Disparities In Adverse Birth Outcomes Research Articles

Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes

Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.

The impact of free antiretroviral therapy for pregnant non-citizens and their infants in Botswana.

In December 2019, the Botswana government expanded free antiretroviral therapy (ART) to include non-citizens. We evaluated the impact of this policy change on antenatal care (ANC), antiretroviral therapy coverage and adverse birth outcomes. The Tsepamo Surveillance study collects data at up to 18 delivery sites in Botswana. We compared outcomes in citizens and non-citizens living with HIV before and after antiretroviral therapy expansion to non-citizens. Adverse birth outcomes included preterm delivery (PTD) <37 weeks, very preterm delivery (VPTD) <32 weeks, small for gestational age (SGA) <10th percentile, very small for gestational age (VSGA) <3rd percentile, stillbirth and neonatal death. Log-binomial regression models were constructed to generate risk ratios. From August 2014 to September 2021, 45,576 (96.5%) citizens and 1513 (3.2%) non-citizens living with HIV delivered; 954 (62.9%) non-citizen deliveries were before the antiretroviral therapy expansion, and 562 (37.1%) were after. Non-citizen ANC attendance among pregnant people living with HIV increased from 79.2% pre-expansion to 87.2% post-expansion (p<0.001), and became more similar to citizens (96.0% post-expansion). Non-citizens receiving any antenatal antiretroviral therapy increased from 65.5% pre-expansion to 89.9% post-expansion (p < 0.001), also more similar to citizens (97.2% post-expansion). Infants born to non-citizens with singleton gestations in the pre-expansion period had significantly greater risk of PTD (aRR = 1.28, 95% CI, 1.11, 1.46), VPTD (aRR = 1.89, 95% CI, 1.43, 2.44) and neonatal death (aRR = 1.69, 95% CI, 1.03, 2.60), but reduced SGA risk (aRR = 0.75; 95% CI, 0.62, 0.89) compared with citizens. Post-expansion, greater declines in most adverse outcomes were observed in non-citizens, with largely similar outcomes between non-citizens and citizens. Non-significant differences were observed for non-citizenship in PTD (aRR = 0.84, 95% CI, 0.66, 1.06), VPTD (aRR = 0.57, 95% CI, 0.28, 1.01), SGA (aRR = 0.91, 95% CI, 0.72, 1.13), VSGA (aRR = 0.87, 95% CI, 0.58, 1.25), stillbirth (aRR = 0.71, 95% CI, 0.35, 1.27) and neonatal death (aRR = 1.35, 95% CI, 0.60, 2.62). Following the expansion of free antiretroviral therapy to non-citizens, gaps narrowed in ANC and antiretroviral therapy use in pregnancy between citizens and non-citizens living with HIV. Disparities in adverse birth outcomes were no longer observed.

Structural racism, air pollution and the association with adverse birth outcomes in the United States: the value of examining intergenerational associations.

Structurally racist policies and practices of the past are likely to be a driving factor in current day differences in exposure to air pollution and may contribute to observed racial and ethnic disparities in adverse birth outcomes in the United States (U.S.). Non-Hispanic Black women in the U.S. experience poorer health outcomes during pregnancy and throughout the life course compared to non-Hispanic White women. This disparity holds even among non-Hispanic Black women with higher socioeconomic status. Reasons for this finding remain unclear, but long-term environmental exposure, either historical exposure or both historical and ongoing exposure, may contribute. Structural racism likely contributes to differences in social and environmental exposures by race in the U.S. context, and these differences can affect health and wellbeing across multiple generations. In this paper, we briefly review current knowledge and recommendations on the study of race and structural racism in environmental epidemiology, specifically focused on air pollution. We describe a conceptual framework and opportunities to use existing historical data from multiple sources to evaluate multi-generational influences of air pollution and structurally racist policies on birth and other relevant health outcomes. Increased analysis of this kind of data is critical for our understanding of structural racism's impact on multiple factors, including environmental exposures and adverse health outcomes, and identifying how past policies can have enduring legacies in shaping health and well-being in the present day. The intended purpose of this manuscript is to provide an overview of the widespread reach of structural racism, its potential association with health disparities and a comprehensive approach in environmental health research that may be required to study and address these problems in the U.S. The collaborative and methodological approaches we highlight have the potential to identify modifiable factors that can lead to effective interventions for health equity.

