Toward the elimination of race-based medicine: replace race with racism as preeclampsia risk factor

      Pregnancy-related morbidity and mortality continue to disproportionately affect birthing people who identify as Black. The use of race-based risk factors in medicine exacerbates racial health inequities by insinuating a false conflation that fails to consider the underlying impact of racism. As we work toward health equity, we must remove race as a risk factor in our guidelines to address disparities due to racism. This includes the most recent US Preventive Services Taskforce, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine guidelines for aspirin prophylaxis in preeclampsia, where the risk factor for “Black race” should be replaced with “anti-Black racism.” In this commentary, we reviewed the evidence that supports race as a sociopolitical construct and the health impacts of racism. We presented a call to action to remove racial determination in the guidelines for aspirin prophylaxis in preeclampsia and more broadly in our practice of medicine.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Louis J.M.
        • Menard M.K.
        • Gee R.E.
        Racial and ethnic disparities in maternal morbidity and mortality.
        Obstet Gynecol. 2015; 125: 690-694
        • Rosenberg D.
        • Geller S.E.
        • Studee L.
        • Cox S.M.
        Disparities in mortality among high risk pregnant women in Illinois: a population based study.
        Ann Epidemiol. 2006; 16: 26-32
        • Goffman D.
        • Madden R.C.
        • Harrison E.A.
        • Merkatz I.R.
        • Chazotte C.
        Predictors of maternal mortality and near-miss maternal morbidity.
        J Perinatol. 2007; 27: 597-601
        • Berg C.J.
        • Harper M.A.
        • Atkinson S.M.
        • et al.
        Preventability of pregnancy-related deaths: results of a state-wide review.
        Obstet Gynecol. 2005; 106: 1228-1234
        • Roberts D.E.
        Fatal invention: how science, politics, and big business re-create race in the twenty-first century.
        New Press, New York, NY2011
        • Gannon M.
        Race is a social construct, scientists argue.
        Scientific American, 2016 (Available at:)
        • Tsai J.
        • Cerdeña J.P.
        • Khazanchi R.
        • et al.
        There is no ‘African American Physiology’: the fallacy of racial essentialism.
        J Intern Med. 2020; 288: 368-370
        • Bonham V.L.
        • Green E.D.
        • Pérez-Stable E.J.
        Examining how race, ethnicity, and ancestry data are used in biomedical research.
        JAMA. 2018; 320: 1533-1534
        • Henderson J.T.
        • Whitlock E.P.
        • O’Connor E.
        • Senger C.A.
        • Thompson J.H.
        • Rowland M.G.
        Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2014; 160: 695-703
        • Henderson J.T.
        • Vesco K.K.
        • Senger C.A.
        • Thomas R.G.
        • Redmond N.
        Aspirin use to prevent preeclampsia and related morbidity and mortality.
        Agency for Healthcare Research and Quality (US), Rockville, MD2021
        • LeFevre M.L.
        • U.S. Preventive Services Task Force
        Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2014; 161: 819-826
        • ACOG Committee Opinion No
        743: low-dose aspirin use during pregnancy.
        Obstet Gynecol. 2018; 132: e44-e52
        • Davidson K.W.
        • Barry M.J.
        • et al.
        • US Preventive Services Task Force
        Aspirin use to prevent preeclampsia and related morbidity and mortality: US Preventive Services Task Force recommendation statement.
        JAMA. 2021; 326: 1186-1191
        • Bryant A.S.
        • Cahill A.G.
        • Kuller J.A.
        • Louis J.M.
        • Turrentine M.A.
        Low-dose aspirin use for the prevention of preeclampsia and related morbidity and mortality.
        American College of Obstetricians and Gynecologists, 2021 (Available at:)
        • Cunningham B.A.
        Race: a starting place.
        Virtual Mentor. 2014; 16: 472-478
        • Chadha N.
        • Lim B.
        • Kane M.
        • Rowland B.
        Toward the abolition of biological race in medicine: transforming clinical education, research, and practice.
        (Available at:)
        • Eichelberger K.Y.
        • Alson J.G.
        • Doll K.M.
        Should race be used as a variable in research on preterm birth?.
