Differences in the self-reported racism experiences of US-born and foreign-born Black pregnant women

Associations between vicarious racism and psychoactive substance use depend on strength of ethnic identity

Racism is a pervasive threat to health with differential impact based on race and ethnicity. Considering the continued perpetration and visibility of racism online and in the news, vicarious racism, or "secondhand" racism when hearing about or witnessing racism being committed against members of one's ethnic or racial group, is a particularly urgent threat in the context of such disparities and their subsequent health consequences. The current study examines if frequency of exposure to vicarious racism and the emotional impact of those experiences are linked to psychoactive substance use, and explores the role of ethnic identity in moderating these relationships. In a cross-sectional survey, 504 adult participants aged 18-78 (M age = 30.15, SD = 11.52, 52.6% female) identifying as Black/African American or Latine reported on their experiences with vicarious racism and alcohol, marijuana, and tobacco use over the past 30 days. Logistic regression was utilized to test hypotheses. Primary findings indicate that greater emotional impact of vicarious racism was associated with a 50% increase in odds of alcohol consumption and that ethnic identity moderated the association between vicarious racism and marijuana use. Greater emotional impact of vicarious racism was related to more marijuana use for those lower on ethnic identity, whereas there was no association for those higher on ethnic identity. Vicarious racism was not related to tobacco use. Results suggest that ethnic identity might be protective in the association of vicarious racism on substance use. Further research on this topic is needed as vicarious racism becomes an increasingly common experience among marginalized populations.

Risk of Adverse Perinatal Outcomes Among African-born Black Women in California, 2011-2020

BACKGROUND

African-born women have a lower risk of preterm birth and small for gestational age (SGA) birth compared with United States-born Black women, however variation by country of origin is overlooked. Additionally, the extent that nativity disparities in adverse perinatal outcomes to Black women are explained by individual-level factors remains unclear.

METHODS

We conducted a population-based study of nonanomalous singleton live births to United States- and African-born Black women in California from 2011 to 2020 (n = 194,320). We used age-adjusted Poisson regression models to estimate the risk of preterm birth and SGA and reported risk ratios (RR) and 95% confidence intervals (CI). Decomposition using Monte Carlo integration of the g-formula computed the percentage of disparities in adverse outcomes between United States- and African-born women explained by individual-level factors.

RESULTS

Eritrean women (RR = 0.4; 95% CI = 0.3, 0.5) had the largest differences in risk of preterm birth and Cameroonian women (RR = 0.5; 95% CI = 0.3, 0.6) in SGA birth, compared with United States-born Black women. Ghanaian women had smaller differences in risk of preterm birth (RR = 0.8; 95% CI = 0.7, 1.0) and SGA (RR = 0.9; 95% CI = 0.8, 1.1) compared with United States-born women. Overall, we estimate that absolute differences in socio-demographic and clinical factors contributed to 32% of nativity-based disparities in the risk of preterm birth and 26% of disparities in SGA.

CONCLUSIONS

We observed heterogeneity in risk of adverse perinatal outcomes for African- compared with United States-born Black women, suggesting that nativity disparities in adverse perinatal outcomes were not fully explained by differences in individual-level factors.

Disparities in birth outcomes within the U.S. White population: Prevalence of low birth weight among immigrant mothers from the Middle East and North Africa

