Inequalities In Birth Outcomes Research Articles

How structural racism, neighborhood deprivation, and maternal characteristics contribute to inequities in birth outcomes.

Decades of disparities in health between infants born to Black and White mothers have persisted in recent years, despite policy initiatives to improve maternal and reproductive health for Black mothers. Although scholars have increasingly recognized the critical role that structural racism plays in driving health outcomes for Black people, measurement of this relationship remains challenging. This study examines trends in preterm birth and low birth weight between 2007 and 2018 separately for births to Black and White mothers. Using a multivariate regression model, we evaluated potential factors, including an index of racialized disadvantage as well as community- and individual-level factors that serve as proxy measures for structural racism, that may contribute to White-Black differences in infant health. Finally, we assessed whether unequal effects of these factors may explain differences in birth outcomes. We found that differences in the effects of these factors appear to explain about half of the underlying disparity in infant health.

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.

Road to Equity in Maternal and Child Health: Honoring the Past and Blazing New Paths.

This paper is a historical account of an initiative, as recalled by the authors who were directly involved, that brought to the forefront the long-standing and unjust reproductive health inequities in the United States. It is composed of three distinct but interrelated parts that together map the past, present, and future of addressing racial inequities in Maternal and Child Health. This paper is composed of three distinct but interrelated parts that together map the past, present, and future of addressing racial inequities in Maternal and Child Health.Part I recounts the history and achievements of a Centers for Disease for Control and Prevention initiative in the 1980-90's, led by the Prematurity Research Group in the Division of Reproductive Health, Pregnancy and Infant Health Branch. This initiative stimulated a paradigm shift in how we understand and address black infant mortality and the inequities in this outcome. Part II illustrates examples of some exemplary programmatic and policy legacies that stemmed either directly or indirectly from the Centers for Disease for Control and Prevention paradigm shift. Part III provides a discussion of how effectively the current practice in Maternal and Child Health applies this paradigm to address inequities and proposes a path for accelerating Title V agencies' progress toward birth equity. This CDC initiative was transformative in that it raised the visibility of African American researchers,moved the field from a focus on traditional epidemiologic risks such as personal health promotion and medical interventions, to include racism as a risk factor for inequitable birth outcomes. The paradigm examinedthe specific roles of historical and structural racism, and the racialized, contextualized, and temporal exposures that are unique to Black women's experiences in the United States. The initiative radically changed the narratives about the underlying factors contributing to inequities in birth outcomes of Black women, altered the way we currently approach addressing inequities, and holds the keys for transforming practice to a more holistic and systematic approach to building sustained organizational structures in maternal and child health that accelerate the achievement of birth equity.

Health Equity Considerations in State Bills Related to Doula Care (2015-2020).

Racial inequities in birth outcomes persist in the United States. Doula care may help to decrease inequities and improve some perinatal health indicators, but access remains a challenge. Recent doula-related state legislative action seeks to improve access, but the prioritization of equity is unknown. We reviewed recent trends in doula-related legislation and evaluated the extent to which new legislation addresses racial health equity. We conducted a landscape analysis of the LegiScan database to systematically evaluate state legislation mentioning the word "doula" between 2015 and 2020. We identified and applied nine criteria to assess the equity focus of the identified doula-related legislative proposals. Our final sample consisted of 73 bills across 24 states. We observed a three-fold increase in doula-related state legislation introduced over the study period, with 15 bills proposed before 2019 and 58 proposed in 2019-2020. Proposed policies varied widely in content and scope, with 53.4% focusing on Medicaid reimbursement for doula care. In total, 12 bills in 7 states became law. Seven of these laws (58.3%) contained measures for Medicaid reimbursement for doula services, but none guaranteed a living wage based on the cost of living or through consultation with doulas. Only two states (28.6%; Virginia and Oregon) that passed Medicaid reimbursement for doulas also addressed other racial equity components. There has been an increase in proposed doula-related legislation between 2015 and 2020, but racial health equity is not a focus among the laws that passed. States should consider using racial equity assessments to evaluate proposed doula-related legislation.

