Why Do Black Women Experience Higher Rates of Preterm Birth?

Neighborhood racial composition and experiences of racial discrimination: Associations with cytokines during pregnancy among African American women

Background

Preterm birth rates are consistently higher in African American (AA) pregnancies compared to White pregnancies in the United States. Neighborhood racial composition, experiences of racial discrimination, and systemic inflammation are factors that have been associated with preterm birth and other adverse pregnancy outcomes that may account for these disparities. Here, we investigated whether perceived neighborhood racial composition and experiences of discrimination were predictive of cytokine levels during pregnancy among AA individuals.

Methods

545 AA individuals completed surveys and had blood samples collected at prenatal clinics in the Midwest at three timepoints (8-18,19-29, and 30-36 weeks gestation) throughout pregnancy. Pro-inflammatory [interferon (IFN)-γ, interleukin (IL)-6, IL-8, tumor necrosis factor (TNF)-α, macrophage migration inhibitory factor (MIF)] and anti-inflammatory cytokines (IL-10) were quantified. Multivariate and multilevel models were used to examine associations of perceived neighborhood racial composition and experiences of racial discrimination with cytokine levels, controlling for relevant covariates.

Results

Perceived neighborhood racial composition was significantly associated with MIF at 30-36 weeks gestation in multivariate regression (p < 0.001). Living in neighborhoods with more compared to fewer White people was predictive of higher levels of MIF (b = 0.599, SE = 0.12, p < 0.001). Experiences of discrimination were also associated with higher levels of MIF (β = 0.141, SE = 0.07, p = 0.036). Neither predictor was associated with other cytokines. Follow-up analyses revealed that neighborhood racial composition was also predictive of higher MIF levels at 8-18 weeks gestation (p = 0.02) and at 19-29 weeks gestation (p = 0.04).

Conclusions

Living in neighborhoods with more White individuals and having more lifetime experiences of racial discrimination were positively related to levels of the pro-inflammatory cytokine, MIF, among pregnant AA individuals. MIF's known positive relationships with chronic stress and preterm birth suggest that these elevations in MIF may have negative health consequences. Future studies should explore whether MIF serves as a pathway between neighborhood racial composition or experiences of racial discrimination and preterm birth risk among AA individuals.

Social mobility and perinatal depression in Black women

Background

Higher socioeconomic position is associated with better birth outcomes and maternal mental health, although this relationship is less consistent for Black women. The literature is limited on the impact of social mobility across the life course on mental health of pregnant women. This study examines the impact of perceived financial status across the life-course on depressive symptoms during pregnancy among Black women.

Methods

Data were from the Life-course Influences of Fetal Environments (LIFE) retrospective cohort study among pregnant Black women in metropolitan Detroit, Michigan. Depressive symptoms in the two weeks prior to birth were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. Social mobility was determined at three intervals over the life course using self-report of financial status during childhood, adolescence, and current age in pregnancy.

Results

1,410 pregnant women participated, ranging in age from 18 to 45 years old. CES-D scores ranged from 0 to 53 (mean = 15.3) and 26% of the sample reported high depressive symptoms. In each age interval, higher financial status was associated with significant protective effect on depressive symptoms, and the magnitude of the effect increased across the life course. Trajectory analysis demonstrated that both the upward (4.51; 95% CI, 2.43-6.6) and downward (4.04; 95% CI, 2.62-5.46 and 3.09; 95% CI, 1.57-4.62) life-course social mobility groups had increased mean CES-D scores compared to the static social mobility group.

Conclusion

This study describes the importance of previous childhood and current financial status effects on mental health in Black pregnant women.