Immigration from the Middle East and North Africa (MENA) has diversified the U.S. non-Hispanic White population. Analyzing health disparities within this group is a complex task due to data limitations across most federal and state data collection systems. This study investigates disparities in the risk of giving birth to a low-birth-weight infant among foreign-born non-Hispanic White MENA and non-MENA mothers and by MENA mothers' nationality. This population-based study uses Restricted-Use Detail Natality Data from 2016 to 2019 accessed through the National Center for Health Statistics and provided by the Centers for Disease Control and Prevention. The study examines the risk of giving birth to a low-birth-weight infant (<2500g) among foreign-born non-Hispanic White mothers by MENA/non-MENA status as the primary independent variable of interest. Logistic regression models are used to control for social and demographic characteristics, medical risk factors, and measures of prenatal care adequacy. Results are presented as odds ratios. Among foreign-born non-Hispanic White mothers, 139,708 (32%) are classified as MENA and 296,093 (68%) as non-MENA. Results show that after controlling for social and demographic characteristics, medical factors, and measures of prenatal care adequacy, foreign-born non-Hispanic White MENA mothers have greater odds of giving birth to a low-birth-weight infant than their non-MENA counterparts (OR: 1.443, p-value <0.001). Increased immigration from the MENA region has contributed to changes in health profiles among foreign-born non-Hispanic White mothers. As this group grows, understanding the impact of immigration on the composition of the non-Hispanic White population, and consequently, racial disparities in the U.S., is crucial for researchers and policymakers.

Racial and ethnic inequities in stillbirth in the US: Looking upstream to close the gap: Seminars in Perinatology

Though stillbirth rates in the United States improved over the previous decades, inequities in stillbirth by race and ethnicity have persisted nearly unchanged since data collection began. Black and Indigenous pregnant people face a two-fold greater risk of experiencing the devastating consequences of stillbirth compared to their White counterparts. Because race is a social rather than biological construct, inequities in stillbirth rates are a downstream consequence of structural, institutional, and interpersonal racism which shape a landscape of differential access to opportunities for health. These downstream consequences can include differences in the prevalence of chronic health conditions as well as structural differences in the quality of health care or healthy neighborhood conditions, each of which likely plays a role in racial and ethnic inequities in stillbirth. Research and intervention approaches that utilize an equity lens may identify ways to close gaps in stillbirth incidence or in responding to the health and socioemotional consequences of stillbirth. A community-engaged approach that incorporates experiential wisdom will be necessary to create a full picture of the causes and consequences of inequity in stillbirth outcomes. Investigators working in tandem with community partners, utilizing a combination of qualitative, quantitative, and implementation science approaches, may more fully elucidate the underpinnings of racial and ethnic inequities in stillbirth outcomes.

African immigrants' favorable preterm birth rates challenge genetic etiology of the Black-White disparity in preterm birth

Background

We examined over a million California birth records for 2010 through 2021 to investigate whether disparities in preterm birth (PTB) by nativity and race support the widely held but hitherto unsubstantiated belief that genetic differences explain the persistent Black-White disparity in PTB.

Methods

We examined PTB rates and risk ratios among African-, Caribbean-, and U.S.-born Black women compared to U.S.-born White women. Multivariate analyses adjusted for maternal age, education, number of live births, delivery payer, trimester of prenatal care initiation, pre-pregnancy BMI, smoking, and prevalence of poverty in a woman's residence census tract; and for paternal education.

Results

In adjusted analyses, African-born Black women's PTB rates were no different from those of U.S.-born White women.

Discussion

The results add to prior evidence making a genetic etiology for the racial disparity in PTB unlikely. If genetic differences tied to "race" explained the Black-White disparity in PTB among U.S.-born women, the African immigrants in this study would have had higher rates of PTB, not the lower rates observed. Multiple explanations for the observed patterns and their implications are discussed. Failure to distinguish causes of PTB from causes of the racial disparity in PTB have likely contributed to erroneous attribution of the racial disparity to genetic differences. Based on the literature, unmeasured experiences of racism, including racism-related stress and adverse environmental exposures, are plausible explanations for the PTB disparity between Black and White U.S.-born women. The favorable birth outcomes of African-born Black immigrants may reflect less exposure to racism during sensitive life periods, e.g., childhood, when they were in African countries, where Black people are in the racial majority.

