Structural Racism and Odds for Infant Mortality Among Infants Born in the United States 2010

Systemic racism and Non-Hispanic Black to Non-Hispanic White disparities in infant mortality at the county level

OBJECTIVE

To use a novel measure of systemic racism to examine its relationship with Non-Hispanic Black (NHB) to Non-Hispanic White (NHW) racial disparities in infant mortality across U.S. counties.

STUDY DESIGN

In this cross-sectional study, a composite, multi-dimensional measure of systemic racism at the county level was developed using confirmatory factor analysis based on indicators across five dimensions of systemic racism. Using linear regression analysis, we examined the relationship between the systemic racism factor scores and the NHB to NHW racial disparities in county-level infant mortality rates. Additionally, we performed a multi-level analysis of infant mortality, with births nested within counties by running a random intercept model that controlled for factors at both the individual and county levels to take into account the clustered nature of the data.

RESULTS

There were 325 counties that met inclusion criteria for the county level analysis and 1181 counties for the individual level analysis. Each one standard deviation increase in the Systemic Racism Index was associated with an increase of 10.4% in the Non-Hispanic Black to Non-Hispanic White infant mortality rate ratio at the county level (aOR 1.104, 95% CI [1.061-1.148]). After controlling for individual level clinical factors and county level factors, each one standard deviation increase in the systemic racism index score was associated with a decrease of 3.5% in the NHW infant mortality rate (aOR 0.965, 95% CI [0.943-0.988]).

CONCLUSION

Systemic racism is significantly associated with differences between counties in the magnitude of their Non-Hispanic Black to Non-Hispanic White racial disparities in infant mortality rates.

Suboptimal factors in maternal and newborn care for refugees: Lessons learned from perinatal audits in the Netherlands

INTRODUCTION

Refugees and their healthcare providers face numerous challenges in receiving and providing maternal and newborn care. Research exploring how these challenges are related to adverse perinatal and maternal outcomes is scarce. Therefore, this study aims to identify suboptimal factors in maternal and newborn care for asylum-seeking and refugee women and assess to what extent these factors may contribute to adverse pregnancy outcomes in the Netherlands.

METHODS

We conducted a retrospective analysis of national perinatal audit data from 2017 to 2019. Our analysis encompassed cases with adverse perinatal and maternal outcomes in women with a refugee background (n = 53). Suboptimal factors in care were identified and categorized according to Binder et al.'s Three Delays Model, and the extent to which they contributed to the adverse outcome was evaluated.

RESULTS

We identified 29 suboptimal factors, of which seven were related to care-seeking, six to the accessibility of services, and 16 to the quality of care. All 53 cases contained suboptimal factors, and in 67.9% of cases, at least one of these factors most likely or probably contributed to the adverse perinatal or maternal outcome.

CONCLUSION

The number of suboptimal factors identified in this study and the extent to which they contributed to adverse perinatal and maternal outcomes among refugee women is alarming. The wide range of suboptimal factors identified provides considerable scope for improvement of maternal and newborn care for refugee populations. These findings also highlight the importance of including refugee women in perinatal audits as it is essential for healthcare providers to better understand the factors associated with adverse outcomes to improve the quality of care. Adjustments to improve care for refugees could include culturally sensitive education for healthcare providers, increased workforce diversity, minimizing the relocation of asylum seekers, and permanent reimbursement of professional interpreter costs.

Structural gendered racism and preterm birth inequities in the United States

Structural gendered racism - the "totality of interconnectedness between structural racism and sexism" - is conceptualized as a fundamental cause of the persistent preterm birth inequities experienced by Black and Indigenous people in the United States. Our objective was to develop a state-level latent class measure of structural gendered racism and examine its association with preterm birth among all singleton live births in the US in 2019. Using previously-validated inequity indicators between White men and Black women across 9 domains (education, employment, poverty, homeownership, health insurance, segregation, voting, political representation, incarceration), we conducted a latent profile analysis to identify a latent categorical variable with k number of classes that have similar values on the observed continuous input variables. Racialized group-stratified multilevel modified Poisson regression models with robust variance and random effects for state assessed the association between state-level classes and preterm birth. We found four distinct latent classes that were all characterized by higher levels of disadvantage for Black women and advantages for White men, but the magnitude of that difference varied by latent class. We found preterm birth risk among Black birthing people was higher across all state-level latent classes compared to White birthing people, and there was some variation of preterm birth risk across classes among Black but not White birthing people. These findings further emphasize the importance of understanding and interrogating the whole system and the need for multifaceted policy solutions.