Implementation of cross-sector partnerships: a description of implementation factors related to addressing social determinants to reduce racial disparities in adverse birth outcomes.

Traditional perinatal care alone cannot address the social and structural determinants that drive disparities in adverse birth outcomes. Despite the wide acceptance of partnerships between healthcare systems and social service agencies to address this challenge, there needs to be more research on the implementation factors that facilitate (or hinder) cross-sector partnerships, particularly from the perspective of community-based organizations. This study aimed to integrate the views of healthcare staff and community-based partner organizations to describe the implementation of a cross-sector partnership designed to address social and structural determinants in pregnancy. We used a mixed methods design (in-depth interviews and social network analysis) to integrate the perspectives of healthcare clinicians and staff with those of community-based partner organizations to identify implementation factors related to cross-sector partnerships. We identified seven implementation factors related to three overarching themes: relationship-centered care, barriers and facilitators of cross-sector partnerships, and strengths of a network approach to cross-sector collaboration. Findings emphasized establishing relationships between healthcare staff, patients, and community-based partner organizations. This study provides practical insights for healthcare organizations, policymakers, and community organizations that aim to improve access to social services among historically marginalized perinatal populations.

Examining Twitter-Derived Negative Racial Sentiment as Indicators of Cultural Racism: Observational Associations With Preterm Birth and Low Birth Weight Among a Multiracial Sample of Mothers, 2011-2021.

Large racial and ethnic disparities in adverse birth outcomes persist. Increasing evidence points to the potential role of racism in creating and perpetuating these disparities. Valid measures of area-level racial attitudes and bias remain elusive, but capture an important and underexplored form of racism that may help explain these disparities. Cultural values and attitudes expressed through social media reflect and shape public norms and subsequent behaviors. Few studies have quantified attitudes toward different racial groups using social media with the aim of examining associations with birth outcomes. We used Twitter data to measure state-level racial sentiments and investigate associations with preterm birth (PTB) and low birth weight (LBW) in a multiracial or ethnic sample of mothers in the United States. A random 1% sample of publicly available tweets from January 1, 2011, to December 31, 2021, was collected using Twitter's Academic Application Programming Interface (N=56,400,097). Analyses were on English-language tweets from the United States that used one or more race-related keywords. We assessed the sentiment of each tweet using support vector machine, a supervised machine learning model. We used 5-fold cross-validation to assess model performance and achieved high accuracy for negative sentiment classification (91%) and a high F1 score (84%). For each year, the state-level racial sentiment was merged with birth data during that year (~3 million births per year). We estimated incidence ratios for LBW and PTB using log binomial regression models, among all mothers, Black mothers, racially minoritized mothers (Asian, Black, or Latina mothers), and White mothers. Models were controlled for individual-level maternal characteristics and state-level demographics. Mothers living in states in the highest tertile of negative racial sentiment for tweets referencing racial and ethnic minoritized groups had an 8% higher (95% CI 3%-13%) incidence of LBW and 5% higher (95% CI 0%-11%) incidence of PTB compared to mothers living in the lowest tertile. Negative racial sentiment referencing racially minoritized groups was associated with adverse birth outcomes in the total population, among minoritized mothers, and White mothers. Black mothers living in states in the highest tertile of negative Black sentiment had 6% (95% CI 1%-11%) and 7% (95% CI 2%-13%) higher incidence of LBW and PTB, respectively, compared to mothers living in the lowest tertile. Negative Latinx sentiment was associated with a 6% (95% CI 1%-11%) and 3% (95% CI 0%-6%) higher incidence of LBW and PTB among Latina mothers, respectively. Twitter-derived negative state-level racial sentiment toward racially minoritized groups was associated with a higher risk of adverse birth outcomes among the total population and racially minoritized groups. Policies and supports establishing an inclusive environment accepting of all races and cultures may decrease the overall risk of adverse birth outcomes and reduce racial birth outcome disparities.

Racial and Ethnic Disparities in the Perinatal Health of Infants Conceived by ART.