Structural racism, nativity and risk of adverse perinatal outcomes among Black women

BACKGROUND

Black women in the United States (US) have the highest risk of preterm birth (PTB) and small for gestational age (SGA) births, compared to women of other racial groups. Among Black women, there are disparities by nativity whereby foreign-born women have a lower risk of PTB and SGA compared to US-born women. Differential exposure to racism may confer nativity-based differences in adverse perinatal outcomes between US- and foreign-born Black women. This remains unexplored among US- and African-born women in California.

OBJECTIVES

Evaluate the relationship between structural racism, nativity, PTB and SGA among US- and African-born Black women in California.

METHODS

We conducted a population-based study of singleton births to US- and African-born Black women in California from 2011 to 2017 (n = 131,424). We examined the risk of PTB and SGA by nativity and neighbourhoods with differing levels of structural racism, as measured by the Index of Concentration at the Extremes. We fit crude and age-adjusted Poisson regression models, estimated using generalized estimating equations, with risk ratios (RR) and 95% confidence intervals (CI) as the effect measure.

RESULTS

The proportions of PTB and SGA were 9.7% and 14.5%, respectively, for US-born women, while 5.6% and 8.3% for African-born women. US-born women (n = 24,782; 20.8%) were more likely to live in neighbourhoods with high structural racism compared to African-born women (n = 1474; 11.6%). Structural racism was associated with an elevated risk of PTB (RR 1.19, 95% CI 1.12, 1.26) and SGA (RR 1.19, 95% CI 1.13, 1.25) for all Black women, however, there was heterogeneity by nativity, with US-born women experiencing a higher magnitude of effect than African-born women.

CONCLUSIONS

Among Black women in California, exposure to structural racism and the impacts of structural racism on the risk of PTB and SGA varied by nativity.

The Impact of Language on the Mental Health of Black Quebecers

Quebec's English-speaking Black community finds itself at the intersection of racial and linguistic discrimination, which presents challenges to mental wellness. The present study aims to add necessary detail to the conversations surrounding racism and mental health in Canada while including language as a determinant of health and intersecting element affecting the wellbeing of English-speaking Black Quebecers. We recruited 531 Black adults who are currently living in Quebec to complete a survey on various community-relevant items, including their mental and physical health, their experiences of discrimination, and barriers to accessing mental healthcare. Our analyses revealed that English-speaking participants experience more discrimination across all types and report more barriers to mental healthcare and lower mental health than their French-speaking counterparts. Furthermore, we found that language also had a mediated effect on mental health through discrimination and barriers to mental healthcare. Our study adds to the sparse race-based and intersectional literature about Black people in Canada and substantiates a mechanism by which language affects mental health by exposing Black Quebecers to more discrimination and thus higher barriers to care.

Association Between Perinatal Mental Health and Pregnancy and Neonatal Complications: A Retrospective Birth Cohort Study

BACKGROUND

Maternal mental health as an important precursor to reproductive and neonatal complications remains understudied in the United States, particularly in the Southeastern region, despite high medical costs, maternal morbidity, and infant burden. This study sought to estimate the incidence of perinatal mental health disorders and the associated increased risk of leading pregnancy and infant complications.

METHODS

A population-based retrospective birth cohort of childbirth hospitalizations and readmissions was constructed for women in South Carolina, 1999 to 2017. Prevalence rates were calculated for perinatal mood and anxiety disorders (PMAD), severe mental illness, and mental disorders of pregnancy (MDP). Poisson regression models using generalized estimating equations were used to estimate adjusted relative risks for the association between mental health conditions and severe maternal morbidity, hypertensive disorders of pregnancy, gestational diabetes, cesarean section, preterm birth, and low birthweight.

RESULTS

The most prevalent maternal mental condition was MDP (3.9%), followed by PMAD (2.7%) and severe mental illness (0.13%). PMAD was associated with a higher risk of severe maternal morbidity, hypertensive disorders of pregnancy, and cesarean section, as well as a higher risk of preterm birth and low birthweight infants. Severe mental illness was associated with low birthweight, hypertensive disorders of pregnancy, and cesarean section. Pregnant populations with MDP were more at risk for severe maternal morbidity, preterm birth, hypertensive disorders of pregnancy, low birthweight, and cesarean section. Each maternal mental health outcome was associated with an increased risk for hospital readmissions up to 45 days after childbirth.