Structural Racism and Health Stratification: Connecting Theory to Measurement

Less than 1% of studies on racialized health inequities have empirically examined their root cause: structural racism. Moreover, there has been a disconnect between the conceptualization and measurement of structural racism. This study advances the field by (1) distilling central tenets of theories of structural racism to inform measurement approaches, (2) conceptualizing U.S. states as racializing institutional actors shaping health, (3) developing a novel latent measure of structural racism in states, (4) using multilevel models to quantify the association between structural racism and five individual-level health outcomes among respondents from the Health and Retirement Study (N = 9,020) and the Behavioral Risk Factor Surveillance System (N = 308,029), and (5) making our measure of structural racism publicly available to catalyze research. Results show that structural racism is consistently associated with worse health for Black people but not White people. We conclude by highlighting this study's contributions (theoretical, methodological, and substantive) and important avenues for future research on the topic.

Abortion Restrictiveness and Infant Mortality: An Ecologic Study, 2014-2018

INTRODUCTION

The U.S. has the highest infant mortality rate among peer countries. Restrictive abortion laws may contribute to poor infant health outcomes. This ecological study investigated the association between county-level infant mortality and state-level abortion access legislation in the U.S. from 2014 to 2018.

METHODS

A multivariable regression analysis with the outcome of county-level infant mortality rates, controlling for the primary exposure of state-level abortion laws, and county-level factors, county-level distance to an abortion facility, and state Medicaid expansion status was performed. Incidence rate ratios and 95% CIs were reported. Analyses were conducted in 2022-2023.

RESULTS

There were 113,397 infant deaths among 19,559,660 live births (infant mortality rate=5.79 deaths/1,000 live births; 95% CI=5.75, 5.82). Black infant mortality rate (10.69/1,000) was more than twice the White infant mortality rate (4.87/1,000). In the multivariable model, increased infant mortality rates were seen in states with ≥8 restrictive laws, with the most restrictive (11-12 laws) having a 16% increased infant mortality level (adjusted incidence rate ratios=1.162; 95% CI=1.103, 1.224). Increased infant mortality rates were associated with increased county-level Black race individuals (adjusted incidence rate ratios=1.031; 95% CI=1.026, 1.037), high school education (adjusted incidence rate ratios=1.018; 95% CI=1.008, 1.029), maternal smoking (adjusted incidence rate ratios=1.025; 95% CI=1.018, 1.033), and inadequate prenatal care (adjusted incidence rate ratios=1.045; 95% CI=1.036, 1.055).

CONCLUSIONS

State-level abortion law restrictiveness is associated with higher county-level infant mortality rates. The Supreme Court decision on Dobbs versus Jackson and changes in state laws limiting abortion may affect future infant mortality.

The Effects of Race, Ethnicity, and Maternal Education on Infant Mortality

BACKGROUND

The state of New Jersey has a large Black/African American (AA) versus White racial disparity in infant mortality and educational level at childbirth. This disparity, measured by rate ratio, increases with greater maternal education among varied racial-ethnic groups. The nature of this disparity measured by rate differences has not been explored.

OBJECTIVES

Infant birth and mortality data were used to examine whether racial or ethnic disparities in infant mortality increased with greater maternal education, comparing rate differences and rate ratios. Racial and ethnic variations in the association between maternal education and infant mortality were examined.