Preconception stress exposure from childhood to adolescence and birth outcomes: The impact of stress type, severity and consistency

The negative effects of prenatal stress on offspring health are well established, but there remains little understanding of the influence of stress prior to conception despite known effects on biological systems that are important for a healthy pregnancy. Furthermore, operational definitions of stress vary considerably, and exposure is often characterized via summed, ordinal scales of events. We hypothesized that type, severity, and consistency of preconception stress would be associated with birthweight and gestational age (GA) at birth. Data were drawn from a subsample of participants in the 21-year longitudinal Pittsburgh Girls Study (PGS, N = 2,450) that has followed women annually since childhood. Prior work in the PGS derived three domains of stress exposure between ages 7-17 years related to subsistence (e.g., resource strain, overcrowding), safety (e.g., community violence, inter-adult aggression), and caregiving (e.g., separation, maternal depression). We tested the effects of dimensions of preconception stress on birthweight and GA among offspring of 490 PGS participants who delivered at age 18 or older (n = 490; 76% Black, 20% White, 4% Multiracial). Our hypotheses were partially supported with results varying by stress type and severity and by infant sex. Severity of preconception exposure to subsistence stress was prospectively associated with lower offspring birthweight (B = -146.94, SE = 69.07, 95% CI = -282.66, -11.22). The association between severity of caregiving stress in childhood and adolescence and GA at birth was moderated by infant sex (B = 0.85, SE = .41, 95% CI = 0.04, 1.66), suggesting greater vulnerability to this type of stress for male compared to female infants. Exposure to safety stressors did not predict birth outcomes. Infants of Black compared with White mothers had lower birthweight in all models regardless of preconception stress type, severity or consistency. However, we observed no moderating effects of race on preconception stress-birth outcome associations. Demonstrating specificity of associations between preconception stress exposure and prenatal health has the potential to inform preventive interventions targeting profiles of exposure to optimize birth outcomes.

A Mixed-Methods Study of Experiences During Pregnancy Among Black Women During the COVID-19 Pandemic

Pregnant women experienced disruptions in their prenatal care during the coronavirus disease-2019 (COVID-19) pandemic. While there is emerging research about the impact of COVID-19 on experiences of pregnancy, the majority of studies that have reported on prenatal care and birth during COVID-19 have not incorporated the first-person accounts of Black women. The purpose of this mixed-methods study was to explore the perspectives of Black women on prenatal care, labor, and birth during the pandemic. A total of 33 participants completed questionnaires. Fourteen of these 33 women and an additional 2 participated in qualitative interviews. Descriptive statistics and a mixed-methods analysis were employed. Participants expressed disappointment about disruptions in their experiences of pregnancy including the way their prenatal care was experienced, cancellation of planned "rites of passage," and visitor policy restrictions during and after the birth. Forty-five percent of participants reported being worried about getting COVID-19 and (61%) about their infant getting COVID-19. Many participants experienced a sense of loss that may permeate through other aspects of their lives. Providing extra support and points of contact can help lessen feelings of isolation during the pandemic and can also offer more explanation for rapidly changing policies and procedures.

Views on Exercise Among Black Women During Pregnancy

OBJECTIVE

To describe and understand exercise practices, beliefs about exercise, support for exercise, barriers to exercise, and preferences for a group exercise program in the context of individual and environmental factors among Black women during pregnancy.

DESIGN

Mixed-methods design.

SETTING

Large university-affiliated urban midwifery practice.

PARTICIPANTS

Fourteen Black women who were pregnant.

METHODS

We conducted semistructured interviews to determine participants' exercise practices, beliefs about exercise while pregnant, exercise support and barriers, and preferences for a group pregnancy exercise program. Participants also completed self-report measures for exercise, neighborhood environment, symptoms of depression, and sociodemographic characteristics. We used matrices to facilitate integrated analysis of the interview and self-report data to determine areas of concordance and discordance among the data sources and to note patterns in the data.

RESULTS

We identified and described themes that represented concepts in our data: Exercise Misinformation and Folklore, Supportfor Exercise While Pregnant, Barriers to Exercise While Pregnant, Perceived Health Benefits, and Exercise Program Preferences. Data diverged for some participants on neighborhood as a barrier to exercise. Except for the two participants with high levels of symptoms of depression, data converged regarding symptoms of depression as a barrier to exercise.