CONCLUSIONS

Results demonstrate the escalating burden of PMAD and MDP for pregnant populations over time, with important consequences related to maternal and infant morbidity.

Ethnic, Nativity and Country of Origin Inequities in Preterm Birth Among Hispanic and Non-Hispanic Whites in New York City: What's Stress Got to Do With It?

Hispanic populations experience good birth outcomes despite their socioeconomic disadvantage, a phenomenon referred to as the Hispanic paradox. This health advantage, however, deteriorates over time and understanding of this pattern is limited. Using data from the 2009-2013 New York City (NYC) PRAMS survey linked with birth certificate data, we tested whether stressful life events (SLEs) partially accounted for differences in preterm birth (PTB) between birthing parents across ethnicity, nativity and country of foreign birth (CFB). Experiencing 3+ SLEs in the prenatal period was associated with increased odds of PTB (OR = 1.49, 95% CI 1.13, 1.97). However, stressors were not associated with greater risk of PTB among US-born Hispanic participants, or differences across CFB. SLEs are associated with increased odds of PTB after a threshold of 3+, but do not explain greater PTB among US-born, or some Hispanic subgroups, despite differences in SLEs across ethnicity and CFB among Hispanic birthing parents.

The impact of county-level fees & fines as exploitative revenue generation on US birth outcomes 2011-2015

Fees and fines collected through courts and law enforcement can comprise a considerable proportion of revenue for local governments. Law enforcement, as agents of revenue generation, change policing behavior to increase revenue, at times targeting Black and brown neighborhoods to bolster municipal budgets. This structural racism in revenue generation has not yet been assessed as an exposure for adverse health. Using the 2012 Census of Governments, and 2011-2015 vital statistics from the National Center of Health Statistics, we examine the relationship between countyaverage fees and fines as a percent of total own-source revenue and county-level characteristics, and risk of preterm birth and low birthweight across the United States. Mothers residing in counties with the greatest reliance on fees and fines had 1.08 (95% CI: 1.03-1.12) times the odds of preterm birth and 1.07 (95% CI: 1.02-1.11) times the odds of low birthweight than mothers residing in counties with the least reliance on fees and fines, controlling for individual- and county-level covariates. The addition of countylevel racial composition, and the Index of Concentration at the Extremes (ICE), reduced these associations yet remained statistically significant. Future studies should continue to examine how racist, exploitative revenue generation through police and court activities influences the health of residents.

Pregnancy-Specific Stress and Racial Discrimination Among U.S. Women

OBJECTIVES

Adverse birth outcomes among children born to women of color (WOC) have been associated with discrimination during pregnancy; however, little research has explored stressed caused by discrimination as well as pregnancy-specific stress. The purpose of this study was to examine differences in stress and racial discrimination (lifetime and during pregnancy) between U.S. women of different racial/ethnic groups.

METHODS

Women between 18 and 45 years (n = 198; 101 non-Hispanic White, 58 Black, and 39 other WOC [i.e., Hispanic, Asian/Pacific Islander, American Indian, Mixed Race]) completed an online, cross-sectional survey between December 2019 and March 2020. Participants reported pregnancy-specific stress using the pregnancy distress questionnaire (PDQ) and pregnancy life events scale (PLE) and discrimination via the general ethnic discrimination scale (GED). ANOVAs explored differences between racial/ethnic groups' stress and discrimination.