        AMA J Ethics. 2018; 20: 296-302
        • Yudell M.
        • Roberts D.
        • DeSalle R.
        • Tishkoff S.
        Science and Society. Taking race out of human genetics.
        Science. 2016; 351: 564-565
        • Fuentes A.
        • Ackermann R.R.
        • Athreya S.
        • et al.
        AAPA statement on race and racism.
        Am J Phys Anthropol. 2019; 169: 400-402
        • Vyas D.A.
        • Eisenstein L.G.
        • Jones D.S.
        Hidden in plain sight - reconsidering the use of race correction in clinical algorithms.
        N Engl J Med. 2020; 383: 874-882
        • Maglo K.N.
        • Mersha T.B.
        • Martin L.J.
        Population genomics and the statistical values of race: an interdisciplinary perspective on the biological classification of human populations and implications for clinical genetic epidemiological research.
        Front Genet. 2016; 7: 22
        • Mendez D.D.
        • Spriggs A.L.
        Race as a social construct: the genetic fallacy.
        Am J Obstet Gynecol. 2008; 198: 484
        • Johnson J.D.
        • Louis J.M.
        Does race or ethnicity play a role in the origin, pathophysiology, and outcomes of preeclampsia? An expert review of the literature.
        Am J Obstet Gynecol. 2022; 226: S876-S885
        • Ghosh G.
        • Grewal J.
        • Männistö T.
        • et al.
        Racial/ethnic differences in pregnancy-related hypertensive disease in nulliparous women.
        Ethn Dis. 2014; 24: 283-289
        • Tong M.
        • Artiga S.
        Use of race in clinical diagnosis and decision making: overview and implications.
        Kaiser Family Foundation, 2021 (Available at:)
        • Grobman W.A.
        • Lai Y.
        • Landon M.B.
        • et al.
        Development of a nomogram for prediction of vaginal birth after cesarean delivery.
        Obstet Gynecol. 2007; 109: 806-812
        • Vyas D.A.
        • Jones D.S.
        • Meadows A.R.
        • Diouf K.
        • Nour N.M.
        • Schantz-Dunn J.
        Challenging the use of race in the vaginal birth after cesarean section calculator.
        Womens Health Issues. 2019; 29: 201-204
        • Grobman W.A.
        • Sandoval G.
        • Rice M.M.
        • et al.
        Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity.
        Am J Obstet Gynecol. 2021; 225: 664.e1-664.e7
        • Hamm R.F.
        • Wang E.Y.
        • Levine L.D.
        • Srinivas S.K.
        Association between race and hemoglobin at delivery or need for transfusion when using race-based definitions for treatment of antepartum anemia.
        Obstet Gynecol. 2021; 138: 108-110
        • Peralta C.A.
        • Lin F.
        • Shlipak M.G.
        • et al.
        Race differences in prevalence of chronic kidney disease among young adults using creatinine-based glomerular filtration rate-estimating equations.
        Nephrol Dial Transplant. 2010; 25: 3934-3939
        • Eneanya N.D.
        • Boulware L.E.
        • Tsai J.
        • et al.
        Health inequities and the inappropriate use of race in nephrology.
        Nat Rev Nephrol. 2022; 18: 84-94
        • Delgado C.
        • Baweja M.
        • Crews D.C.
        • et al.
        A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on reassessing the inclusion of race in diagnosing kidney disease.
        Am J Kidney Dis. 2022; 79: 268-288.e1
        • Vyas D.A.
        • James A.
        • Kormos W.
        • Essien U.R.
        Revising the atherosclerotic cardiovascular disease calculator without race.
        Lancet Digit Health. 2022; 4: e4-e5
        • Nanna M.G.
        • Navar A.M.
        • Zakroysky P.
        • et al.
        Association of patient perceptions of cardiovascular risk and beliefs on statin drugs with racial differences in statin use: insights from the patient and provider assessment of lipid management registry.
        JAMA Cardiol. 2018; 3: 739-748
        • Centers for Disease Control and Prevention
        Racism is a serious threat to the public’s health.
        (Available at:)
        Date: 2021
        Date accessed: December 20, 2021
        • Jones C.P.