METHODS

Data were from the New Jersey State Health Assessment Data for all New Jersey births between 2014 and 2018 stratified by race and ethnicity, maternal education, and infant mortality ( n = 481,333). R software was used to create a data set and estimate additive and multiplicative interactions, rate differences, and rate ratios for infant mortality by maternal race/ethnicity and educational levels among four racial-ethnic groups.

RESULTS

Infant mortality was significantly greater for Black/AA and Hispanic mothers than for White mothers. At all educational levels, Black/AA mothers had the highest prevalence of infant mortality compared to other racial or ethnic groups. Rate differences in infant mortality showed a decrease in Black/AA-White differences for mothers with a high school education or less compared to mothers with a college degree. However, rate ratios showed an increase in Black/AA-White ratio with increasing education levels for mothers with high school education or less than mothers with a college degree. Risk ratios comparing infant mortality for Black/AA versus Hispanic or Asian mothers showed more than a twofold greater risk at all education levels for Black/AA infants. Finally, college-educated Black/AA mothers had significantly higher rates of infant mortality than White or Hispanic mothers with a high school education or less.

DISCUSSION/IMPLICATIONS

Black/AA mothers with a college degree had a higher infant mortality rate than White, Hispanic, or Asian mothers with a high school education or less. Future research should address contextual/systemic contributors to this disparity.

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.

Structural racism and racial health disparities at the state level: A latent variable approach

Introduction Structural racism is increasingly being recognized as a fundamental cause of racial health disparities. We used a novel measure of structural racism at the state level to examine the relationship between structural racism and disparities in death rates from firearm homicide, infant mortality, HIV, diabetes, stroke, hypertension, asthma, and kidney disease between non-Hispanic Black and non-Hispanic White people in the United States. Methods We used confirmatory factor analysis to measure the latent construct of structural racism for all 50 states. The model included seven indicators across the structural racism domains of residential segregation, economic status/employment, education, incarceration, political participation and representation, environmental racism, and racial equity inclusion. Weights for each of the indicators were determined by examining alternative models and selecting the model with the best fit statistics. The resulting factor scores, representing the level of structural racism in each state across the seven domains, were then used as predictor variables in a series of linear regressions with the ratio of Black to White death rates for each health outcome as the dependent variables. Results We found significant relationships between higher levels of the latent structural racism measure and greater disparities between non-Hispanic Black and non-Hispanic White people in age-adjusted death rates for firearm homicide, infant mortality, HIV, asthma, and obesity. The magnitude of this relationship was greatest for firearm homicide, with each one standard deviation increase in a state's structural racism factor score being associated with an increase of 4.54 (95% CI, 2.91-6.17) in that state's Black-White firearm homicide rate ratio. Conclusions This research provides further evidence that structural racism is a fundamental cause of racial health disparities and that to repair these inequities, macro-level changes in societal structures, institutions, resource allocation, representation, and power will be necessary.

Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis

Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

Developing a resiliency model for survival without major morbidity in preterm infants

OBJECTIVE

Develop and validate a resiliency score to predict survival and survival without neonatal morbidity in preterm neonates <32 weeks of gestation using machine learning.

STUDY DESIGN

Models using maternal, perinatal, and neonatal variables were developed using LASSO method in a population based Californian administrative dataset. Outcomes were survival and survival without severe neonatal morbidity. Discrimination was assessed in the derivation and an external dataset from a tertiary care center.

RESULTS

Discrimination in the internal validation dataset was excellent with a c-statistic of 0.895 (95% CI 0.882-0.908) for survival and 0.867 (95% CI 0.857-0.877) for survival without severe neonatal morbidity, respectively. Discrimination remained high in the external validation dataset (c-statistic 0.817, CI 0.741-0.893 and 0.804, CI 0.770-0.837, respectively).

CONCLUSION

Our successfully predicts survival and survival without major morbidity in preterm babies born at <32 weeks. This score can be used to adjust for multiple variables across administrative datasets.

