developmental delays.10 Research on the racial disparities in PTB has largely focused on various levels of exposure to protective and risk factors including health behaviors of the mother, prenatal care utilization, and access to care. The mechanisms by which these factors contribute to PTB, however, are not well understood. Socioeconomic stressors, perceived racial discrimination, and stressful events over the life course have the potential to induce a stress response in African American women leading to PTB.11 Perceived racial discrimination is one such chronic stressor that research suggests is a risk factor for PTB, low birth weight, and very low birth weight, which are among the leading causes of infant mortality in the United States.12 More clearly defining perceived racial discrimination in the African American pregnant population has the potential to better explain the phenomenon and how it relates to adverse birth outcomes.

Statements of Significance

What is known or assumed to be true about this topic?

In the United States, African American mothers have more than twice the rate of PTB and infant mortality than non-Hispanic White mothers. Studies have found that experiences of perceived racial discrimination, over the life course and during pregnancy, have the potential to cause a stress response in the mother that may lead to shortened gestation.

What this article adds:

To our knowledge, perceived racial discrimination in the pregnant African American population has not been formally defined as a concept. We chose Rodgers' evolutionary method for this concept analysis in an effort to provide foundation and clarity to enhance the ongoing process of beginning to define perceived racial discrimination in the pregnant African American population. The evolutionary method is systematic and focuses on clear steps for analysis. This serves to clarify, describe, and explain concepts that are central to nursing science.

A limited number of studies have investigated the relationship between perceived racial discrimination and the incidence of PTB in the African American population; however, the majority of them have found that a relationship does indeed exist. One study found that African American mothers of very low-birth-weight infants were 3 times as likely as African American mothers of normal birth weight infants to have experienced racial discrimination13; another study found that experiences of discrimination doubled the risk of PTB, which often results in low birth weight or very low birth weight.9 Perceived racial discrimination in pregnancy is a concept that is not well understood among health care providers. The purpose of this concept analysis is to more clearly define perceived racial discrimination in the pregnant African American population. The article includes discussion of conceptual definitions and attributes of perceived racial discrimination in the African American pregnant population using Rodgers'14,15 evolutionary method of concept analysis. Antecedents, consequences, exemplars, and hypotheses are also presented.


Definitions of racial discrimination are varied, yet all include the concept of unequal treatment stemming from skin color or other individual characteristics.2,16 Understanding factors that may contribute to a greater risk of PTB, such as perceived racial discrimination, offers promise in identifying preventive measures and therefore a reduction in racial disparities that affect the health and well-being of African Americans. Relevant existing literature suggests that chronic exposure to racial discrimination may cause the body to be more physically reactive in stressful or potentially stressful social situations.17 One study proposed that routine racial discrimination can become a chronic stressor that may erode an individual's protective resources and increase vulnerability to physical illness18; another study found that perceived racial discrimination may lead to inflammation in the body because over- or underactivity of allostatic systems produces allostatic load.19 Allostasis occurs when the physiological systems within the body fluctuate to meet demands from external stressors. Systems of allostasis that promotes adaptation include the autonomic nervous system, the metabolic system, the hypothalamic-pituitary-adrenal (HPA) axis, and the gastrointestinal, kidney, and immune systems. Biological mediators of these systems (cortisol, cytokines, sympathetic and parasympathetic transmitters, for example) operate iteratively in an interactive network to maintain allostasis.20,21

In 1993, McEwen and Stellar20 presented a new theory of the relationship between stress and the processes leading to disease defined as allostatic load. The authors proposed that allostatic load is the “cost of chronic exposure to fluctuating or heightened neural or neuroendocrine response resulting from repeated or chronic environmental challenge that an individual reacts to as being particularly stressful.”20(p2093) Allostatic load is essentially carryover stress. Instead of returning to a healthy baseline of homeostasis, the altered chemical state caused by chronic exposure to stressors accumulates and creates wear and tear on many organ systems, or weathering. McEwen and Stellar20 presented evidence for stress effects on a number of pathophysiological conditions including asthma, gastrointestinal disorders, myocardial infarction, diabetes, cancer, viral infections, and autoimmune disorders. The theory of allostatic load is the most common framework guiding research investigating the relationship between perceived racial discrimination and adverse birth outcomes in the African American population. This theory was used as the guiding framework for this evolutionary concept analysis.


