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NARRATIVE REVIEW Open Access

Incorporating Measures of Structural Racism into Population Studies of Reproductive Health in the United States: A Narrative Review Julianna G. Alson,1 Whitney R. Robinson,2–4 LaShawnDa Pittman,5 and Kemi M. Doll1

Abstract Purpose: Black women in the United States face poor outcomes across reproductive health measures—from pregnancy outcomes to gynecologic cancers. Racial health inequities are attributable to systemic racism, but few population studies of reproductive health outcomes integrate upstream measures of systemic racism, and those who do are limited to maternal and infant health outcomes. Advances in understanding and inter- vening on the pathway from racism to reproductive health outcomes are limited by a paucity of methodological guidance toward this end. We aim to fill this gap by identifying quantitative measures of systemic racism that are salient across reproductive health outcomes. Methods: We conducted a review of literature from 2000 to 2019 to identify studies that use quantitative mea- sures of exposure to systemic racism in population reproductive health studies. We analyzed the catalog of lit- erature to identify cohesive domains and measures that integrate data across domains. For each domain, we contextualize its use within population health research, describe metrics currently in use, and present opportu- nities for their application to reproductive health research. Results: We identified four domains of systemic racism that may affect reproductive health outcomes: (1) civil rights laws and legal racial discrimination, (2) residential segregation and housing discrimination, (3) police vio- lence, and (4) mass incarceration. Multiple quantitative measures are available for each domain. In addition, a multidimensional measure exists and additional domains of systemic racism are salient for future development into distinct measures. Conclusion: There are quantitative measures of systemic racism available for incorporation into population stud- ies of reproductive health that investigate hypotheses, including and beyond those related to maternal and in- fant health. There are also promising areas for future measure development, such as the child welfare system and intersectionality. Incorporating such measures is critical for appropriate assessment of and intervention in racial inequities in reproductive health outcomes.

Keywords: reproductive health; population health; African Americans; racism

1Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington, USA. 2Department of Epidemiology, UNC Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. 3Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. 4Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. 5Department of American Ethnic Studies, University of Washington, Seattle, Washington, USA.

*Address correspondence to: Julianna G. Alson, MPH, Department of Obstetrics and Gynecology, University of Washington School of Medicine, 1959 NE Pacific Street, Box 356460, Seattle, WA 98195-0005, USA, E-mail: [email protected]

ª Julianna G. Alson et al., 2021; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Health Equity Volume 5.1, 2021 DOI: 10.1089/heq.2020.0081 Accepted January 18, 2021

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Introduction Black women in the United States face poor outcomes across nearly all domains of reproductive health—from sexually transmitted disease to pregnancy to gynecologic cancers.1 Rigorous investigation of racial health inequi- ties requires an analysis of racism,2–4 which is well recog- nized as a fundamental cause and social determinant of racial health inequities.3,5–8 Racism has adversely affected Black women’s health since the enslavement of African people in North America.9,10 Black women have been ad- vocating for autonomy, dignity, and rights in reproduc- tive health for as long.11 Thanks to this long-standing labor, the clinical reproductive health field recognizes the role of racism as a structural determinant of health.12

While racism manifests at the institutional, interpersonal, and internalized levels,2 systemic racism refers to the to- tality of constantly reconstituting and reinforcing social and political systems and their policies, practices, and ideologies that engender inequities.4,5

Yet, few public health studies incorporate measures of systemic racism.13 Health research has historically been predominated by a conceptualization of race as an individual-level genetic trait or a population-level confounder rather than a rough proxy for risk of expo- sure to the mechanisms of social stratification in a race-conscious society.14,15 When racism has been in- corporated, it is primarily in regard to interpersonal racial discrimination.16 In reproductive health, studies incorporating any level of racism have primarily focused on the outcomes of preterm birth, low birth weight, and infant mortality. Emerging research in maternal and in- fant health incorporates some measures of structural rac- ism.17–19 While these are significant contributions, there is a need for population reproductive health studies— beyond perinatal outcomes—to include measures of systemic racism to identify underlying mechanisms of outcomes among Black women, and to provide the evidence base for effective intervention.