County-level jail incarceration, community economic distress, rurality, and preterm birth among women in the US South

Introduction

The USA has higher rates of preterm birth and incarceration than any other developed nation, with rates of both being highest in Southern states and among Black Americans, potentially due to rurality and socioeconomic factors. To test our hypothesis that prior-year county-level rates of jail admission, economic distress, and rurality were positively associated with premature birth rates in the county of delivery in 2019 and that the strength of these associations is greater for Black women than for White or Hispanic women, we merged five datasets to perform multivariable analysis of data from 766 counties across 12 Southern/rural states.

Methods

We used multivariable linear regression to model the percentage of babies born premature, stratified by Black (Model 1), Hispanic (Model 2), and White (Model 3) mothers. Each model included all three independent variables of interest measured using data from the Vera Institute, Distressed Communities Index, and Index of Relative Rurality.

Results

In fully fitted stratified models, economic distress was positively associated with premature births among Black (F = 33.81, p < 0.0001) and White (F = 26.50, p < 0.0001) mothers. Rurality was associated with premature births among White mothers (F = 20.02, p < 0.0001). Jail admission rate was not associated with premature births among any racial group, and none of the study variables were associated with premature births among Hispanic mothers.

Conclusions

Understanding the connections between preterm birth and enduring structural inequities is a necessary scientific endeavor to advance to later translational stages in health-disparities research.

Study designs, measures and indexes used in studying the structural racism as a social determinant of health in high income countries from 2000-2022: evidence from a scoping review

BACKGROUND

Globally, structural racism has been well documented as an important social determinant of health (SODH) resulting in racial inequality related to health. Although studies on structural racism have increased over the years, the selection of appropriate designs, measures, and indexes of measurement that respond to SODH has not been comprehensively documented. Therefore, the lack of evidence seems to exist. This scoping review was conducted to map and summarize global evidence on the use of various designs, measures, and indexes of measurement when studying structural racism as a social determinant of health.

METHODS

We performed a scoping review of global evidence from 2000 to 2022 published in 5 databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, Web of Science, ProQuest, and relevant grey literature on structural racism. We conducted a systematic search using keywords and subject headings around 3 concepts. We included peer reviewed original research/review articles which conceived the framework of social determinants of health (SODH) and studied structural racism.

RESULTS

Our review identified 1793 bibliographic citations for screening and 54 articles for final review. Articles reported 19 types of study design, 87 measures of exposure and 58 measures of health outcomes related to structural racism. 73 indexes or scales of measurement were used to assess health impacts of structural racism. Majority of articles were primary research (n = 43/54 articles; 79.6%), used quantitative research method (n = 32/54 articles; 59.3%) and predominantly conducted in the United States (n = 46/54 articles; 85.2.6%). Cross-sectional study design was the most used design (n = 17/54 articles; 31.5%) followed by systematic review (n = 7/54 articles; 13.0%) and narrative review (n = 6/54 articles; 11.1%). Housing and residential segregation was the largest cluster of exposure with the highest impact in infant health outcome.

CONCLUSIONS

Our review found several key gaps and research priorities on structural racism such as lack of longitudinal studies and availability of structural or ecological data, lack of consensus on the use of consolidated appropriate measures, indexes of measurement and appropriate study designs that can capture complex interactions of exposure and outcomes related to structural racism holistically.

Racism measurement and influences, variations on scientific racism, and a vision

The knowledge base regarding the impact of racism and discrimination on African American health and well-being has grown significantly since the first models of racism and health, but many questions remain. In this commentary, I discuss three challenges requiring attention in future research. The first is measurement. The second is consideration of individual and contextual influences that shape vulnerability to racism. The third challenge is racism in science itself (e.g., racial disparities in funding, absence, and erasure of African American voices in scientific discourse on health disparities). I discuss the benefits of addressing these challenges and offer a vision of what research on racism and African American health and well-being might look like as we move toward the eradication of racism and promotion of health equity.