Rodgers' evolutionary method of concept analysis is the best method for clarifying the concept of perceived racial discrimination in the African American pregnant population because the process of inductive inquiry allows for a discovery approach to literature review. The evolutionary process moves from observation to broader generalizations and theories, and it allows for refining of a concept rather than a finite definition. This approach to concept analysis is more contemporary than previous approaches that viewed a definition as an endpoint. Existing definitions of perceived racial discrimination are broad and fragmented, and they also are influenced by cultural norms over time. This approach to concept analysis serves to achieve the final purpose of Rodgers'14,15 method, which is to provide the foundation and clarity to enhance the ongoing process of beginning to define perceived racial discrimination in the African American pregnant population.

The evolutionary method is systematic and focuses on clear steps for analysis. This serves to clarify, describe, and explain concepts that are central to nursing science.22 There are 6 steps in Rodgers' evolutionary method. While several of the steps may be conducted simultaneously, they each mark an important part in the process. The steps in Rodgers' approach include the following:

(1) Identify the concept of interest and associated expressions (including surrogate terms); (2) identify and select an appropriate realm (setting and sample) for data collection; (3) collect data relevant to identify: (a) the attributes of the concept; and (b) the contextual basis of the concept, including interdisciplinary, sociocultural, and temporal (antecedent and consequential occurrences) variations, and the contextual basis of the concept; (4) analyze data regarding the characteristics of the concept; (5) identify an exemplar of the concept, if appropriate; and (6) identify implications, hypotheses, and implications for future development of the concept.14(p85)

To conduct the literature review for this concept analysis, PubMed and CINAHL databases were searched with the key words “perceived racial discrimination” or “racial discrimination” AND “pregnancy” AND “African American.” In addition to searching the databases for peer-reviewed sources, an investigation of the gray literature was conducted. The Figure provides a detailed flow diagram of the literature search, which was limited to focusing on English language articles published between 2000 and 2020. An initial search in PubMed produced a total of 84 sources, CINAHL produced 329, and a Google search aimed at discovering gray literature uncovered more than 3 million results. The search phrase entered in Google was “perceived racial discrimination in African American pregnancy.” The sources selected from the Google search were chosen utilizing the search engine's algorithm. When a user enters a query in the Google search engine, the program searches for matching resources. The results that are most relevant to the search terms are presented in descending order. This relevancy is determined by more than 200 factors.23 Because these results are listed in order of relevance, review of the results was limited to the first 10 pages. From there, 5 sources were chosen as representative of the majority of what was found in an initial scan of the search results. From PubMed and CINAHL, duplicates were removed, decreasing the sample size from 413 to 341 articles. Of those, exclusions were made for US-based studies (written in English). After abstract review, the sample size was reduced to 54. Following full-text review and data extraction, a final sample size of 28 sources were chosen for analysis (PubMed and CINAHL, n = 24; gray literature, n = 4).

PRISMA flow diagram.


Conceptual definitions

Discrimination, in general, has been defined as being hassled or made to feel inferior due to one's race, ethnicity, or color.24 More specifically, perceived (ie, self-reported) racial discrimination has been defined as a behavioral manifestation of the everyday negative attitudes, judgments, or unfair treatment toward individuals or members of a group by a discriminator,25 and that perception is paramount to the theoretical foundation of racism as a stressor.26 Perceived racial discrimination in health care is thought to be higher among some sociodemographic groups, particularly the African American population.27 It is hypothesized that race may be a good predictor of health outcomes in race-conscious societies, such as the United States. In the United States, race is a social category that is assigned to a person on the basis of physical attributes. This classification system has the potential to impact a person's opportunities and experiences, for better or for worse.28


According to Rodgers,14 attributes provide the true definition of a concept, as opposed to a singular, generic definition. Identifying a cluster of attributes is essential to characterizing the concept of perceived racial discrimination in the pregnant African American population.

Racism is a stressor that has been shown to lead to lower rates of health care utilization and adverse health outcomes,11 and in pregnancy, this is thought to be a possible explanation for racial disparities in infant mortality in the United States.29 The evidence suggests that prenatal stress in African American women can, at least in part, be attributed to the legacy and accumulation of distinct lifetime experiences of discrimination and mistreatment. In fact, childbearing and motherhood in African American women have been and continue to be discouraged and devalued.30 While American society places great importance on being a mother, the attitude that African American women, particularly those who are poor, should not have children persists.30 To provide a definition of perceived discrimination in the African American pregnant population, it was necessary to identify the attributes of the concept. These attributes emerged as the review of literature revealed that African American women experience unique challenges in the perinatal course. The attributes of perceived racial discrimination in the African American pregnant population are as follows: (a) self-reported experiences of discrimination; (b) barriers to prenatal care; and (c) contradictory social pressures regarding motherhood and race.