CONCLUSION

Health care providers can successfully promote exercise if they provide education about exercise during pregnancy, help pregnant women overcome barriers to exercise, prompt women to exercise with partners for tangible and social support while pregnant, and refer women to exercise programs for pregnant women if available.

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.

Racial and Ethnic Disparities in Birth Outcomes and Labor and Delivery Charges Among Massachusetts Women With Intellectual and Developmental Disabilities

Understanding the pregnancy experiences of racial and ethnic minority women with intellectual and developmental disabilities (IDD) is critical to ensuring that policies can effectively support these women. This research analyzed data from the 1998-2013 Massachusetts Pregnancy to Early Life Longitudinal (PELL) data system to examine the racial and ethnic disparities in birth outcomes and labor and delivery charges of U.S. women with IDD. There was significant preterm birth disparity among non-Hispanic Black women with IDD compared to their non-Hispanic White peers. There were also significant racial and ethnic differences in associated labor and delivery-related charges. Further research, examining potential mechanisms behind the observed racial and ethnic differences in labor and delivery-related charges in Massachusetts' women with IDD is needed.

Social Determinants of Pregnancy-Related Mortality and Morbidity in the United States: A Systematic Review

OBJECTIVE

To synthesize the literature on associations between social determinants of health and pregnancy-related mortality and morbidity in the United States and to highlight opportunities for intervention and future research.

DATA SOURCES

We performed a systematic search using Ovid MEDLINE, CINAHL, Popline, Scopus, and ClinicalTrials.gov (1990-2018) using MeSH terms related to maternal mortality, morbidity, and social determinants of health, and limited to the United States.

METHODS OF STUDY SELECTION

Selection criteria included studies examining associations between social determinants and adverse maternal outcomes including pregnancy-related death, severe maternal morbidity, and emergency hospitalizations or readmissions. Using Covidence, three authors screened abstracts and two screened full articles for inclusion.

TABULATION, INTEGRATION, AND RESULTS

Two authors extracted data from each article and the data were analyzed using a descriptive approach. A total of 83 studies met inclusion criteria and were analyzed. Seventy-eight of 83 studies examined socioeconomic position or individual factors as predictors, demonstrating evidence of associations between minority race and ethnicity (58/67 studies with positive findings), public or no insurance coverage (21/30), and lower education levels (8/12), and increased incidence of maternal death and severe maternal morbidity. Only 2 of 83 studies investigated associations between these outcomes and socioeconomic, political, and cultural context (eg, public policy), and 20 of 83 studies investigated material and physical circumstances (eg, neighborhood environment, segregation), limiting the diversity of social determinants of health studied as well as evaluation of such evidence.

CONCLUSION

Empirical studies provide evidence for the role of race and ethnicity, insurance, and education in pregnancy-related mortality and severe maternal morbidity risk, although many other important social determinants, including mechanisms of effect, remain to be studied in greater depth.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42018102415.

Personal Versus Group Experiences of Racism and Risk of Delivering a Small-for-Gestational Age Infant in African American Women: a Life Course Perspective