Although racial and ethnic disparities in adverse birth outcomes have been well documented, it is unknown whether such disparities diminish in women who use medically assisted reproduction (MAR). We examined differences in the association between maternal race and ethnicity and adverse birth outcomes among women who conceived spontaneously and those who used MAR, including assisted reproduction technology (ART), eg, in-vitro fertilization, and also non-ART MAR, eg, fertility drugs. We conducted a population-based retrospective cohort study using data on all singleton births (N = 7 545 805) in the United States from 2016 to 2017. The outcomes included neonatal and fetal death, preterm birth, and serious neonatal morbidity, among others. Modified Poisson regression was used to estimate adjusted rate ratios (aRR) and 95% confidence intervals (CI) and to assess the interactions between race and ethnicity and mode of conception. Overall, 93 469 (1.3%) singletons were conceived by MAR. Neonatal mortality was twofold higher among infants of non-Hispanic Black versus non-Hispanic White women in the spontaneous-conception group (aRR = 1.9, 95% CI: 1.8-1.9), whereas in the ART-conception group, neonatal mortality was more than fourfold higher in infants of non-Hispanic Black women (aRR = 4.1, 95% CI: 2.9-5.9). Racial and ethnic disparities between Hispanic versus non-Hispanic White women were also significantly larger among women who conceived using MAR with regard to preterm birth (&lt;34 weeks) and perinatal mortality. Compared to women who conceived spontaneously, racial and ethnic disparities in adverse perinatal outcomes were larger in women who used MAR. More research is needed to identify preventive measures for reducing risks among vulnerable women who use medically assisted reproduction.

Sociodemographic and Biological Factors of Health Disparities of Mothers and Their Very Low Birth-Weight Infants.

Background:Black mothers and their very low birth-weight infants in the United States have increased risk of adverse neonatal and maternal health outcomes compared with White mothers and infants. Disparities in adverse birth outcomes associated with sociodemographic factors are difficult to quantify and modify, limiting their usefulness in assessing intervention effects.Purpose:To test hypotheses that (1) the biological factors of maternal testosterone and cortisol are associated with sociodemographic factors and (2) both factors are associated with neonatal health and maternal mental health and healthy behaviors between birth and 40 weeks' gestational age.Methods:We used a descriptive, longitudinal design. Eighty-eight mothers and very low birth-weight neonates were recruited from a tertiary medical center in the United States. Data on sociodemographic factors and neonatal health were collected from medical records. Maternal mental health and healthy behaviors were collected with questionnaires. Maternal salivary testosterone and cortisol levels were measured using enzyme immunoassays. Data were analyzed primarily using general linear and mixed models.Results:High testosterone and/or low cortisol levels were associated with younger age, less education, enrollment in a federal assistance program, being unmarried, being Black, poorer neonatal health, and delayed physical growth. Low cortisol level was related to higher levels of depressive symptoms. Black mothers had fewer healthy behaviors than White mothers.Implications for Practice and Research:Findings confirm that biological factors are associated with sociodemographic factors, and both are associated with neonatal health and maternal mental health and healthy behaviors. We propose using sociodemographic and biological factors concurrently to identify risk and develop and evaluate ante- and postpartum interventions.Video abstract available at https://journals.na.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=59

Racial disparities in birth outcomes following assisted reproduction

Racial disparities in adverse birth outcomes are well known. We examined the differences in the association between race/ethnicity and adverse birth outcomes between women who conceived spontaneously and those who used non-invasive assisted reproduction (nART), e.g., fertility drugs; and invasive assisted reproduction (iART), e.g., in-vitro-fertilization. A population-based retrospective cohort study, including data on all singleton (N=7,545,805) and twin (N=260,183) births in the USA, 2016-2017, from the National Centre for Health Statistics. Logistic regression was used to estimate adjusted odds ratios (AOR) and 95% confidence intervals (CI) and to assess statistical significance of the interaction between race/ethnicity and mode of conception (both self-reported). Twin births were analyzed separately. In women with singletons, assisted reproduction was used among 69778 (1.7%) non-Hispanic white women, 4669 (0.4%) African-American, 11124 (2.1%) Asian, and 7680 (0.4%) Hispanic women. AORs are shown in Tables 1&2. The largest increase in racial disparity was observed in neonatal mortality among women who used iART; African-American women had 4.4-fold higher risk compared with non-Hispanic white women (AOR=4.4, 95% CI 3.0-6.4), while this risk was 2-fold in the spontaneous conception group (AOR=1.9, 95% CI 1.8-2.0). In twins, assisted reproduction was used in 25,886 (17.4%) non-Hispanic white twins, 2004 (4.2%) African-American, 4198 (1.6%) Asian, and 3346 (24.8%) Hispanic twins. Twin results were similar, but slightly attenuated. Disparity in selected maternal morbidity was not different across the groups. Racial disparities in adverse perinatal outcomes among women who conceived spontaneously were aggravated in women who conceived by assisted conception. In particular, the disparity in neonatal mortality between African-American and non-Hispanic white women with ART was 2-fold larger than the disparity in those who conceived spontaneously. More research is needed to identify specific preventive measures after assisted conception among racial/ethnic minority women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Reconsidering upstream approaches to improving population health