Self-reported experiences of discrimination

More than half of the sources chosen for this concept analysis provided both quantitative and qualitative self-reported data related to discrimination either during pregnancy or cumulatively over the life course. The Everyday Discrimination Scale31 was a commonly used tool; however, the qualitative studies that incorporated this concept provided rich experiences of discrimination. One qualitative study, in particular, examined the experiences of racial discrimination during prenatal care from the perspectives of African American women. The researchers included several direct quotes in the article from women's actual experiences with racism both from their providers and from society in general.32 Perception of experiences of discrimination is best captured when self-reported by the individual; therefore, it is a critical attribute of the concept of interest.

Barriers to prenatal care

Racism is a stressor that leads to lower rates of health care utilization and adverse health outcomes.11 Prenatal care provides an opportunity for women to access care and receive preventive services, nutritional support, social services, and education.33 African American women are much more likely to fail to present for prenatal care, which places them at a higher risk for adverse pregnancy outcomes.34 Lack of insurance, unreliable or absent transportation, financial constraints, lack of childcare, loss of work, and poor patient-provider relationships are the predominant barriers to prenatal care. African American women are twice as likely to face these barriers to prenatal care as White women.35

Contradictory social pressures regarding motherhood and race

In American society, there are strong expectations for women to become mothers. Women who do not have children are often not perceived as “real” women; therefore, most women in the United States choose to have children.12 However, motherhood and childbearing in the African American culture have a history of being discouraged and devalued. Despite the civil rights movement and presumed social equality, the attitude that poor, African American women should not have children persists.36 In fact, there have been funded campaigns to persuade them to use long-term birth control or be sterilized.37 The evidence suggests that prenatal stress in African American women can, at least in part, be attributed to the legacy and accumulation of distinct lifetime experiences of discrimination and mistreatment. Herein lies the conundrum: In order to be a real woman, you need to have children; however, if you are Black in America, society resents when you have children and attempts to prevent you from becoming a mother.


Antecedents are events or incidents that must occur or be in place prior to the occurrence of the concept.14 The antecedents to perceived racial discrimination in the African American pregnant population are pregnancy and being African American. Without these two distinctions, the concept does not exist. Studies have found that there is something unique about being born Black in the United States that puts a woman at a greater risk for PTB, the consequences of which are the leading cause of infant mortality for African American babies.38,39 The risk of adverse pregnancy outcomes, as reflected by moderately low birth weight, has increased by more than 40% for US-born Black women as compared with their mothers or grandmothers who were born in Africa or the Caribbean.40


According to Rodgers, “Consequences are the result of the use of a concept in a practical situation.”14(p7) They are what happens as a result of the concept. Consequences of perceived racial discrimination in the African American pregnant population are stress and possibly adverse birth outcomes that include low birth weight, very low birth weight, PTB, and/or other infant mortalities/morbidities.

Stress is a negative consequence of perceived racial discrimination that was a common thread in the review of literature. Several studies found that psychosocial stress among African American women is associated with PTB or low-birth-weight infants.41–43 Stress has the potential to accelerate cellular aging44 and can lead to wear and tear on the body that can result in illness and mortality.4 Perceived racial discrimination may induce chronic, cumulative stress, which over the life course, can be damaging to physiological processes leading to adverse maternal and infant health outcomes.42

Empirical evidence points to a relationship between discrimination (either during pregnancy or over a lifetime) and adverse birth outcomes even after controlling for other factors such as medical complications, sociodemographic differences, and negative health behaviors.29 The majority of the studies found perceived racial discrimination to have a negative impact on birth outcomes. One study found that African American mothers who delivered preterm infants reported more experiences with racial discrimination during their lifetime than African American mothers who delivered infants at full term.45


According to Rodgers,14 it is important to identify at least one exemplar in order to provide a “practical demonstration of the concept in a relevant context.” Salm Ward et al32 conducted a qualitative study to examine the experiences of racial discrimination during prenatal care from the perspectives of African American women. One participant relayed an experience with her midwife that occurred after the pregnant mother had missed an appointment. “I told [my midwife] I didn't like going to my appointments, and one day she just asked me, ‘Do you do crack?’ ... Just because I don't want to come to my appointments, I gotta be a drug addict?” Other participants discussed how experiences of discrimination interfered with them getting jobs, services for their children, and appropriate medical attention. Another participant said, “It's not gonna change. It's not, cause it's been like this forever. You learn to go last.” This study found that there was a strong theme of perceptions of being treated differently by providers, clinic staff, and others (store clerks, for example) during prenatal care and at other times during the pregnancy. Women in the study described experiences of unintentional discrimination, such as stereotypes about being African American, and although the offender did not mean a comment as a racist one, there was a perception of discrimination, nonetheless. One of the leading researchers in this field, James Collins, MD, stresses that there is something about growing up as a Black female in the United States that is not good for your childbearing health. He posits that that “something” is related to experiences of racism.13