The majority of studies investigating the relationship between racism/racial discrimination and birth outcomes have focused on perceived experiences of racism/racial discrimination directed at oneself (personal racism). However, evidence suggests individuals report with greater frequency racism/racial discrimination directed at friends, family members, or other members of their racial/ethnic group (group racism). We examined how much African American (AA) women report lifetime experiences of perceived racism or racial discrimination, both personal and group, varied by maternal age. We also investigated whether reports of personal and group racism/racial discrimination were associated with the risk of delivering a small-for-gestational age (SGA) infant and how much maternal age in relation to developmental life stages (adolescence [≤ 18 years], emerging adulthood [19-24 years], and adulthood [≥ 25 years]) moderated the relationship. Data stem from the Baltimore Preterm Birth Study, a hybrid prospective/retrospective cohort study that enrolled 872 women between March 2000 and July 2004 (analyzed in 2016-2017). Spline regression analyses demonstrated a statistically significant (p value for overall association < 0.001) and non-linear (p value = 0.044) relationship between maternal age and the overall racism index. Stratified analysis showed experiences of racism overall was associated with a higher odds ratio of delivering an SGA infant among AA women aged ≥ 25 years (OR = 1.45, 95% CI 1.02-2.08). The overall racism index was not associated with the SGA infant odds ratio for emerging adults (OR = 0.86, 95% CI 0.69-1.06) or adolescents (OR = 0.92, 95% CI 0.66-1.28). Multiple aspects of racism and the intersection between racism and other contextual factors need to be considered.

Early-life neighborhood context, perceived stress, and preterm birth in African American Women

Stressors from multiple sources, across the life-course, may have independent and joint associations with preterm birth (PTB) risk in African American women. Using data from the Life-course Influences on Fetal Environments Study (LIFE; 2009-2011) of post-partum African American women from Metropolitan Detroit, Michigan (n=1365), we examined the association between perceived stress and PTB, and effect modification by perceptions of early-life neighborhood social control and disorder. We defined PTB as birth before 37 completed weeks of gestation. We used Cohen's Perceived Stress scale, and valid and reliable scales of early-life (age 10) neighborhood social control and social disorder to quantify exposures. We estimated prevalence ratios (PR) and 95% confidence intervals (CI) with log binomial regression models- with separate interaction terms for perceived stress and each early-life neighborhood scale. We considered p < 0.10 significant for interaction terms. PTB occurred in 16.4% (n=224) of the study participants. In the total sample, perceived stress was not associated with PTB rates. However, there was suggestive evidence of a joint association between perceived stress and early-life neighborhood social disorder (p for interaction = 0.06), such that among women who reported high early-life neighborhood social disorder (n=660), perceived stress was positively associated with PTB (adjusted PR: 1.31; 95% CI: 1.05, 1.63). There was no association between perceived stress and PTB for women in the low early-life neighborhood social disorder strata (n=651) (adjusted PR: 0.95, 95% CI: 0.75, 1.21). There was no evidence that early-life neighborhood social control modified the association between perceived stress and PTB. Our results suggest that early-life neighborhood stressors may magnify the association between current perceived stress and PTB rates, in African American women. More research to confirm and explicate the biologic and/or psychosocial mechanisms of the reported association is warranted.

Psychosocial Factors and Preterm Birth Among Black Mothers and Fathers

OBJECTIVE

Black women are more likely to live in disadvantaged neighborhoods and experience racial discrimination and psychological stress compared with White women. These factors have been related to preterm birth (PTB). However, research is limited on the associations of disadvantaged neighborhoods, racial discrimination, and psychological stress among expectant Black fathers and PTB. This review focuses on what is known about psychosocial factors in relation to PTB among Black parents.

METHODS

The Scopus database was used to search for studies using keywords of adverse childhood experiences, neighborhood environment, racial discrimination, psychological stress, depressive symptoms/depression, coping, locus of control, social support, and mother-father relationship. Each of these keywords was combined with the term preterm birth. This review focused on the associations of these psychosocial factors collected during the prenatal period and risk for PTB. However, due to lack of data for some of these factors during the prenatal period, studies conducted in the immediate period after birth were included. The focus of this review was on research conducted with Black expectant fathers given the limited data on the association between paternal psychosocial factors and PTB. This review only highlights studies that examined the associations of maternal psychosocial factors and PTB. It does not present a comprehensive review of studies on maternal factors given the extent of the studies that examined these associations.

