Available online 20 December 2023, 151865

Author links open overlay panel, , Narrative Abstract

Though stillbirth rates in the United States improved over the previous decades, inequities in stillbirth by race and ethnicity have persisted nearly unchanged since data collection began. Black and Indigenous pregnant people face a two-fold greater risk of experiencing the devastating consequences of stillbirth compared to their White counterparts. Because race is a social rather than biological construct, inequities in stillbirth rates are a downstream consequence of structural, institutional, and interpersonal racism which shape a landscape of differential access to opportunities for health. These downstream consequences can include differences in the prevalence of chronic health conditions as well as structural differences in the quality of health care or healthy neighborhood conditions, each of likely plays a role in racial and ethnic inequities in stillbirth. Research and intervention approaches that utilize an equity lens may identify ways to close gaps in stillbirth incidence or in responding to the health and socioemotional consequences of stillbirth. A community-engaged approach that incorporates experiential wisdom will be necessary to create a full picture of the causes and consequences of inequity in stillbirth outcomes. Investigators working in tandem with community partners, utilizing a combination of qualitative, quantitative, and implementation science approaches, may more fully elucidate the underpinnings of racial and ethnic inequities in stillbirth outcomes.

Section snippetsData sources for investigating stillbirth inequity

Vital records data compiled by NCHS represent a key source for understanding the epidemiology of stillbirth in the United States. Data quality has increased over time due to a variety of improvements in data collection, including reduced state-level variability in definitions, use of fetal death certificates, and more uniformity in race, ethnicity, and demographic reporting. The US Standard Report of Fetal Death (revised 2003) collects information such as maternal age, education, preconception

Racism, not race, shapes health inequities in stillbirth

A clear understanding of the sociostructural basis of race in the US is necessary to understand and provide context to epidemiologic findings of health inequities in stillbirth. Race is a socially-constructed categorization of humans based on certain phenotypic characteristics (i.e., skin or eye color, facial structural features, or hair texture/color) that has been fluid over time and also inappropriately imbued with biological meaning throughout the history of the US.13 As the Human Genome

Addressing stillbirth risk in ways that promote health equity

Addressing inequalities in stillbirth outcomes will require a health equity and population health lens on interventions at every level, from basic and translational science to clinical interventions and sociostructural change.7 It is important to distinguish between efforts to reduce stillbirth and efforts to close gaps in stillbirth rates, and acknowledge important improvements in the former over the last 50 years in the US while also pointing to a lack of success in the latter (Figure 1). In

Listening to learn – community-engaged approaches to achieving equity in stillbirth outcomes

Community-engaged or community-led participatory research is gaining traction as an opportunity to close equity gaps in adverse pregnancy outcomes.83, 84, 85, 86 The importance of experiential wisdom and lived expertise cannot be understated with regard to contextualizing, undergirding, and driving epidemiologic research from “what and where” to “how and why.”87 Qualitative, quantitative, and mixed-methods approaches can be utilized in a community-engaged framework. The National Academy of

Postpartum care after stillbirth – an opportunity to achieve health equity through support and meaning-making

Qualitative and quantitative research with parents shows critical gaps in care for birthing people and co-parents following a stillbirth.88, 89, 90 Consensus-based guidelines exist for in-hospital care, but there is limited evidence on best practices for care following delivery discharge.89,91,92

Following a stillbirth, postpartum people have elevated risks of adverse physical and mental health outcomes, including postpartum readmission and severe maternal morbidity compared to people who gave

Paradigm Shifts are Necessary to Reduce Inequity in Stillbirth Outcomes

Improved clinical care or identification of other causes of stillbirth, when viewed in isolation, are unlikely to close racial equity gaps in stillbirth outcomes. Rather, we must bring an anti-racist research and clinical practice approach to bear on the provision of care, and on the development and implementation of interventions. Fostering meaningful partnerships with marginalized communities and incorporating experiential wisdom into future research may help to reduce inequity in stillbirth

Acknowledgements/Disclosures

MPD reports salary support from the March of Dimes as part of the Reproductive Scientist Development Program and research support from the University of Utah Office of the Vice President for Research and U-CARES, NICHD 1U54HD113169-01 and NIMHD 1R21MD019175-01A1. This work was not directly funded by these grants.

CJRH has no disclosures

KKS's reports salary support from NHLBI k99/R01, K99HL161355.

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