Hypotheses and implications

The final step in Rodgers' evolutionary method of concept analysis is to identify hypotheses and implications for future development of the concept.14 One hypothesis for this concept is “Pregnant African American women with significant experiences of perceived racial discrimination over their lifetime will have higher rates of PTB than non-Hispanic White women after accounting for sociodemographic factors.” Another possible hypothesis is “Pregnant African American women who rate significant experiences of perceived racial discrimination will have newborns with lower birth weights than pregnant African American women who rate nonsignificant experiences of perceived racial discrimination during pregnancy.” Implications for future development of the concept include the following: (a) pregnant African Americans should be made aware of the potential risk for adverse birth outcomes related to perceived racial discrimination; (b) health care providers should screen African American patients with reliable tools such as the Experiences of Discrimination tool46–48 or the Perceived Racism Scale31 in order to identify at-risk patients; and (c) implementation of a life course approach to pregnancy in this population has potential to decrease adverse birth outcomes.

The life course approach goes beyond short-term interventions to address the health care needs of African American women over the course of their lifetime. It is a comprehensive plan aimed at supporting the women physically, socially, and emotionally preconceptually and beyond the postpartum period.49 A life course approach aims to improve health behaviors in the African American population and might help close the gap between African American and White IMRs by addressing early life disadvantages and the cumulative stress it has placed on the person.50 It is unrealistic to expect prenatal care alone to reverse the negative effects of a lifetime of perceived racial discrimination.51


The definition of perceived racial discrimination in the African American pregnant population that was derived through this evolutionary concept analysis has the potential to help providers identify patients at risk for adverse birth outcomes related to the chronic stress caused by the concept of interest. Understanding the factors contributing to adverse birth outcomes may help identify methods to close the racial gap in the IMR in the United States. The data synthesized in this review provide evidence for a relationship between perceived racial discrimination and low birth weight and/or PTB in the African American population as a valid contributing factor. Several studies found that experiences of perceived racial discrimination may act as acute or chronic stressors that could lead to adverse outcomes.52 The consensus in the literature reviewed was that the ability of individuals to adapt to or better cope with experiences of racial discrimination could modify its negative effect on health outcomes. Some potential modifiers might include social support, coping strategies, and removal of barriers to accessing prenatal care. Furthermore, the link between perceived racial discrimination and negative health behaviors such as substance abuse or improper utilization of prenatal care could provide even more evidence for the significance of the problem.25

Many studies have examined whether or not factors such as maternal age, lifestyle, socioeconomic status, or education can explain the racial gap in the IMR in the United States. Even when accounting for all of those factors, there is not a significant link. In fact, college-educated African American women are more likely to have a preterm or low-birth-weight baby than their White counterpart.53 This evidence demands exploration of other causative factors for the racial gap in the IMR. Recent studies have examined the role of stress and adverse health outcomes in general.54–56 Extending that evidence to the investigation of the role that stress caused by a lifetime of discrimination experiences has on birth outcomes would be an important contribution to the literature and may help solve the puzzle that is the racial gap in the IMR.6 The profession of nursing is inherently positioned to lead the way in the reduction of adverse birth outcomes for African American mothers and babies. The evidence clearly points to nursing-driven initiatives that would begin to close the racial gap in maternal mortality and PTB rates. From education to early identification of at-risk individuals to the positive impact that expanded midwifery services and other advance practice nursing roles could have on the quality of care African American mothers receive.40


The purpose of this article was to introduce the concept of perceived racial discrimination in the pregnant African American population, discuss the significance of the problem, and present existing literature on the concept of interest. Perceived racial discrimination in the pregnant African American population consists of the following attributes: (a) self-reported experiences of discrimination; (b) barriers to prenatal care; and (c) contradictory social pressures regarding motherhood and race. The consequences of the concept are stress and adverse birth outcomes. By using Rodgers' evolutionary method as the basis for this concept analysis, this emerging concept was more clearly defined.

An obvious gap in the literature was the lack of studies aimed at identifying modifiers for the attributes of the concept. Further defining perceived racial discrimination in the pregnant African American population has the potential to uncover modifiers that may help close the gap in the Black-White IMR in the United States. Future studies investigating the relationship of perceived racial discrimination and adverse birth outcomes are needed and the findings from future studies on the concept are highly relevant to the National Institute of Child Health and Human Development mission to elucidate mechanisms underlying health disparities in PTB.57 Such studies have the potential to guide intervention research that would begin to close the racial gap in the IMR in the United States.


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adverse birth outcomes; Black; concept analysis; perceived discrimination; preterm birth; racial discrimination; racism; stress

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