Summary: New research suggests that clinical labs should consider self-reported race when screening for spina bifida and other open neural tube defects to improve prenatal care equity for Black individuals.


  1. Including self-reported race in alpha-fetoprotein (AFP) testing ensures more accurate and equitable screening results for pregnant Black individuals.
  2. Omitting race from AFP testing algorithms leads to a significant increase in false-positive rates for Black individuals, causing unnecessary additional diagnostic tests and anxiety.
  3. The study supports using self-reported race in prenatal serum screening, aligning with professional guidelines to enhance reliability and fairness in prenatal care.

New research demonstrates that clinical labs should account for the self-reported race of pregnant individuals when screening for spina bifida and other open neural tube defects. This finding, which was presented in the Association for Diagnostics & Laboratory Medicine’s (formerly AACC’s) Clinical Chemistry journal, could improve prenatal care for pregnant Black individuals.

Addressing Racial Inequities

In the wake of the racial reckoning that took place in 2020, the medical community has embarked on a major push to advance health equity, the ADLM says. A significant component of this has involved reevaluating the use of race in a wide range of clinical testing algorithms. For example, research found that race-based calculations for estimated glomerular filtration rate (eGFR)—a test for kidney function—were actually leading to delayed diagnosis and poorer outcomes for Black patients with kidney disease. Clinical labs are therefore now excluding race from their eGFR calculations.

Considering Race in AFP Testing

The medical community has also been questioning the use of race in the test for alpha-fetoprotein (AFP), which is used to diagnose open neural tube defects such as spina bifida during pregnancy. Current testing algorithms for AFP account for race because self-reported Black individuals on average have higher AFP levels than White individuals. However, recent studies have recommended omitting race when screening for these birth defects.

A team of researchers led by Glenn E. Palomaki, PhD, of Women & Infant’s Hospital in Providence, Rhode Island, set out to determine the clinical impact of omitting race from AFP testing. Palomaki’s team first separately compared the AFP levels of pregnant White individuals and those of pregnant Black individuals against the median AFP level of pregnant individuals. Maternal weight, which is also higher on average in self-reported Black individuals, was also considered. They then used the same statistical analysis but eliminated self-reported race from the algorithm.

Further reading: Prenatal Diagnosis Linked to Earlier Congenital Heart Disease Surgery

When self-reported race was used, the positivity rate of the screen was roughly equivalent among Black and White individuals. However, when self-reported race and maternal weight were not accounted for in the analysis, 1.49% of those identifying as Black were positive for open neural tube defects, while only 0.63% of those identifying as White were positive, a 2.36-fold difference, according to the ADLM. This discrepancy does not reflect the real-life disparity in open neural tube defect prevalence and would create inequitable burdens for Black individuals, including additional diagnostic testing that may be costly and invasive, as well as maternal anxiety.

“Accounting for maternal race and weight, as well as other possible covariates such as smoking status, plays a critical role in ensuring reliability and equity in various prenatal screening programs,” the study’s authors wrote. “Our results, together with existing professional recommendations and other current publications, endorse the use of self-reported race in prenatal serum screening.”