Racism, xenophobia, and discrimination: mapping pathways to health outcomes

Despite being globally pervasive, racism, xenophobia, and discrimination are not universally recognised determinants of health. We challenge widespread beliefs related to the inevitability of increased mortality and morbidity associated with particular ethnicities and minoritised groups. In refuting that racial categories have a genetic basis and acknowledging that socioeconomic factors offer incomplete explanations in understanding these health disparities, we examine the pathways by which discrimination based on caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour affect health. Discrimination based on these categories, although having many unique historical and cultural contexts, operates in the same way, with overlapping pathways and health effects. We synthesise how such discrimination affects health systems, spatial determination, and communities, and how these processes manifest at the individual level, across the life course, and intergenerationally. We explore how individuals respond to and internalise these complex mechanisms psychologically, behaviourally, and physiologically. The evidence shows that racism, xenophobia, and discrimination affect a range of health outcomes across all ages around the world, and remain embedded within the universal challenges we face, from COVID-19 to the climate emergency.

Measuring institutional and structural racism in research on adolescence and developmental science

Dismantling racism and oppression in adolescence requires sound measurement and rigorous methods. In this commentary, we discuss the measurement of institutional and structural racism and approaches to operationalizing structures and systems in adolescent research. Drawing on a recent framework for the conceptualization, measurement, and analysis of institutional racism and health (Needham et al., Journal of Racial and Ethnic Health Disparities, in press), we highlight several considerations for measuring institutional and structural racism. These include definitional issues, the tension between individual- and area-level measures, questions of timing, and matters of design and analysis. We conclude with suggestions to address gaps in existing literature and call for transdisciplinary training, collaboration, and partnership to promote the healthy development of Black and Indigenous People of Color (BIPOC) adolescents and young people.

State-Level Socioeconomic Racial Inequity and Food Insecurity in the U.S

INTRODUCTION

Racial inequities in food insecurity have been documented for the past 2 decades in the U.S., with the prevalence of food insecurity among Black households being 2-3 times higher than that among White households across time. The purpose of this study was to determine the association between socioeconomic indicators of structural racism at the state level and food insecurity among White and Black households in the U.S.

METHODS

This study is a secondary analysis of pooled, cross-sectional data from the Current Population Survey and the American Community Survey, 2015-2019 (N=158,551 Black and White households). Data analysis occurred in 2021-2022. The outcome was household food insecurity, and the exposure was structural racism indicators, operationalized as state-level racial inequities in income, earnings, education, unemployment, and home ownership. Individual-, household-, and state-level sociodemographic covariates were included.

RESULTS

Among Black households, state-level racial inequities in income, unemployment, and home ownership were associated with 34% (OR=1.34; 95% CI=1.05, 1.70), 14% (OR=1.14; 95% CI=1.02, 1.28), and 11% (OR=1.11; 95% CI=1.05, 1.16) higher odds of food insecurity, respectively. For White households, state-level racial inequities in income, education, unemployment, and home ownership were associated with 21% (OR=0.79; 95% CI=0.63, 0.98), 27% (OR=0.73; 95% CI=0.66, 0.85), 10% (OR=0.90; 95% CI=0.82, 0.98), and 8% (OR=0.92; 95% CI=0.89, 0.95) lower odds of food insecurity, respectively.

CONCLUSIONS

Structural racism may be a key driver of food insecurity among Black households and may be protective against food insecurity among White households. Implementing policies addressing state-level racial inequity in socioeconomic indicators could be effective at reducing racial inequities in food insecurity.

Racism and perinatal health inequities research: where we have been and where we should go