Racial and socioeconomic disparities in health outcomes have been well documented. 1 Blumenshine P Egerter S Barclay CJ Cubbin C Braveman PA Socioeconomic disparities in adverse birth outcomes: a systematic review. Am J Prev Med. 2010; 39: 263-272 Summary Full Text Full Text PDF PubMed Scopus (477) Google Scholar , 2 Matoba N Collins Jr, JW Racial disparity in infant mortality. Semin Perinatol. 2017; 41: 354-359 Crossref PubMed Scopus (43) Google Scholar Although overall global rates of poor birth outcomes have decreased, decades of research and interventions have not eliminated disparities. However, much intervention research has focused on individual-level risk factors and groups at high risk. In The Lancet, Jennifer Jardine and colleagues 3 Jardine J Walker K Gurol-Urganci I et al. Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study. Lancet. 2021; (published online Nov 1.)https://doi.org/10.1016/S0140-6736(21)01595-6 Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar report on population attributable fractions, which indicate the proportion of a particular outcome that would be removed if a risk factor did not exist or was more similar to a reference population. The use of population attributable fractions is an important contribution because it demonstrates the excess risk of poor outcomes that can be attributed to population-level factors. The authors provide a potential roadmap for future interventions, emphasising the role of widespread health promotion in improving population-level health metrics over targeted, individual-level interventions that have less population impact. 4 Rose G Sick individuals and sick populations. Int J Epidemiol. 1985; 14: 32-38 Crossref PubMed Scopus (2188) Google Scholar This study 3 Jardine J Walker K Gurol-Urganci I et al. Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study. Lancet. 2021; (published online Nov 1.)https://doi.org/10.1016/S0140-6736(21)01595-6 Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar included 1·16 million singleton births in England, which represented 94% of England's births obtained from administrative hospital data linked to the National Maternity and Perinatal Audit between 2015 and 2017. The authors report that 24% of stillbirths, 19% of preterm births, and 31% of fetal growth restriction could be attributed to socioeconomic inequality. The women included in the sample were 77·2% White, 11·9% south Asian, 4·9% Black, 1·8% mixed ethnicity, and 4·2% other ethnicity. Perhaps most striking were the authors’ findings on the intersection of race and socioeconomic disadvantage, describing that more than half of stillbirths, a third of preterm births, and nearly two-thirds of fetal growth restriction among south Asian and Black women could be eliminated if their risk factors were equal to the least socioeconomically deprived White women. The authors suggest that this finding supports a combination of population-based and risk-based approaches, but does not consider the inextricable link between ethnic background and socioeconomic deprivation. 5 Kane JB Miles G Yourkavitch J King K Neighborhood context and birth outcomes: going beyond neighborhood disadvantage, incorporating affluence. SSM Popul Health. 2017; 3: 699-712 Crossref PubMed Scopus (17) Google Scholar Additionally, the association between race or socioeconomic inequality and birth outcomes might vary because of factors like social support and experiences of racism and discrimination. In combination with the limitation of using an area-level index of deprivation, the authors acknowledge potential inaccuracies and bias in the population attributable fractions. 6 Mansournia MA Altman DG Population attributable fraction. BMJ. 2018; 360: k757 Crossref PubMed Scopus (114) Google Scholar They rightfully note that more detailed causal mediation analysis is a research priority. Moreover, because the definition of fetal growth restriction varies by the reference used, which itself varies by ethnic mix in the index population, 7 Grantz KL Fetal growth curves: is there a universal reference?. Obstet Gynecol Clin North Am. 2021; 48: 281-296 Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar interpretations of this outcome are unclear. Indeed, the authors may be capturing small-for-gestational age rather than fetal growth restriction, which may not indicate pathology. Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort studyOur results indicate that socioeconomic and ethnic inequalities were responsible for a substantial proportion of stillbirths, preterm births, and births with FGR in England. The largest inequalities were seen in Black and South Asian women in the most socioeconomically deprived quintile. Prevention should target the entire population as well as specific minority ethnic groups at high risk of adverse pregnancy outcomes, to address risk factors and wider determinants of health. Full-Text PDF

The Racial Configuration of Parent Couples and Premature Birth: an Analysis of the Utah Population Database.