There is limited methodological guidance toward this goal. Gee and Ford4 describe approaches to conceptual- izing structural racism. Groos et al.20 operationalize se- lected concepts for general health research, yet call for further elucidation of these measures specific to subdis- ciplines. To our knowledge, efforts in reproductive health have been limited to conceptual frameworks focusing on maternal health, infant health, and HIV/sexually transmitted diseases (STDs).10,21 The goal of this narra- tive review is to fill this gap by describing quantitative measures of exposure to systemic racism that can be ap- plied in population-based studies of reproductive health.

Definition of reproductive health We consider reproductive health to comprise all clinical, quality of life, and health service outcomes related to fertility management and childbearing, menstruation and menopause, benign and malignant gynecologic con- ditions, and sexual functioning. Our approach to repro- ductive health is indebted to the Reproductive Justice movement, a grassroots movement for the rights and health of women of color, which was founded in the mid-1990s.11 Accordingly, we place reproductive health within the sociopolitical context of interlocking systems of power and oppression and recognize that freedom from these systems is critical for realizing reproductive justice.

Methods Three conceptual frameworks guide our review. The Ecosocial Theory guides us toward literature that consid- ers disease process as the embodiment of socioecological context—including social inequity, resource deprivation, and societal-level and historical trauma.22 Fundamental Cause Theory guides selection of measures that give rise to differential access to ‘‘flexible resources’’ that operate along ‘‘replaceable pathways’’ from racism to health.5,23

Public Health Critical Race Praxis is the methodological approach to our work.24 Its tenets provide the framework by which we critically review the literature.

Using these frameworks, we conducted a review of lit- erature from 2000 to 2019 to identify studies that use quantitative measures of exposure to systemic racism in population reproductive health studies. We first exam- ined reproductive health literature and then broadened to general population health research. We excluded any study that did not include measures at the structural or systemic level. We cataloged each measure, its applica- tion, and available data sources. We then analyzed the catalog of literature to identify cohesive domains and measures that integrate data across domains. For each do- main, we contextualize its use within population health research. We then describe metrics currently in use and opportunities for their application to reproductive health research. Given limited evidence on the topic, we make conceptually founded bridges between bodies of evi- dence. Finally, we discuss potential measures for future development.

Results Domains We identified four prominent domains of systemic rac- ism that may affect reproductive health outcomes: (1)

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civil rights laws and legal racial discrimination, (2) res- idential segregation and housing discrimination, (3) police violence, and (4) mass incarceration. Table 1 aligns markers of exposure to structural racism with measures for inclusion in research.

Civil rights laws and legal racial discrimination Context in population health research. Legal racial discrimination has shaped access to resources, includ- ing mobility, income, employment, wealth, family and reproductive self-determination, and education since the founding documents of the United States.25 The 1964 U.S. Civil Rights Act (CRA) and other civil rights laws have changed the context in which racism oper- ates, including by increasing access to resources (e.g., initiating reproductive and infant health services for Black people).21,26 Yet legal racial discrimination per- sists, as do the lingering effects of overturned laws. For example, any U.S.-born Black person 56 years of age and older in 2020 lived with Jim Crow laws, which mandated segregation of health care facilities, restricted access to health care, and provided federal funding of eugenics programs, which included coercive reproductive health

procedures (e.g., forced sterilization). Immigration policy is another form of legal racial discrimination that carries out systemic racism by prohibiting access to citizenship and associated rewards to groups considered non- White. Such practices have appeared in the United States since the Naturalization Act of 1790.4 For any individual Black person living in the United States of any age, legalized racial discrimination and the remnants of overturned laws persist.9,21

Measures for use in population health studies. There is no single established measure of exposure to legal discrimination or its abolition. Time periods spanning the passage of civil rights laws and their enforcement mechanisms, or spanning the adoption or repeal of rel- evant immigration policies, along with meaningful geo- graphic units, can be used to construct cohorts that serve as proxies. Research using age-period-cohort models shows improvement in life expectancy and premature mortality among Black populations born in the decade following passage of the CRA compared with the decade before27 and that Black women born in the late 1960s had a 70% decrease in adult health risk factors and im- proved birth outcomes compared with Black women