RESULTS

Pregnant Black women are more likely to report living in disadvantaged neighborhoods; experiencing racial discrimination, psychological stress, and depressive symptoms; using avoidance coping; and reporting lower levels of social support compared with White women. Limited data suggest that Black expectant fathers experience higher rates of everyday unfair treatment because of race/ethnicity compared with White fathers. Research suggests that these psychosocial factors have been related to PTB among pregnant Black women; however, research is limited on examining these associations among expectant Black fathers.

CLINICAL IMPLICATIONS

Maternal-child nurses are in the position to assess these psychosocial factors among expectant parents. Nurses should also assess risk factors for PTB for both expectant parents and provide support to couples who are at risk for PTB.

Physical Activity and Risk of Preterm Birth in a Cohort of African American Women

BACKGROUND

Few studies have identified modifiable risk factors that are associated with the prevention of preterm delivery (PTD). This study examined the relationship between PTD and physical activity during pregnancy.

METHODS

Data were obtained by medical record review and postpartum questionnaires from a cohort of African American women (N = 1,410) delivering singleton infants. Physical activity was self-reported and analyses compared any and none. Additional analyses classified leisure time physical activity (LTPA) and walking for a purpose as 0, 1 to 19, 20 to 39, and 40 minutes per day or more and stair climbing as 0, 1 to 5, 6 to 9, and 10 or more times per day. Log-Poisson models adjusted for previous PTD, pregnancy complications, and income were used to examine the association between PTD and physical activity during pregnancy across body mass index categories.

RESULTS

Overall, 16.4% of deliveries were preterm. LTPA was associated with a decreased prevalence of PTD (prevalence ratio [PR], 0.73; 95% confidence interval [CI], 0.55-0.96), but stratification by maternal prepregnancy body mass index suggested that LTPA was only protective against PTD among women with normal weight (PR, 0.43; 95% CI, 0.23-0.79). Stair climbing 10 or more times per day was associated with a decreased prevalence of PTD among women with normal weight (PR, 0.32; 95% CI, 0.11-0.94) and women with overweight (PR, 0.24; 95% CI, 0.07-0.80) only. Walking for a purpose (e.g., to the store, the bus stop, or to work) was not associated with PTD.

CONCLUSIONS

African American women who participate in either LTPA or stair climbing during pregnancy have a decreased prevalence of PTD, but the protective effect varied by maternal body mass index.

Evaluation of a Multilevel Intervention to Reduce Preterm Birth Among Black Women in Newark, New Jersey: A Controlled Interrupted Time Series Analysis

Objective To evaluate the effectiveness of a multilevel intervention, Healthy Babies are Worth the Wait (HBWW), in reducing preterm birth (PTB) and very preterm birth (VPTB) among black women in Newark, NJ. Methods HBWW is a program linking the local March of Dimes office, providers, community-based organizations, and public health institutions to increase uptake of evidence based preterm birth interventions. We used birth certificate data before (2009-2011) and after (2012-2015) the introduction of HBWW in Newark. We estimated differences in PTB and VPTB between these periods among black women in Newark and compared them to rate differences among black women in the rest of NJ (difference-in-differences). We used interrupted time series analysis (ITSA) to examine declines in PTB and VPTB following the introduction of HBWW controlling for secular trends. All models adjusted for maternal age, education and parity. Results PTB declined in Newark 1.1 case per 100 (95% confidence interval (CI) - 2.3, 0) and in the rest of NJ 0.5 case per 100 (- 1.4, 0.4) (difference-in-differences = 0.6 fewer cases per 100 in Newark, 95% CI - 1.6, 0.3). VPTB declined in both Newark (- 0.6 cases per 100, 95% CI - 1.0, 0) and the rest of NJ (- 0.2 cases per 100, 95% CI - 0, 0.3) (difference-in-differences = 0.4 fewer cases per 100 in Newark, 95% CI - 0.9, 0). However, using ITSA the downward VPTB trend in Newark was not different from the rest of NJ or pre-intervention trends. Conclusions for Practice Our study supports the importance of critically evaluating and advancing complex interventions to reduce PTB among black women.