In this paper, we analyze detailed maternal and paternal race information in a 25-year time series of birth record data to consider racial inequities in premature births experienced by women of color and women within interracial parent couples. We analyze birth outcomes within Utah, a historically racially homogeneous state experiencing growing racial diversity and interracial marriage over the past two decades. Our analyses consider disparities in preterm birth according to maternal race and the interracial status of couples for all birth certificate records within the Utah Population Database from 1989 to 2015 (N = 1,148,818). Our results, consistent with a dyadic perspective on minority stress, indicate that maternal race and interracial parent-couple status are each significantly associated with heightened risk of premature birth. The odds of preterm birth are significantly greater among all four racialized groups in the analyses (African Americans, Asians, Native Americans, and Native Hawaiian or Pacific Islanders) as compared to White women. Furthermore, we find that mothers in mixed-race parent couples with either a white or a black father experience a greater risk of preterm birth than mothers parenting with a father of the same race. Our results suggest that in order to capture the complete perspective on racial-ethnic disparities in adverse birth outcomes, outcomes pivotal for subsequent health outcomes over the life course, it is critical to address racism's toxic effects across multiple levels of lived experience-from the individual level, to the parent dyad, to the local community and beyond.

The Impact of Residing in a Gang Territory on AdverseBirth Outcomes: Evidence from Los Angeles.

Gang violence remains an ongoing crisis in many communities in the United States. This paper assesses the potential association of gang-occupied neighborhoods with birth outcomes. Adverse birth outcomes serve as a "barometer" of population health, denoting both poor conditions for human development and portending future public health concerns. We draw upon (1) Los Angeles County Vital Statistics Birth Records (2008-2012), (2) GIS information on gang territory boundaries, (3) LA city geo-coded crime data, and (4) the 2010 U.S. Census and 2006-2010 American Community Survey. We find an association between gang-occupied neighborhoods and adverse birth outcomes; however, this association is largely explained by other neighborhood socio-demographic characteristics, crime notwithstanding. We also find that gangland neighborhoods tend to exacerbate the effects of crime for all birth outcomes, but only significantly so for small for gestational age births. Lastly, gang co-residence, crime, and other neighborhood demographics explain a substantial portion of socioeconomic and racial/ethnic disparities in adverse birth outcomes. Gangland neighborhoods appear to be a novel contributor to both population health and health disparities. Future studies should address these relationships in a broad range of metropolitan settings, paying careful attention to causal linkages and moderating effects of gangs and crime.

The Association between Maternal Experiences of Interpersonal Discrimination and Adverse Birth Outcomes: A Systematic Review of the Evidence.

In the present systematic review, we argue that maternal experiences of interpersonal discrimination at least partially account for the disproportionate rates of adverse birth outcomes in minority populations. Since the 1990s, research in this area has slowly, but steadily increased, shedding more light on the insidious nature of interpersonal discrimination and its toxic health effects. With the aim of bringing this topic to the fore in academic as well as clinical settings, this paper provides a state-of-the-art review of the empirical knowledge on the relationship between maternal experiences of discrimination and birth outcomes. Of 5901 articles retained in the literature search, 28 met the predefined inclusion criteria. Accounting for a range of health and behavioral factors, the vast majority of these studies support the notion that maternal experiences of interpersonal discrimination predict a range of adverse birth outcomes, including preterm birth, low birth weight, and various physiological markers of stress (allostatic load) in both mother and child pre- and postpartum. Several moderators and mediators of this relationship were also identified. These related primarily to the type (first-hand and vicarious), timing (childhood, adolescence, and adulthood), frequency, and pervasiveness of discrimination experienced, as well as to maternal mental health and coping. More research into these factors, however, is required to definitively determine their significance. We discuss these findings as they relate to the general health repercussions of interpersonal discrimination, as well as in terms of applied prenatal care and interventions. Ultimately, we argue that assessing maternal experiences of interpersonal discrimination in prenatal care may represent a considerable asset for mitigating existing majority-minority disparities in adverse birth outcomes.

Associations between historical redlining and birth outcomes from 2006 through 2015 in California.