Table 1. Recommended Measures for Inclusion in Population-Based Studies of Reproductive Health in the United States

Domain Construct measured Measure Novel reproductive health

applications

Civil Rights laws and legal racial discrimination

Legal and regulatory determinants of racial discrimination

Construction of cohorts in survey or administrative databases based on:

- 1964 passage of the U.S. Civil Rights Act. - Designation of Jim Crow status of area of residence. - Age-period-birth cohorts based on Jim Crow status of

area of residence and passage of U.S. Civil Rights Act. - Timing and geography of other federal and state

legislation or enforcement rules/regulations

Quality of contraceptive care Hysterectomy rates (use and

overuse) Transgenerational epigenetic stress

mechanisms underlying gynecologic disease

Residential Segregation and Housing Discrimination

Spatial polarization by race and income

Index of Concentration at the Extremes Quality of management of gynecologic pain

Care delay for benign or malignant gynecologic disease

Composite resource deprivation

Area Deprivation Index

Denial of home ownership in particular areas

Redlining Index Quality of treatment for gynecologic cancer

Use of hysterectomy alternatives for uterine fibroids

Denial of financial resources for home ownership

Racial Bias in Mortgage Lending Index

Police Violence Individual or community- level exposure to the fatal or nonfatal violence of policing

- Estimation of rates of police killings by geography, based on validated data sources.

- Use of data from Survey of Police-Public Encounters. - Inclusion of Jackson, Hogue, Philips contextualized

stress measure police violence items in survey research

Physiologic stress mechanisms underlying gynecologic disease severity (fibroids, endometriosis, and infertility).

Care delay for gynecologic cancer due to restricted mobility and/or fear of criminalization

Mass Incarceration Individual or community- level exposure to incarceration

No established measures. - Individual exposure to incarceration using Public Use

Microdata Samples. - Estimation of population rates of incarceration for a

select geographic area. - Estimation of population-level prevalence of formerly

incarcerated individuals by geographic area

Hysterectomy rates among incarcerated people.

Gynecologic cancer familial risk screening and prevention in setting of disrupted families

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born earlier that decade.28 Turning to geographic varia- tion, estrogen receptor-negative breast cancer is signifi- cantly higher among Black women born in counties with active Jim Crow Laws, compared with peers born in counties without Jim Crow laws.29

The impact of variation in laws’ implementation or enforcement can also be assessed using temporal or geo- graphic cohorts. Hospitals’ compliance with the 1965 Medicaid Act—which enforced Title VI of the CRA by tying funding to measures of integration—may have driven decreases in infant mortality.28 Infant health im- provements during that time may have also been driven by implementation of maternal and child health funding under 1963 and 1965 mandates for health care provision to poor and Black populations.30,31

Applications to reproductive health. Measures of legal racial discrimination can be incorporated into a wide range of reproductive health research. Compulsory sterilization programs, for example, are salient to current reproductive health outcomes, including quality of con- traceptive care delivery, mismatch between community preferences and current contraceptive offerings,32

and earned mistrust of the medical system, which may inhibit care-seeking behaviors, and embodiment of historical societal-level trauma. County-level associ- ations between hysterectomy rate and race, independent of health care access, illustrate continued relevance of Jim Crow laws for gynecologic health.33 Black women— especially those in the U.S. South—remain at higher risk of premenopausal hysterectomy.34 Higher rates of hys- terectomy is concerning in its own right, and may also limit community knowledge necessary to self-assess symptoms of gynecologic cancer, such as bleeding after menopause.35 The imprint of legalized discrim- ination as chronic stress may increase the burden of fibroids and endometriosis.36 Intergenerational ef- fects may occur through cultural and institutional ideologies and practices, epigenetic37 and biological embodiment of trauma and stress,38 and durable maladaptive community beliefs and attitudes.32,39

Given these conceptual links, measures of legal racial discrimination—using age-period-birth cohorts and geography relative to the passage and enforcement of civil rights laws—can be incorporated into popu- lation reproductive health studies.