Adaptation of the Person-Centered Maternity Care Scale in the United States: Prioritizing the Experiences of Black Women and Birthing People.

Mistreatment by health care providers disproportionately affects Black, Indigenous, and other people of color in the United States. The goal of this study is to adapt the global Person-Centered Maternity Care (PCMC) scale for use in the United States, with particular attention to the experiences of Black women and birthing people. We used a community-engaged approach including expert reviews and cognitive interviews to assess content validity, relevance, comprehension, and comprehensiveness of the PCMC items. Surveys of 297 postpartum people, 82% of whom identified as Black, were used for psychometric analysis in which we assessed construct and criterion validity and reliability. The University of California, San Francisco California Preterm Birth Initiative's Community Advisory Board, which consists of community members, community-based health workers, and social service providers in Northern California, provided input during all stages of the project. Through an iterative process of factor analysis, discussions with the Community Advisory Board, and a prioritization survey, we eliminated items that performed poorly in psychometric analysis, yielding a 35-item PCMC-U.S. scale with subscales for dignity and respect, communication and autonomy, and responsive and supportive care. The Cronbach's alpha for the full scale is 0.95 and for the subscales is 0.87. Standardized summative scores range from 0 to 100, with higher scores indicating more PCMC. Correlations with related measures indicated high criterion validity. The 35-item PCMC-U.S. scale and its subscales have high validity and reliability in a sample of predominantly Black women. This scale provides a tool to support efforts to reduce the inequities in birth outcomes experienced by Black, Indigenous, and other people of color.

Biomarkers of pre-pregnancy allostatic load and subsequent adverse birth outcomes

Racial disparities in birth outcomes are seemingly intractable. Using person-centered methods and drawing from the life course and Weathering Hypothesis literatures, we used data from the National Longitudinal Study of Adolescent to Adult Health to group non-Hispanic White and non-Hispanic Black women ages 24–34 into latent classes based on pre-pregnancy biomarkers of allostatic load. Stratified analyses yielded four latent classes among non-Hispanic White women, characterized by: 1) high blood pressure, 2) high body mass index and waist circumference, 3) high total cholesterol and triglycerides, and low high-density lipoprotein, and 4) low-risk, and two latent classes among non-Hispanic Black women, characterized by: 1) high body mass index and waist circumference, and moderate-risk blood pressure, hbA1c, and c-reactive protein, and 2) low-risk. Allostatic load class membership and other maternal- and infant-level covariates were then included simultaneously as predictors of three separate dichotomous outcomes: preterm birth, macrosomia, and low birth weight in multilevel logistic regression models. In a separate multilevel linear regression model, the same variables were simultaneously entered to predict continuously measured birthweight. In multilevel, multivariate models, White women in the high-risk body mass index and waist circumference class, as compared to the high-risk blood pressure class, had infants with higher birthweights. Other comparisons were not significant or not of meaningful magnitude. Prioritizing temporality so that allostatic load measurement preceded first birth likely biased the composition of the analytical sample. Additional research is needed to help medical providers and public health practitioners understand the complex biological and social mechanisms underlying inequities in birth outcomes and identify prevention strategies.

Transdisciplinary Imagination: Addressing Equity and Mistreatment in Perinatal Care.

Inequities in birth outcomes are linked to experiential and environmental exposures. There have been expanding and intersecting wicked problems of inequity, racism, and quality gaps in childbearing care during the pandemic. We describe how an intentional transdisciplinary process led to development of a novel knowledge exchange vehicle that can improve health equity in perinatal services. We introduce the Quality Perinatal Services Hub, an open access digital platform to disseminate evidence based guidance, enhance health systems accountability, and provide a two-way flow of information between communities and health systems on rights-based perinatal services. The QPS-Hub responds to both community and decision-makers’ needs for information on respectful maternity care. The QPS-Hub is well poised to facilitate collaboration between policy makers, healthcare providers and patients, with particular focus on the needs of childbearing families in underserved and historically excluded communities.