        Levels of racism: a theoretic framework and a gardener’s tale.
        Am J Public Health. 2000; 90: 1212-1215
        • Jones C.P.
        Toward the science and practice of anti-racism: launching a national campaign against racism.
        Ethn Dis. 2018; 28: 231-234
        • Jones C.P.
        Confronting institutionalized racism.
        Phylon. 2002; 50: 7-22
        • Nazroo J.Y.
        The structuring of ethnic inequalities in health: economic position, racial discrimination, and racism.
        Am J Public Health. 2003; 93: 277-284
        • Centers for Disease Control and Prevention
        Racial and ethnic disparities continue in pregnancy-related deaths.
        (Available at:)
        • Braveman P.A.
        • Heck K.
        • Egerter S.
        • et al.
        The role of socioeconomic factors in Black-White disparities in preterm birth.
        Am J Public Health. 2015; 105: 694-702
        • Krieger N.
        • Waterman P.D.
        • Spasojevic J.
        • Li W.
        • Maduro G.
        • Van Wye G.
        Public health monitoring of privilege and deprivation with the index of concentration at the extremes.
        Am J Public Health. 2016; 106: 256-263
        • Kramer M.R.
        • Hogue C.J.
        • Dunlop A.L.
        • Menon R.
        Preconceptional stress and racial disparities in preterm birth: an overview.
        Acta Obstet Gynecol Scand. 2011; 90: 1307-1316
        • Simons R.L.
        • Lei M.K.
        • Beach S.R.
        • et al.
        Economic hardship and biological weathering: the epigenetics of aging in a U.S. sample of black women.
        Soc Sci Med. 2016; 150: 192-200
        • Goosby B.J.
        • Heidbrink C.
        Transgenerational consequences of racial discrimination for African American health.
        Sociol Compass. 2013; 7: 630-643
        • Barcelona de Mendoza V.
        • Huang Y.
        • Crusto C.A.
        • Sun Y.V.
        • Taylor J.Y.
        Perceived racial discrimination and DNA methylation among African American women in the InterGEN study.
        Biol Res Nurs. 2018; 20: 145-152
        • White VanGompel E.
        • Lai J.S.
        • Davis D.A.
        • et al.
        Psychometric validation of a patient-reported experience measure of obstetric racism© (The PREM-OB Scale™ suite).
        Birth. 2022; ([Epub ahead of print])
        • Williams D.R.
        • Yu Y.
        • Jackson J.S.
        • Anderson N.B.
        Racial differences in physical and mental health: socio-economic status, stress and discrimination.
        J Health Psychol. 1997; 2: 335-351
        • Sternthal M.J.
        • Slopen N.
        • Williams D.R.
        Racial disparities in health: how much does stress really matter?.
        Du Bois Rev. 2011; 8: 95-113
        • Farmer H.R.
        • Wray L.A.
        • Thomas J.R.
        Do race and everyday discrimination predict mortality risk? Evidence from the health and retirement study.
        Gerontol Geriatr Med. 2019; 52333721419855665
        • Malawa Z.
        • Gaarde J.
        • Spellen S.
        Racism as a root cause approach: a new framework.
        Pediatrics. 2021; 147e2020015602
        • Dyer L.
        • Chambers B.D.
        • Crear-Perry J.
        • Theall K.P.
        • Wallace M.
        The Index of Concentration at the Extremes (ICE) and pregnancy-associated mortality in Louisiana, 2016-2017.
        Matern Child Health J. 2022; 26: 814-822
        • Chambers B.D.
        • Baer R.J.
        • McLemore M.R.
        • Jelliffe-Pawlowski L.L.
        Using index of concentration at the extremes as indicators of structural racism to evaluate the association with preterm birth and infant mortality-California, 2011-2012.
        J Urban Health. 2019; 96: 159-170
        • American Academy of Pediatrics
        American Academy of Pediatrics calls for elimination of race-based medicine.
        (Available at:)
        • Krieger N.
        • Boyd R.W.
        • Fernando D.M.
        • Maybank E.
        Medicine’s privileged gatekeepers: producing harmful ignorance about racism and health. Health Affairs Blog. 2021.
        (Available at:) (Accessed May 5, 2022)