Residential segregation and housing discrimination Context in population health research. Racial resi- dential segregation is the geographic separation of

groups based on race. Segregation is a well-established determinant of adverse outcomes among Black popula- tions in the United States.40–43 Mechanisms of segrega- tion’s impact on health include isolation, resource deprivation, and concentrating exposures to poverty, community violence, and environmental toxins.40,43

In addition, social network disruption can reduce the economic and social stability required to access health care and other health-promoting resources.4,8 Social networks may be disrupted due to constrained choice in housing due to displacement related to rising hous- ing costs, housing discrimination, and the eradication of place-based subsidized housing toward ‘‘urban re- newal’’ projects.44

Living in geographic areas characterized by racial and economic polarization is associated with higher rates of less treatable breast cancer subtypes,45 in- creased odds of hypertension,46 diabetes, obesity,47

premature mortality,48 and racial disparities cancer.41

Experiences of residential segregation early in life can have adverse consequences across the life course.49 Some studies illustrate a potential protective effect of living in racially homogenous areas, perhaps due to increased so- cial cohesion where there is racial concordance between neighbors.40,50

Housing discrimination—including mortgage loan discrimination and redlining—has been used as mea- sures of structural precedents of segregation.50 Race- based housing discrimination was outlawed with the Fair Housing Act in 1968,50–52 but housing discrimina- tion and its health effects persist.43 Living in a neigh- borhood characterized by high racial bias in mortgage lending has been associated with increased all-cause mortality among Black women diagnosed with breast cancer50,53 and colorectal cancer.53 Residing in neigh- borhoods with a history of redlining increases vulnera- bility to declines in self-rated health.51

Experiences of residential segregation early in life have adverse health consequences across the life course, even after relocation,49 and these stressors persist across generations.37

Measures for use in population-based health studies. Racial bias in mortgage lending and redlining is cap- tured with indices using spatially continuous estima- tes.50 The mortgage lending bias index represents the adjusted odds of home mortgage application denial for a Black compared to a White applicant within a geo- graphic area. The redlining index represents the odds of denial of a mortgage application in particular areas

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compared with other areas.50 Both measures use data from the Home Mortgage Disclosure Act database.

Two summary metrics of the conditions created by segregation are prominent in the literature: The Area Deprivation Index (ADI) and the Index of Concentra- tion at the Extremes (ICE). The ADI, which comprises 17 household-level socioeconomic indicators, describes the socioeconomic disadvantage of an area with high reliability and validity across census tracts.54 Although not explicitly a measure of racism-related variables, the ADI comprises indicators of conditions that can be conceptualized as downstream effects of systemic rac- ism. Datasets at the state- and census-block levels using American Community Survey data for two timeframes in the 2000s are publicly available.55 The ICE quantifies the spatial feature of inequitable group relationships within an area and can be constructed using census data to describe racial or economic spatial inequity, or both in combination.56 The combined race and economic ICE outperforms measures using only race, income, or simple poverty rates in estimating the risk of health outcomes such as maternal health,56 and toxic environmental exposure.57 ICE is adaptable to dif- ferent scales,56 which is useful for disentangling effects across geographic units.4

Applications to reproductive health. Multiple oppor- tunities exist to investigate the role of residential segrega- tion and housing discrimination in reproductive health outcomes. For example, while it is well documented that Black women residing in areas with higher disadvan- tage in the context of racialized and economic-based spa- tial inequity experience greater odds of infant mortality and preterm birth18,58,59; this pathway has been included in only a single study of gynecologic cancers and in no studies of benign gynecologic conditions of which we are aware. Promisingly, an association was found be- tween higher scores on the ADI and cervical cancer in- cidence, late-stage diagnosis, and mortality rates, with a greater association for Black than White women.60,61

Using ADI and ICE in studies of gynecologic cancers62

and conditions such as fibroids63 would be a novel contri- bution to the literature. Including both measures would help to differentiate the roles of resource deprivation and inequity. Further upstream, mortgage loan bias and redlining could be used to examine the role of systematic disinvestment and segregation in these same outcomes within the life course and across generations.