Where are the labor markets?: Examining the association between structural racism in labor markets and infant birth weight.

Racist policies and practices that restrict Black, as compared to white workers, from employment may drive racial inequities in birth outcomes among workers. This study examined the association between structural racism in labor markets, measured at a commuting zone where workers live and commute to work, and low-birthweight birth. We found the deleterious effect of structural racism in labor markets among US-born Southern Black pregnant people of working age, but not among African- or Caribbean-born counterparts in any US region. Our analysis highlights the intersections of structural racism, culture, migration, and history of racial oppression that vary across regions and birth outcomes of Black workers.

State Policies, Racial Disparities, and Income Support: A Way to Address Infant Outcomes and the Persistent Black-White Gap?

Low birth weight and preterm births vary by state, and Black mothers typically face twice the risk that their white counterparts do. This gap reflects an accumulation of psychosocial and material exposures that include interpersonal racism, differential experience with area-level deprivation such as residential segregation, and other harmful exposures that the authors refer to as "institutional" or "structural" racism. The authors use logistic regression models and a dataset that includes all births from 1994 to 2017 as well as five state policies from this period-Aid to Families with Dependent Children/Temporary Aid for Needy Families, housing assistance, Medicaid, minimum wage, and the earned income tax credit (EITC)-to examine whether these state social policies, designed to provide a financial safety net, are associated with risk reduction of low birth weight and preterm birth to Black and white mothers, and whether variations in state generosity attenuate the racial inequalities in birth outcomes. The authors also examine whether the relationship between state policies and racial inequalities in birth outcomes is moderated by the education level of the mother. We find that the EITC reduces the risk of low birth weight and preterm birth for Black mothers. The impact is much less consistent for white mothers. For both Black and white mothers, the benefits to birth outcomes are larger for mothers with less education.

Socioeconomic inequalities in birth outcomes: An 11-year analysis in Colombia.

ObjectiveTo examine socioeconomic inequalities in birth outcomes among infants born between 2008 and 2018 and assessed trends in inequalities during that period in Colombia, a middle-income country with high levels of inequality emerging from a long internal armed conflict.MethodsUsing birth certificate data in Colombia, we analysed the outcomes of low birth weight, an Apgar score <7 at 5 minutes after birth and the number of prenatal visits among full-term pregnancies. Maternal education and health insurance schemes were used as socioeconomic position (SEP) indicators. Inequalities were estimated using the prevalence/mean of the outcomes across categories of the SEP indicators and calculating the relative and slope indices of inequality (RII and SII, respectively).ResultsAmong the 5,433,265 full-term singleton births analysed, there was a slight improvement in the outcomes analysed over the study period (lower low-birth-weight and Apgar<7 prevalence rates and higher number of prenatal visits). We observed a general pattern of social gradients and significant relative (RII) and absolute (SII) inequalities for all outcomes across both SEP indicators. RII and SII estimates with their corresponding CIs revealed a general picture of no significant changes in inequalities over time, with some particular, time-dependent exceptions. When comparing the initial and final years of our study period, inequalities in low birth weight related to maternal education increased while those in Apgar score <7 decreased. Relative inequalities across health insurance schemes increased for the two birth outcomes but decreased for the number of prenatal visits.ConclusionThe lack of a consistent improvement in the magnitude of inequalities in birth outcomes over an 11-year period is a worrying issue because it could aggravate the cycle of inequality, given the influence of birth outcomes on health, social and economic outcomes throughout the life course. The findings of our analysis emphasize the importance of policies aimed at providing access to quality education and providing a health care system with universal coverage and high levels of integration.

Maternal depressive symptoms, sleep, and odds of spontaneous early birth: implications for racial inequities in birth outcomes.