For more than a century, substantial racial and ethnic inequities in perinatal health outcomes have persisted despite technical clinical advances and changes in public health practice that lowered the overall incidence of morbidity. Race is a social construct and not an inherent biologic or genetic reality; therefore, racial differences in health outcomes represent the consequences of structural racism or the inequitable distribution of opportunities for health along racialized lines. Clinicians and scientists in obstetrics and gynecology have a responsibility to work to eliminate health inequities for Black, Brown, and Indigenous birthing people, and fulfilling this responsibility requires actionable evidence from high-quality research. To generate this actionable evidence, the research community must realign paradigms, praxis, and infrastructure with an eye directed toward reproductive justice and antiracism. This special report offers a set of key recommendations as a roadmap to transform perinatal health research to achieve health equity. The recommendations are based on expert opinion and evidence presented at the State of the Science Research Symposium at the 41st Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in 2021. Recommendations fall into 3 broad categories-changing research paradigms, reforming research praxis, and transforming research infrastructure-and are grounded in a historic foundation of the advances and shortcomings of clinical, public health, and sociologic scholarship in health equity. Changing the research paradigm requires leveraging a multidisciplinary perspective on structural racism; promoting mechanistic research that identifies the biologic pathways perturbed by structural racism; and utilizing conceptual models that account for racism as a factor in adverse perinatal outcomes. Changing praxis approaches to promote and engage multidisciplinary teams and to develop standardized guidelines for data collection will ensure that paradigm shifts center the historically marginalized voices of Black, Brown, and Indigenous birthing people. Finally, infrastructure changes that embed community-centered approaches are required to make shifts in paradigm and praxis possible. Institutional policies that break down silos and support true community partnership, and also the alignment of institutional, funding, and academic publishing objectives with strategic priorities for perinatal health equity, are paramount. Achieving health equity requires shifting the structures that support the ecosystem of racism that Black, Brown, and Indigenous birthing people must navigate before, during, and after childbearing. These structures extend beyond the healthcare system in which clinicians operate day-to-day, but they cannot be excluded from research endeavors to create the actionable evidence needed to achieve perinatal health equity.

Infant Outcomes among Teenage and Young Mothers: Racial Inequities and the Role of Educational Attainment

OBJECTIVE

To examine the association of age-appropriate maternal educational attainment in teenage and young mothers on infant health outcomes across racial/ethnic groups.

STUDY DESIGN

In this retrospective, cross-sectional study using Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research Natality data (2016-2017), we included live births comparing 14- to 19- year-old mothers with 20- to 24-year-old mothers. To analyze the association of maternal age-appropriate education (≥8th grade for 15-18 years of age, 9th-12th grade/completed high school for 19-24 years of age), we conducted multivariable regression adjusting for mothers' demographics, reporting adjusted incidence rate ratios with 95% CI for infant mortality rate, and logistic regression for extreme prematurity and low birth weight, reporting aORs with 95% CI.

RESULTS

From 2016 to 2017, there were 1 976 334 live births among women 14-24 years of age; 407 576 (20.6%) were in 14- to 19-year-olds. In the multivariable model, increased term infant mortality rate was associated with age 14-19 years (adjusted incidence rate ratio 1.18, 95% 1.10, 1.27), age-inappropriate education (adjusted incidence rate ratio 1.38, 95% CI 1.28, 1.48), and non-Hispanic Black mothers (adjusted incidence rate ratio 1.21, 95% CI 1.12, 1.30). Extreme prematurity was associated with women age 14-19 years (aOR 1.35, 95% CI 1.30, 1.40), non-Hispanic Black (aOR 2.50, 95% CI 2.39, 2.61), and Hispanic mothers (aOR 1.09, 95% CI 1.04, 1.15). Term infant low birth weight was associated with age 14-19 years (aOR 1.14, 95% CI 1.12, 1.16), age-inappropriate education for non-Hispanic White (aOR 1.16, 95% CI 1.11, 1.21), and non-Hispanic Black (aOR 1.08, 1.04, 1.12) mothers.

CONCLUSIONS

Inadequate maternal educational attainment, which is influenced by modifiable social policies, is associated with increased adverse infant outcomes in mothers 14-24 years of age.