Finally, qualitative research could supplement these quantitative measures to better understand the rich

and complex role of social network formation and dis- ruption in stress, gynecologic care delay, other mecha- nisms of harm, and coping responses.

Police violence Context in population health research. Police violence is a mechanism of structural racism that is of pressing public health concern.8,64,65 Today’s institution of polic- ing originated with slave patrols in the South, efforts to control immigrant populations in the North, and brutal- ization of Indigenous people across the continent. Its en- trenchment has been bolstered by laws and policies that encourage overpolicing of Black neighborhood, reflect xenophobic and White supremacist ideologies, and criminalize behaviors more effectively addressed through public health intervention.64 Policing is enacted by poli- cies and actions of police departments, federal law en- forcement, and immigration enforcement (including immigration policies and enforcement practices). Physi- cal and psychological violence occur through use of force, psychological intimidation, and community-level surveillance.65–68 Pathways to adverse health outcomes include direct injury and psychological harm, acute and chronic trauma and stress, and behavior change to limit exposure to policing, which inhibit access to health- promoting resources.65–68 Exposure to police violence also causes economic hardship due to costs of injury and judicial processes, or elimination of a household or community adult.65 Black people are at higher risk of death and nonfatal injury compared with White people.65

The adverse effects of police violence on Black people ex- tend beyond direct encounters. In states with higher rates of police-involved deaths of unarmed Black people, Black people experience more days of mental health distress.69

Prevalence of asthma, diabetes, and high blood pressure is higher in neighborhoods where pedestrian stops are more likely to escalate into frisking, and where the fre- quency of such stops is higher among people of color.70

Measures in population-based studies of reproductive health. Efforts to incorporate measures of police vio- lence into population health studies are made more dif- ficult by limitations of official administrative databases: the Centers for Disease Control and Prevention’s National Violent Death Reporting System, the U.S. National Vital Statistics System, and the Federal Bureau of Investigation’s Uniform Crime Reporting System.71,72

Databases that combine reports from official sources, crowd-sourcing, news, and public records request ac- count for the largest possible proportion of actual

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cases.72 For example, the Fatal Encounters database has been used to estimate county-level racial inequity in risk of homicide by police among males.73 State-level mental health effects have been investigated using the Mapping Police Violence database, linked to Behavioral Risk Factor Surveillance System data.69 Studies of health effects of immigration enforcement often use popu- lation surveys or administrative data from a timeframe before and after an immigration raid or policy change.74,75

The Survey of Police-Public Encounters captures self-reported police violence using a 27-item scale and has been conducted among a representative sam- ple in four urban areas in the United States.76 Finally, the Jackson, Hogue, Philips contextualized stress mea- sure assesses contextual and intersectional racial and gendered stress and includes two indicators of expo- sure to police violence.77 Using this measure, a positive association was found between antenatal depressive symptoms and anticipated negative youth encounters with police.78

Applications to reproductive health. Given the strength of association between stress and adverse repro- ductive health outcomes, and the documented associa- tion between psychological distress and police violence, it may be that police violence has far-reaching effects in reproductive health through early life, chronic, and in- tergenerational stress. This pathway is evident in studies finding adverse birth outcomes among Latinx parents following immigration raids or apprehensions,74,79 and for Latina, Middle Eastern/North African, and Arab women following changes in the social and political environment toward anti-immigrant sentiments.80,81

Anxiety related to constrained resources follow- ing an immigration raid has contributed to decisions to delay childbearing—demonstrating another stress pathway.82

To broaden this evidence to other forms of policing and across reproductive health domains, the Jackson, Hogue, Philips contextualized stress measure78 could be incorporated into population surveys investigating the role of stress not only in birth outcome but also in fibroids or histologic subtypes of gynecologic cancer, for example. Data from sources on policing exposure described above could be linked to nationally represen- tative surveys that include mental health outcomes.

Limited mobility due to overpolicing of Black neighborhoods could also impact the ability to seek care for gynecologic health issues—abnormal

uterine bleeding, pelvic pain from fibroids or endo- metriosis, and infertility. These conditions are asso- ciated with markedly worse burden and/or worse outcomes among Black women, but are not directly life threatening, so are particularly susceptible to care delays.