Delivery prior to full term affects 37% of US births, including ~400,000 preterm births (<37 weeks) and >1,000,000 early term births (37-38 weeks). Approximately 70% of cases of shortened gestation are spontaneous-without medically-indicated cause. Elucidation of modifiable behavioral factors would have considerable clinical impact. This study examined the role of depressive symptoms and sleep quality in predicting the odds of spontaneous shortened gestation among 317 women (135 black, 182 white) who completed psychosocial assessment in mid-pregnancy. Adjusting for key covariates, black women had 1.89 times higher odds of spontaneous shortened gestation compared to White women (OR [95% CI] = 1.89 [1.01, 3.53], p = 0.046). Women who reported only poor subjective sleep quality (PSQI > 6) or only elevated depressive symptoms (CES-D ≥ 16) exhibited no statistically significant differences in odds of spontaneous shortened gestation compared to those with neither risk factor. However, women with comorbid poor sleep and depressive symptoms exhibited markedly higher odds of spontaneous shortened gestation than those with neither risk factor (39.2% versus 15.7% [OR (95% CI) = 2.69 (1.27, 5.70)], p = 0.01). A higher proportion of black women met criteria for both risk factors (23% of black women versus 11% of white women; p = 0.004), with a lower proportion experiencing neither risk factor (40.7% of black versus 64.3% of white women; p < 0.001). Additive effects of poor subjective sleep quality and depressive symptoms were observed with markedly higher odds of spontaneous shortened gestation among women with both risk factors. Racial inequities in rates of comorbid exposure corresponded with inequities in shortened gestation. Future empirical studies and intervention efforts should consider the interactive effects of these commonly co-morbid exposures.

Interracial/ethnic marriage and adverse birth outcomes: The effect of neighborhood racial/ethnic composition.

Race/ethnicity is associated with adverse birth outcomes in the United States. However, mostly mother's race/ethnicity has been considered. We examined the associations of mother's and parents' race/ethnicity with low birth weight, small for gestational age, preterm birth and infant mortality among New York City women between 2012 and 2017. We also examined the independent and joint effects of neighborhood racial/ethnic composition. We found that mother's and parents' race/ethnicity are associated with adverse birth outcomes; these associations are outcome-specific; and neighborhood racial/ethnic composition is not only associated with such outcomes but also modifies the association of mother's and parents' race/ethnicity with these outcomes. Our findings underscore the need to consider the race/ethnicity of women's partners and their neighborhoods calling attention to the role of context where individuals reside, and their daily interactions take place. These findings may have implications beyond New York City as our society becomes more racial/ethnic diverse and interracial/ethnic marriage becomes more common in the United States.

Lessons Learned from Implementing a Place-Based, Racial Justice-Centered Approach to Health Equity

As theories about the causes of racial inequities in infant mortality evolve, they are becoming increasingly complex. Interventions to address these inequities must be similarly complex, incorporating both upstream and downstream approaches. The Best Babies Zone Initiative (BBZ) has been in operation since 2012 with an aim of reducing racial inequities in infant mortality. BBZ is designed to be flexible and responsive to the conditions creating toxic stress in communities of color. After seven years of operation in nine sites across the United States, and interventions implemented in housing, economic, and environmental justice, the Initiative has identified strategies to support the development and advancement of aligned programs. Lessons learned and opportunities were identified across the Initiative's theoretical foundation (the life course perspective) and each of the four foundational strategies: place-based, community-driven, multi-sector work that contributes to broader social movements. Overarching lessons learned about advancing equity in MCH were identified including: the need to focus explicitly on racial equity, the imperative of shifting the time horizon for change, and the importance of identifying sustainable funding mechanisms. A complex initiative such as BBZ is relatively nascent in the field of Maternal and Child Health. However it represents an innovative approach to building community power and fostering strategic organizational partnerships in service of addressing root causes of racial inequities in birth outcomes. The lessons learned and opportunities identified by BBZ can serve as a foundation from which to build other programs and initiatives to advance racial justice.

