Racial and ethnic inequity are a well-recognized phenomenon in neonatal and infant care. Since the pioneering 1997 study by David and Collins,1 it has been clear that inequities are not the result of biology or genetics. In their study, they demonstrated that inequities in neonatal outcomes, in their case birth weight, were due to the unique lived experience of Black women in the United States. Since then, countless studies have demonstrated racial and ethnic inequities across multiple domains in the neonatal period, including preterm birth,2, 3, 4 Neonatal Intensive Care Unit (NICU)-associated morbidities,5, 6, 7, 8 neonatal death,9 patient-reported experiences,10 and health services utilization after NICU discharge.11,12

The fundamental driver of racial and ethnic inequities is racism, which creates a hierarchical system of differential access to resources and opportunities.13, 14, 15 Racism exists at multiple levels. Structural racism is the “totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, employment[…and] health care[.]”16 Institutional racism, while similar, is the racism that is embedded in laws and policies.14 Together, structural and institutional racism can be understood as “macro-level racism,” as it impacts the lived experience of minoritized individuals and communities by shaping their environment rather than through interpersonal interactions. At the micro-level, interpersonal and internalized racism lead to inequities by impacting interpersonal interactions between patients, families, and healthcare staff and by impacting minoritized individuals’ self-image and agency within the healthcare system respectively.14,17 Together, these four levels of racism conspire to create and maintain inequity.

Since 2020, there has been increased focus and attention to developing interventions to address health inequity and focusing on racism.18 Roadmaps, guides, and potentially better practices have been published to facilitate health equity research, interventions, and publication.19, 20, 21, 22, 23, 24 However, as healthcare systems have limited resources and competing priorities, and sociopolitical tides shifts, the focus on health inequity must have firm justification beyond external pressures or individual-level commitment to achieving health justice. A lack of external justification beyond those presented by health equity advocates and anti-racist organizations places these efforts at high risk for deprioritization and neglect. However, by providing a firm grounding within bioethical frameworks for health equity work within neonatal care, efforts can be sustained even under threatening conditions. In this narrative review, we present two bioethical frameworks—the four pillars and the ethics of care—that couple with the four levels of racism to provide a bioethical justification to pursue health equity in neonatology.