Mass incarceration Context in population health research. Mass incar- ceration in jails, prisons, and immigration detention centers is recognized as a steadily worsening mecha- nism of structural racism.83,84 Punitive policies and overpolicing of Black neighborhoods have resulted in the disproportionate impact of incarceration on Black people.83 Black children are five times more likely than White children to experience maternal incarcera- tion.85 In 2006, nearly half of Black women had an immediate or extended family member imprisoned.86

Adverse health outcomes occur during incarcera- tion and after release through policies and discrimi- nation that inhibit access to housing, employment, and health care.5,8,84

Adverse health effects also occur among popula- tions that are proximate to incarceration by relation- ship or geography. Parental incarceration is associated with asthma, behavioral issues, anxiety, depression, and worse overall self-rated health.84 Women whose partners are incarcerated are at greater risk for stroke, heart attack, and poor self-rated overall health.87

Higher rates of incarceration are associated with higher community-level prevalence of asthma and psy- chiatric morbidity.84 Community effects may occur be- cause of financial strain; legal financial obligations place an immense burden on families and communities, and are often shouldered by women.88 Other mechanisms include reduced social support due to the removal of community members, incarceration-related stigma, or forced displacement; political disenfranchisement; and higher levels of both acute and chronic stress.

Measures for use in population health studies. Linking administrative incarceration data with population-level health metrics provides the most accurate method by which to estimate health effects and inequities.84 State– level rates of incarceration can be estimated using Public Use Microdata Samples data, which are collected at the decennial census and contain flags for sample members who are institutionalized.84,89,90 A more nuanced estima- tion of all current and formerly incarcerated individuals

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to assess community-level effects can be constructed90

using a combination of data sources from the U.S. Department of Justice and U.S. Bureau of Prisons.84,90

Applications to reproductive health. Studies that have leveraged state-level data to study the effects of incarceration on reproductive health have docu- mented higher incidence of infant mortality, poorer access to or quality of prenatal care,91 risk of contract- ing infections disease,92 and racial disparities within these outcomes.84 Parental incarceration is associated with increased risk of infant mortality and increases in inflammatory markers among female children85— well documented as part of the pathway connecting pre-conception stress with adverse pregnancy out- comes.93 Coercive contraceptive practices and family separation are also more likely to occur in the context of mass incarceration.68,91

These measures might be meaningfully extended to studies of reproductive health outcomes beyond mater- nal and infant outcomes. Pathways for future investiga- tion include the role of mass incarceration in (1) care delay, due to limited social support or economic strain, which may contribute to later-stage diagnosis of gyneco- logic cancers; or (2) physiologic stress mechanisms that promote more aggressive gynecologic disease.36,62,63 In addition, access to care for any of these conditions may be hindered by fear of incarceration due to punitive ap- proaches to behaviors such as drug use, or to conditions such as homelessness or immigration status, all of which are better addressed through an approach that prioritizes addressing structural causes of these conditions.

Multidomain measures Employing multidimensional measures of structural racism may be useful to understand the interlocking and compounding harms of its various mechanisms, which may otherwise be obfuscated when using only discrete measures. Lukachko et al.94 identify four do- mains for measuring state-level variation in exposure to structural racism: the Black–White relative propor- tions of political participation, employment and job status, educational attainment, and judicial treat- ment.94 Data for the index are drawn from the U.S. Census Bureau; National Conference of State Legisla- tures; Bureau of Labor Statistics; and the Sentencing Project.94 Using this index, higher levels of structural racism have been associated with higher odds of small-for-gestational-age birth95 and higher rates of

infant mortality96 among Black residents. This mea- sure could be feasibly applied across the spectrum of reproductive health outcomes.