Family involvement in pregnancy and psychological health among pregnant Black women

Social determinants of health influence psychological health in pregnancy and contribute to health inequities in birth outcomes. This study examines the association between family involvement during pregnancy and psychological health among Black women. Pregnant women in Detroit, MI and Columbus, OH were recruited between 8 and 29 weeks' gestation (n = 203). Higher family involvement was associated with lower depressive symptoms (CES-D; β = −1.3, p < 0.001), perceived stress (β = −0.8, p < 0.001), and anxiety (β = −0.39, p < 0.01), and higher levels of psychological well-being (β = 2.2, p < 0.001). Family involvement may be a protective factor for pregnant Black women.

Exploring Experiences of Structural Racism and its Influence on Maternal and Child Health

IntroductionSystematic racism and racial discrimination have been proposed as significant risk factors that contribute to health disparities in maternal and child health outcomes for African American families. There is evidence to suggest that racism is associated with poor birth outcomes. Most studies have examined the role of interpersonal racism, whereas few explore the role of systemic racism. Additionally, few studies have examined the mechanisms by which systemic racism impacts health from the perspective of those affected. This study explored the systems and aspects of structural racism affecting racial inequities in birth outcomes in Baltimore City.ResultsIn this qualitative study, we conducted 3 focus groups with Baltimore City residents (n = 20) and 2 focus groups with maternal, infant, and early childhood home visiting program staff (n = 18). Participants were asked to identify and unpack the systems external to the community that create the current realities of racial inequities in birth outcomes in Baltimore City. Focus groups were recorded, transcribed, and coded to identify themes.MethodsA variety of systems were identified as playing a role in the health of pregnant and postpartum people and infants including: medical, justice, government, neighborhood environment, schools, and commercial/retail. For most systems, racism was described as acting by way of: the quality and availability of goods and services; bias, stereotyping, and racial profiling; and power imbalance. Within the health care system, participants commonly reported experiencing disrespectful medical care and described the ways in which it impacts their health.DiscussionMidwives, nurses, and other health care professionals have a role to play in undoing systemic racism. Understanding the sources and mechanisms by which systemic racism affects the lives of childbearing families is foundational to that work.

A Scoping Review of Socioeconomic Inequalities in Distributions of Birth Outcomes: Through a Conceptual and Methodological Lens.

The extant literature has examined social inequalities in high-risk categories of birth weight and gestational age (i.e., low birth weight and preterm birth) with little attention given to their distributional nature. As such, a scoping review was conducted to understand how researchers have conceptualized and analyzed socioeconomic inequalities in entire distributions of these birth outcomes. Bibliographic databases were searched from their inception until August 2016 for articles from five similar, English-speaking, advanced capitalist democracies: Canada, United States, United Kingdom, Australia and New Zealand. Twenty-one studies were included in the review, all of which provided rationales for examining socioeconomic inequalities in the entire distribution of birth weight. Yet, only three studies examined non-uniform associations of socioeconomic factors across the distribution of birth weight using conditional quantile regression, while the majority focused on mean birth weight using descriptive analysis or linear regression to analyze inequalities. Nevertheless, study results indicated that socioeconomic inequalities exist throughout the distribution of birth weight, extending beyond the high-risk category of low birth weight. Although social inequalities in distributions of birth weight have been conceptualized, few studies have analytically engaged with this concept. As such, this review supports further investigation of distributional inequalities in birth outcomes using methodology which allows one to empirically quantify and explain differences in population risk distributions, rather than solely between infants born low birth weight or preterm birth, versus not.

Persisting inequalities in birth outcomes related to neighbourhood deprivation

IntroductionHealth inequalities can be observed in early life as unfavourable birth outcomes. Evidence indicates that neighbourhood socioeconomic circumstances influence health. However, studies looking into temporal trends in inequalities in birth...