Despite being one of the wealthiest nations, disparities in adverse birth outcomes persist across racial and ethnic lines in the United States. We studied the association between historical redlining and preterm birth, low birth weight (LBW), small-for-gestational age (SGA), and perinatal mortality over a ten-year period (2006-2015) in Los Angeles, Oakland, and San Francisco, California. We used birth outcomes data from the California Office of Statewide Health Planning and Development between January 1, 2006 and December 31, 2015. Home Owners' Loan Corporation (HOLC) Security Maps developed in the 1930s assigned neighborhoods one of four grades that pertained to perceived investment risk of borrowers from that neighborhood: green (grade A) were considered "Best", blue (grade B) "Still Desirable", yellow (grade C) "Definitely Declining", and red (grade D, hence the term "redlining") "Hazardous". Geocoded residential addresses at the time of birth were superimposed on HOLC Security Maps to assign each birth a HOLC grade. We adjusted for potential confounders present at the time of Security Map creation by assigning HOLC polygons areal-weighted 1940s Census measures. We then employed propensity score matching methods to estimate the association of historical HOLC grades on current birth outcomes. Because tracts graded A had almost no propensity of receiving grade C or D and because grade B tracts had low propensity of receiving grade D, we examined birth outcomes in the three following comparisons: B vs. A, C vs. B, and D vs. C. The prevalence of preterm birth, SGA and mortality tended to be higher in worse HOLC grades, while the prevalence of LBW varied across grades. Overall odds of mortality and preterm birth increased as HOLC grade worsened. Propensity score matching balanced 1940s census measures across contrasting groups. Logistic regression models revealed significantly elevated odds of preterm birth (odds ratio (OR): 1.02, 95% confidence interval (CI): 1.00-1.05), and SGA (OR: 1.03, 95% CI: 1.00-1.05) in the C vs. B comparison and significantly reduced odds of preterm birth (OR: 0.93, 95% CI: 0.91-0.95), LBW (OR: 0.94-95% CI: 0.92-0.97), and SGA (OR: 0.94, 95% CI: 0.92-0.96) in the D vs. C comparison. Results differed by metropolitan area and maternal race. Similar to prior studies on redlining, we found that worsening HOLC grade was associated with adverse birth outcomes, although this relationship was less clear after propensity score matching and stratifying by metropolitan area. Higher odds of preterm birth and SGA in grade C versus grade B neighborhoods may be caused by higher-stress environments, racial segregation, and lack of access to resources, while lower odds of preterm birth, SGA, and LBW in grade D versus grade C neighborhoods may due to population shifts in those neighborhoods related to gentrification.

Prenatal Depression and Risk of Short Interpregnancy Interval in a Predominantly Puerto Rican Population

Background: Short interpregnancy interval (IPI) is associated with risk of adverse pregnancy outcomes; however, few studies have evaluated the role of depression as a risk factor for short IPI. Puerto Rican women in the United States experience disparities in adverse birth outcomes and have the highest birth rates. Methods: We analyzed the association between prenatal depressive symptoms and IPI in Proyecto Buena Salud, a prospective cohort of predominantly Puerto Rican women in Western Massachusetts (2006-2011). Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) in early, mid, and late pregnancy. We calculated follow-up time as the difference between the date of delivery of the index pregnancy and the last menstrual period of the subsequent pregnancy using medical records and billing data. We defined short IPI as ≤18 months. Results: Of 1262 eligible women, 35% (n = 440) had at least probable minor depression (EPDS scores ≥13) and 25% (n = 315) had probable major depression (EPDS scores ≥15). Participants were followed for a median of 3.7 years (interquartile range = 1.4-6.0 years) and 240 (20.6%) participants experienced a short IPI. After adjusting for risk factors, women with probable minor depression (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] = 1.02-1.88) and probable major depression (aOR = 1.42, 95% CI = 1.02-1.97) during pregnancy had increased odds of short IPI. Conclusions: Prenatal depressive symptoms were common in this Puerto Rican population and were associated with a modest increase in odds of short IPI. Further examination of the pathways through which mental health may affect IPI in vulnerable populations is warranted.

Racial/ethnic disparities in sleep duration and sleep disturbances among pregnant and non-pregnant women in the United States.