Measures for future development There are other mechanisms of structural racism that impact health, for which there are not yet quantitative measures.21 For example, Black people are dispro- portionately exposed to the child welfare system compared with other racial and ethnic groups.97,98

Exposure to foster care can adversely affect adult health outcomes in a cumulative manner, contribut- ing to higher rates of hypertension, asthma, diabetes, cardiovascular risk, chronic health conditions, stroke, and epilepsy,99,100 as well as STDs.99,101 Although no national data are available, there are several large- scale studies that capture foster care involvement and could be linked with reproductive health data. The California Health Interview Survey is the largest statewide health survey administered in the United States. Several regional studies also exist, including the Midwest Evaluation of the Adult Functioning of Former Foster Youth.101

The literature we reviewed largely excludes trans and nonbinary individuals whose reproductive and gyneco- logic health may be uniquely affected by the exposures described above. Developing measures of structural racism that uniquely effect populations with marginal- ized gender and sexual identities will help better assess the underlying, interlocking mechanisms of harm, and candidate intervention foci.22

Indeed, intersectionality—a concept coined by Kim- berlé Crenshaw—is core to the implementation of a re- productive justice framework, and therefore, intersecting identities are a necessary focus of population reproductive health research.102 Having a cognitive or physical dis- ability, for example, which is disproportionately more likely among Black people,103 increases risk of exposure to violent policing and exacerbates health consequences of direct or community-level expo- sure.104 The stress pathways described for each factor above are likely made worse in the case of existing dis- ability. Immigration status is another dimension that warrants attention. The policies, practices, and ideol- ogies of a racialized system of immigration enforce- ment that targets Black people and people of color act as forms of legalized racial discrimination, as mechanisms of policing and incarceration, and drive residential segregation.4, 66–68 Others note the need to understand the intersection of race, nativity,

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and immigration status in health research,4,102,105,106

and emerging research describes the salience of this inter- section for maternal and infant health outcomes.107–109

Discussion Measures of exposure to systemic racism are important to include in population-based studies of reproductive health. The existing evidence suggests there are many plausible hypotheses to be investigated beyond those re- lated to maternal and infant health. We reviewed some of the many domains of systemic racism that engender and exacerbate adverse reproductive health outcomes among Black women in the United States, described existing measures of these domains, and presented op- portunities for applying them in population reproductive health studies. Importantly, we focused on systemic rac- ism. When we limit our understanding of the effects of racism to interpersonal and psychosocial pathways, we reinforce the notion that race and racism occur at the in- dividual level and we obfuscate and absolve the sociopo- litical structure of racism. The carefully constructed scaffolding of interlocking systems and ideologies that reinforce the racialized distribution of resources is inten- tionally hidden from view, not least by limiting the means to measure it. Systemic racism requires our ex- plicit, empirical attention to identify effective means to deconstruct it and its contributions to racial inequities in reproductive health. Efforts to advance equity in re- productive health require population health research that explicitly incorporates measures of systemic racism.

As a fundamental cause of health inequities, sys- temic racism constantly replaces the mechanisms that ensure unequal distribution of power, prestige, social connections, money, and freedom.5,23 Examin- ing and intervening on a single domain or considering domains as static will not reduce racial inequities in reproductive health.23 It is recommended that re- searchers not only include multiple measures in his- torical context but also constantly reassess how measures must be altered to capture the iterative transformation of mechanisms of harm.

Our review corroborates previous recommendations to take a life course perspective that examines mechanisms including social network formation, early childhood stress, and compounding stress,110 and to integrate epigenetic mechanisms.111,112 Finally, while our focus is systemic rac- ism in the United States, our domain and framework could be adapted for other contexts.

Efforts to improve reproductive health outcomes among Black women require population health re-

search that explicitly incorporates measures of sys- temic racism. Our review illustrates conceptual and methodological paths toward that end.

Author Disclosure Statement No competing financial interests exist.

Funding Information No funding was received for the development of this manuscript.

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Cite this article as: Alson JG, Robinson WR, Pittman L, Doll KM (2021) Incorporating measures of structural racism into population studies of reproductive health in the United States: a narrative review, Health Equity 5:1, 49–58, DOI: 10.1089/heq.2020.0081.

Abbreviations Used ADI¼Area Deprivation Index

CRA¼Civil Rights Act ICE¼ Index of Concentration at the Extremes

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