Ethnic disparity in health literacy related to interaction with the health care provider

Abstract With the current orientation towards patient-centered care, the health literacy level is an important predictor for the engagement in preventive health care services. Research has shown that adult immigrants have lower levels of health literacy compared to the host populations, however little is known about the health literacy of pregnant, immigrant women. The aim of this study was to analyze whether ethnic minority women found it more difficult to actively engage with their health professionals than ethnic Danish women did. Using cross-sectional data we studied the difference in the Health Literacy Questionnaire (HLQ) domain on actively engagement with health care providers between non-Western born and ethnic Danish women (n = 406). Pregnant women were recruited in 2016 from the largest maternity ward in Denmark. The mean health literacy level of actively engagement for ethnic Danish women was 4.15 and for non-Western born women, it was 3.97. In an adjusted model the non-Western born women had 1.15 (CI:-0.30; -0.01) lower levels of actively engagement compared to ethnic Danish women. These results indicate that this domain of the HLQ seems to be a useful link in understanding ethnic inequality in birth outcomes and thus relevant in the effect evaluation of the MAMAACT study. Currently, the health care system in Denmark has not focused on intercultural competence. The lower levels of self-reported ability to engage with health care providers and the known perspectives of lower patient safety in immigrant groups calls for more research in the interactional dynamics. A theoretical analysis using the concept of cultural health capital could be interesting for assessing how health care providers and non-Western women might value certain attitudes and behaviors exchanged during the encounter differently, which could lead to imbalance as the health care provider has more influence in this setting.

Economic Downturns and Inequities in Birth Outcomes: Evidence From 149 Million US Births.

Using birth certificate data for nearly all registered US births from 1976 to 2016 and monthly data on state unemployment rates, we reexamined the link between macroeconomic variation and birth outcomes. We hypothesized that economic downturns reduce exposure to work-related stressors and pollution while increasing exposure to socioeconomic stressors like job loss. Because of preexisting inequalities in health and other resources, we expected that less-educated mothers and black mothers would be more exposed to macroeconomic variation. Using fixed-effect regression models, we found that a 1-percentage-point increase in state unemployment during the first trimester of pregnancy increased the probability of preterm birth by 0.1 percentage points, while increases in the state unemployment rate during the second/third trimester reduced the probability of preterm birth by 0.06 percentage points. During the period encompassing the Great Recession, the magnitude of these associations doubled in size. We found substantial variation in the impact of economic conditions across different groups, with highly educated white women least affected and less-educated black women most affected. The results highlight the increased relevance of economic conditions for birth outcomes and population health as well as continuing, large inequities in the exposure and impact of macroeconomic fluctuations on birth outcomes.

Experiences of Racism and Preterm Birth: Findings from aPregnancy Risk Assessment Monitoring System, 2004 through2012.

Racial disparities in birth outcomes represent a significant public health concern in the United States. Factors associated with racism have been posited as a mechanism underlying these disparities. Yet, findings from previous studies are mixed and based on small, geographically limited samples. This study aims to examine the relationship between experiences of racism and preterm birth in a population-based sample and to explore the role of adequacy of prenatal care within that relationship. Data from the 2004 through 2012 Pregnancy Risk Assessment Monitoring System were analyzed. The sample included non-Hispanic Black mothers from 11 states and New York City who delivered neonates from 2004 to 2012 (n=11,582). Survey-weighted regression analyses were used to examine the association between women feeling upset by experiences of racism in the 12months before delivery and subsequent preterm birth. Adequacy of prenatal care was tested as an effect modifier. Feeling upset by experiences of racism was significantly associated with greater odds of preterm birth (adjusted odds ratio, 1.29; 95% CI, 1.04-1.59). Results from interaction models revealed that the associations of experiences of racism with preterm birth differed by level of prenatal care, although the interaction term was not significant. Findings suggest that, for non-Hispanic Black women, the emotional effect of experiences of racism may contribute to the risk of preterm birth. Future studies should consider the role of adequate prenatal care in this relationship. Racism is an important public health problem with a measurable impact on preterm birth and should be addressed to eliminate racial inequities in birth outcomes.