Sleep disturbances among pregnant women are increasingly linked to suboptimal maternal/birth outcomes. Few studies in the USA investigating sleep by pregnancy status have included racially/ethnically diverse populations, despite worsening disparities in adverse birth outcomes. Using a nationally representative sample of 71,644 (2,349 pregnant) women from the National Health Interview Survey (2004-2017), we investigated relationships between self-reported pregnancy and six sleep characteristics stratified by race/ethnicity. We also examined associations between race/ethnicity and sleep stratified by pregnancy status. We used average marginal predictions from fitted logistic regression models to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for each sleep dimension, adjusting for sociodemographic and health characteristics. Pregnant women were less likely than non-pregnant women to report short sleep (PROverall =0.75; 95% CI, 0.68-0.82) and more likely to report long sleep (PROverall =2.06; 95% CI, 1.74-2.43) and trouble staying asleep (PROverall =1.34; 95% CI, 1.25-1.44). The association between pregnancy and sleep duration was less pronounced among women aged 35-49years compared to those <35years. Among white women, sleep medication use was less prevalent among pregnant compared to non-pregnant women (PRWhite =0.45; 95% CI, 0.31-0.64), but this association was not observed among black women (PRBlack =0.98; 95% CI, 0.46-2.09) and was less pronounced among Hispanic/Latina women (PRHispanic/Latina =0.82; 95% CI, 0.38-1.77). Compared to pregnant white women, pregnant black women had a higher short sleep prevalence (PRBlack =1.35; 95% CI, 1.08-1.67). Given disparities in maternal/birth outcomes and sleep, expectant mothers (particularly racial/ethnic minorities) may need screening followed by treatment for sleep disturbances. Our findings should be interpreted in the historical and sociocultural context of the USA.

Reducing Inequities in Adverse Birth Outcomes among African American Women in the United States: A Focus on the Life Course Perspective

Adverse birth outcomes are the leading cause of death among infants globally, and the second leading cause of infant deaths in the United States. African-American women have disproportionately higher rates of preterm birth, low birth weight, and infant mortality compared to other racial groups. This is due in part to social inequities, as well as differential exposures to and experience of risk and protective factors before, during, and after pregnancy. The life course perspective framework posits that adverse birth outcomes are not primarily due to experiences during pregnancy, but experiences (environmental exposures, biological, social and behavioral factors, as well as life experiences) across the life course. These experiences negatively affect birth outcomes in current and future generations. Reducing the adverse birth outcome gap between African Americans and other racial groups requires not only increasing access to prenatal care, but also addressing the differential cumulative impact of social inequities and early life disadvantages experienced by the former. It is therefore critically important to focus on the life course perspective when framing solutions to bridge racial disparities in adverse birth outcomes.

Racial and ethnic disparities in adverse birth outcomes: Differences by racial residential segregation.

Racial and ethnic disparities in adverse birth outcomes have persistently been wide and may be explained by individual and area-level factors. Our primary objective was to determine if county-level black-white segregation modified the association between maternal race/ethnicity and adverse birth outcomes using birth records from the National Center for Health Statistics (2012). Based on maternal residence at birth, county-level black-white racial residential segregation was calculated along five dimensions of segregation: evenness, exposure, concentration, centralization, and clustering. We conducted a two-stage analysis: (1) county-specific logistic regression to determine whether maternal race and ethnicity were associated with preterm birth and term low birth weight; and (2) Bayesian meta-analyses to determine if segregation moderated these associations. We found greater black-white and Hispanic-white disparities in preterm birth in racially isolated counties (exposure) relative to non-isolated counties. We found reduced Hispanic-white disparities in term low birth weight in racially concentrated and centralized counties relative to non-segregated counties. Area-level poverty explained most of the moderating effect of segregation on disparities in adverse birth outcomes, suggesting that area-level poverty is a mediator of these associations. Segregation appears to modify racial/ethnic disparities in adverse birth outcomes. Therefore, policy interventions that reduce black-white racial isolation, or buffer the poor social and economic correlates of segregation, may help to reduce disparities in preterm birth and term low birth weight.