Inequities in Availability of Evidence-Based Birth Supports to Improve Perinatal Health for Socially Vulnerable Rural Residents

Rural residents in the United States (US) have disproportionately high rates of maternal and infant mortality. Rural residents who are Black, Indigenous, and People of Color (BIPOC) face multiple social risk factors and have some of the worst maternal and infant health outcomes in the U.S. The purpose of this study was to determine the rural availability of evidence-based supports and services that promote maternal and infant health. We developed and conducted a national survey of a sample of rural hospitals. We determined for each responding hospital the county-level scores on the 2018 CDC Social Vulnerability Index (SVI). The sample's (n = 93) median SVI score [IQR] was 0.55 [0.25-0.88]; for majority-BIPOC counties (n = 29) the median SVI score was 0.93 [0.88-0.98] compared with 0.38 [0.19-0.64] for majority-White counties (n = 64). Among counties where responding hospitals were located, 86.2% located in majority-BIPOC counties ranked in the most socially vulnerable quartile of counties nationally (SVI ≥ 0.75), compared with 14.1% of majority-White counties. In analyses adjusted for geography and hospital size, certified lactation support (aOR 0.36, 95% CI 0.13-0.97), midwifery care (aOR 0.35, 95% CI 0.12-0.99), doula support (aOR 0.30, 95% CI 0.11-0.84), postpartum support groups (aOR 0.25, 95% CI 0.09-0.68), and childbirth education classes (aOR 0.08, 95% CI 0.01-0.69) were significantly less available in the most vulnerable counties compared with less vulnerable counties. Residents in the most socially vulnerable rural counties, many of whom are BIPOC and thus at higher risk for poor birth outcomes, are significantly less likely to have access to evidence-based supports for maternal and infant health.

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.

Antiracism in the Field of Neonatology: A Foundation and Concrete Approaches

Neonatal patients and families from historically marginalized and discriminated communities have long been documented to have differential access to health care, disparate health care, and as a result, inequitable health outcomes. Fundamental to these processes is an understanding of what race and ethnicity represent for patients and how different levels of racism act as social determinants of health. The NICU presents a unique opportunity to intervene with regard to the detrimental ways in which structural, institutional, interpersonal, and internalized racism affect the health of newborn infants. The aim of this article is to provide neonatal clinicians with a foundational understanding of race, racism, and antiracism within medicine, as well as concrete ways in which health care professionals in the field of neonatology can contribute to antiracism and health equity in their professional careers.

Racism and pediatric health outcomes

Racism- a system operating at the intrapersonal, interpersonal, institutional, and structural levels- is a serious threat to the health and wellbeing of children and adolescents. This narrative review highlights racism as a social determinant of health, and describes how racism breeds disparate pediatric health outcomes in infant health, asthma, Type 1 diabetes, mental health, and pediatric surgical conditions. Key examples include the association of residential racial segregation and the alarming infant mortality rate among Black infants as well as the role of redlining and discriminatory housing practices on asthma morbidity among Black children and adolescents. Furthermore, inequitable care practices such as (1) racial and ethnic disparities in insulin pump usage in patients with Type 1 diabetes, (2) lower rates pharmacotherapy initiation in racialized children with mental health disorders, and (3) decreased pain medication management and confirmatory imaging in Black children with acute appendicitis, highlight the role of interpersonal racism in propagating poor health outcomes. An urgent call to action is needed to address pediatric health inequities and ensure all children can live healthy lives. Key strategies must tackle racism at the individual, institutional, and structural levels and include building a diverse workforce, prioritizing research to describe the impact of racism on pediatric health outcomes, initiating improvement efforts to close equity gaps, building community partnerships, co-designing solutions alongside patients and families, and advocating for policy change to address the social conditions that impact children and adolescents of color.

The legacy of structural racism: Associations between historic redlining, current mortgage lending, and health