Racial Disparities and the Effect of Maternal Sexually Transmitted Infections on Adverse Birth Outcomes

Background: Understanding the role of sexually transmitted infections (STIs) in disparities associated with adverse birth outcomes (ABOs) may help target specific interventions for black and white women. Despite extensive research existing on racial disparities in ABOs and STIs, a gap in the literature exists regarding disparities in the association between STIs and ABOs. Methods: This cross-sectional study utilizes data from Missouri vital statistics (n=173,624), years 2010-2012. Exposure was classified as: primary-HIV, either alone or with another STI (gonorrhea, syphilis, hepatitis B, or hepatitis C); secondary-aforementioned STIs without HIV; and unexposed. Outcomes of interest included preterm birth (birth prior to 37 weeks of gestation), low birth weight (less than 2500g), and small for gestational age (weight below the 10th percentile for gestational age). Bivariate and multivariate logistic regression models estimated risk of STIs on ABOs and adjusted for potential confounders (age, education, marital status, prenatal care, health insurance, previous preterm birth, smoking, BMI, weight gain, and chronic health conditions), by calculating odds ratios and 95% confidence intervals for primary and secondary exposures on all three outcomes. Results: HIV exposure was significantly associated with a 72% increased odds (OR: 1.72, 95% CI: 1.03-2.89) for having a low birth weight birth and a 71% increased odds (OR: 1.71, 95% CI: 1.03-2.84) for being small for gestational age, when compared with women without an STI, after adjusting for potential confounding variables. Race was not an effect modifier. Conclusions: Reducing one’s risk of having an STI before pregnancy provides an important primary prevention tactic that can reduce risks for ABOs should one become pregnant.

The South Carolina Multigenerational Linked Birth Dataset: Developing Social Mobility Measures Across Generations to Understand Racial/Ethnic Disparities in Adverse Birth Outcomes in the US South

Objectives To describe the creation of a multigenerational linked dataset with social mobility measures for South Carolina (SC), as an example for states in the South and other areas of the country. Methods Using unique identifiers, we linked birth certificates along the maternal line using SC birth certificate data from 1989 to 2014, and compared the subset of records for which linking was possible with two comparison groups on sociodemographic and birth outcome measures. We created four multi-generational social mobility measures using maternal education, paternal education, presence of paternal information, and a summary score incorporating the prior three measures plus payment source for births after 2004. We compared social mobility measures by race/ethnicity. Results Of the 1,366,288 singleton birth certificates in SC from 1989 to 2014, we linked 103,194, resulting in 61,229 unique three-generation units. Mothers and fathers were younger and had lower education, and low birth weight was more common, in the multigenerational linked dataset than in the two comparison groups. Based on the social mobility summary score, only 6.3% of White families were always disadvantaged, compared to 30.4% of Black families and 13.2% of Hispanic families. Moreover, 32.8% of White families were upwardly mobile and 39.1% of Black families were upwardly mobile, but only 29.9% of Hispanic families were upwardly mobile. Conclusions for Practice When states are able to link individuals, birth certificate data may be an excellent source for examining population-level relationships between social mobility and adverse birth outcomes. Due to its location in the Deep South, the multigenerational SC dataset may be particularly useful for understanding racial/ethnic difference in social mobility and birth outcomes.

Women from racial or ethnic minority and low socioeconomic backgrounds receive more prenatal education: Results from the 2012 to 2014 Pregnancy Risk Assessment Monitoring System.

Racial or ethnic and socioeconomic disparities in adverse birth outcomes are well known, but few studies have examined disparities in the receipt of prenatal health education. The objectives of this study were to examine racial or ethnic and socioeconomic variations in receiving (1) comprehensive prenatal health education and (2) education about human immunodeficiency virus (HIV) testing, breastfeeding, alcohol, and smoking cessation from health care practitioners. Data were drawn from the 2012 to 2014 Pregnancy Risk Assessment Monitoring System (PRAMS). Twenty-seven states were included with an analysis sample size of 68025 participants. Receiving counseling on all listed health topics during prenatal care visits was denoted as comprehensive prenatal health education. Logistic regression was used to examine the association of racial or ethnic and socioeconomic variables with receiving comprehensive prenatal health education, and HIV testing, breastfeeding, alcohol, and smoking cessation advice separately. Multivariable results showed that racial or ethnic minorities and women with a high school degree or less; receiving Women, Infant, and Children (WIC) assistance; and on Medicaid during pregnancy have higher odds of receiving comprehensive prenatal health education (all P≤0.001). Results were similar for receiving HIV testing, breastfeeding, alcohol, and smoking counseling. Low household income was associated with receiving counseling on HIV testing, alcohol, and smoking (all P≤0.001). Despite reporting higher levels of prenatal health education on a variety of health-related topics, disadvantaged women continue to experience disparities in adverse birth outcomes suggesting that education is insufficient in promoting positive behaviors and birth outcomes.