Structural racism, which is embedded in past and present operations of the U.S. housing market, is a fundamental cause of racial health inequities. We conducted an ecologic study to 1) examine historic redlining in relation to current neighborhood lending discrimination and three key indicators of societal health (mental health, physical health, and infant mortality rate (IMR)) and 2) investigate sustained lending disinvestment as a determinant of current neighborhood health in one of the most hypersegregated metropolitan areas in the United States, Milwaukee, Wisconsin. We calculated weighted historic redlining scores from the proportion of 1930s Home Owners' Loan Corporation residential security grades contained within 2010 census tract boundaries. We combined two lending indicators from 2018 Home Mortgage Disclosure Act data to capture current neighborhood lending discrimination: low lending occurrence and high cost loans (measured via loan rate spread). Using historic redlining score and current lending discrimination, we created a 4-level hierarchical measure of lending trajectory. In Milwaukee neighborhoods, greater historic redlining was associated with current lending discrimination (OR = 1.73, 95%CI: 1.16, 2.58) and increased prevalence of poor physical health (β = 1.34, 95%CI: 0.40, 2.28) and poor mental health (β = 1.26, 95%CI: 0.51, 2.01). Historic redlining was not associated with neighborhood IMR (β = -0.48, 95%CI: -2.12, 1.15). A graded association was observed between lending trajectory and health: neighborhoods with high sustained disinvestment had worse physical and mental health than neighborhoods with high investment (poor physical health: β = 5.33, 95%CI: 3.05, 7.61; poor mental health: β = 4.32, 95%CI: 2.44, 6.20). IMR was highest in 'disinvested' neighborhoods (β = 5.87, 95%CI: 0.52, 11.22). Our findings illustrate ongoing legacies of government sponsored historic redlining. Structural racism, as manifested in historic and current forms of lending disinvestment, predicts poor health in Milwaukee's hypersegregated neighborhoods. We endorse equity focused policies that dismantle and repair the ways racism is entrenched in America's social fabric.

Structural racism, racial inequities and urban-rural differences in infant mortality in the US

Background

While evidence shows considerable geographic variations in county-level racial inequities in infant mortality, the role of structural racism across urban–rural lines remains unexplored. The objective of this study was to examine the associations between county-level structural racism (racial inequity in educational attainment, median household income and jail incarceration) and infant mortality and heterogeneity between urban and rural areas.

Methods

Using linked live birth/infant death data provided by the National Center for Health Statistics, we calculated overall and race-specific 2013–2017 5-year infant mortality rates (IMRs) per 1000 live births in every county. Racially stratified and area-stratified negative binomial regression models estimated IMR ratios and 95% CIs associated with structural racism indicators, adjusting for county-level confounders. Adjusted linear regression models estimated associations between structural racism indicators and the absolute and relative racial inequity in IMR.

Results

In urban counties, structural racism indicators were associated with 7%–8% higher black IMR, and an overall structural racism score was associated with 9% greater black IMR; however, these findings became insignificant when adjusting for the region. In white population, structural racism indicators and the overall structural racism score were associated with a 6% decrease in urban white IMR. Both absolute and relative racial inequity in IMR were exacerbated in urban counties with greater levels of structural racism.

Conclusions

Our findings highlight the complex relationship between structural racism and population health across urban–rural lines and suggest its contribution to the maintenance of health inequities in urban settings.

State and Local Government Expenditures and Infant Mortality in the United States

BACKGROUND AND OBJECTIVES

Evidence suggests that government expenditures on non-health care services can reduce infant mortality, but it is unclear what types of spending have the greatest impact among groups at highest risk. Thus, we sought to quantify how US state government spending on various services impacted infant mortality rates (IMRs) over time and whether spending differentially reduced mortality in some subpopulations.

METHODS

A longitudinal, repeated-measures study of US state-level infant mortality and state and local government spending for the years 2000-2016, the most recent data available. Expenditures included spending on education, social services, and environment and housing. Using generalized linear regression models, we assessed how changes in spending impacted infant mortality over time, overall and stratified by race and ethnicity and maternal age group.

RESULTS

State and local governments spend, on average, $9 per person. A $0.30 per-person increase in environmental spending was associated with a decrease of 0.03 deaths per 1000 live births, and a $0.73 per-person increase in social services spending was associated with a decrease of 0.02 deaths per 1000 live births. Infants born to mothers aged <20 years had the single greatest benefit from an increase in expenditures compared with all other groups. Increased expenditures in public health, housing, parks and recreation, and solid waste management were associated with the greatest reduction in overall IMR.

CONCLUSIONS

Investment in non-health care services was associated with lower IMRs among certain high-risk populations. Continued investments into improved social and environmental services hold promise for further reducing IMR disparities.