RESULTS

We found non-Hispanic White (p < 0.05) and other WOC (p < 0.01) reported higher distress during pregnancy than Black women, and other WOC (p < 0.05) reported more stressful prenatal life events (p < 0.05) than non-Hispanic Whites. However, Black (p < 0.001) and other WOC (p < 0.001) both experienced more ethnic discrimination throughout their lifetime and during their pregnancy than non-Hispanic Whites. Also, Black women experienced five times the stress from these encounters than White women (p < 0.001).

CONCLUSIONS FOR PRACTICE

Previously developed pregnancy distress questionnaires may be better suited for non-Hispanic White populations and may miss important experiences unique to marginalized populations such as racial/ethnic discrimination. Adaptations to pregnancy-related stress scales are warranted given the toxicity of discrimination during pregnancy.

Differences in Cervical Cancer Outcomes by Caribbean Nativity in Black and White Women in Florida

OBJECTIVE

Racial disparities among women with cervical cancer have been reported but are understudied in Caribbean immigrants. The objective of this study is to describe the disparities in clinical presentation and outcomes between Caribbean-born (CB) and US-born (USB) women with cervical cancer by race and nativity.

METHODS

An analysis of the Florida Cancer Data Service (FCDS), the statewide cancer registry, was performed to identify women diagnosed with invasive cervical cancer between 1981 and 2016. Women were classified as USB White or Black and CB White or Black. Clinical data were abstracted. Analyses were done using chi square, ANOVA, Kaplan-Meier and Cox proportional hazards models, with significance set at P < .05.

RESULTS

14 932 women were included in the analysis. USB Black women had the lowest mean age at diagnosis, while CB Black women were diagnosed at later stages of disease. USB White women and CB White women had better OS (median OS 70.4 and 71.5 months, respectively) than USB Black and CB Black women (median OS 42.4 and 63.8 months, respectively) (P < .0001). In multivariable analysis, relative to USB Black women, CB Blacks (HR .67, CI .54-.83), and CB White (HR .66, CI .55-.79) had better odds of OS. White race among USB women was not significantly associated with improved survival (P = .087).

CONCLUSION

Race alone is not a determinant of cancer mortality in women with cervical cancer. Understanding the impact of nativity on cancer outcomes is crucial to improve health outcomes.

Black Nativity and Health Disparities: A Research Paradigm for Understanding the Social Determinants of Health

After more than a century of research and debate, the scientific community has yet to reach agreement on the principal causes of racialized disparities in population health. This debate currently centers on the degree to which "race residuals" are a result of unobserved differences in the social context or unobserved differences in population characteristics. The comparative study of native and foreign-born Black populations represents a quasi-experimental design where race is "held constant". Such studies present a unique opportunity to improve our understanding of the social determinants of population health disparities. Since native and foreign-born Black populations occupy different sociocultural locations, and since populations with greater African ancestry have greater genetic diversity, comparative studies of these populations will advance our understanding of the complex relationship between sociocultural context, population characteristics and health outcomes. Therefore, we offer a conceptual framing for the comparative study of native and foreign-born Blacks along with a review of 208 studies that compare the mental and physical health of these populations. Although there is some complexity, especially with respect to mental health, the overall pattern is that foreign-born Blacks have better health outcomes than native-born Blacks. After reviewing these studies, we conclude with suggestions for future studies in this promising area of social and medical research.

Racism and the Reproductive Health Experiences of U.S.-Born Black Women

OBJECTIVE

To explore Black women's lived experiences of racism and the associated effects on reproductive health decisions and the reproductive health care experience.

METHODS

We recruited participants through social media and community outreach. We conducted semi-structured individual interviews focusing on Black women's lived experiences of racism and their effects on reproductive health. We coded and analyzed interview transcripts using process coding methodology.

RESULTS

Participants (N=21) were 21-45 years old and from Boston, Chicago, and Atlanta. Our primary themes were: 1) reproductive health racism across the life course, 2) anti-Black racism in the reproductive health care system, and 3) self-protective actions when interacting with the reproductive health care system. Reproductive racism across the life course included subthemes of early sexualization of Black women, heightened awareness of reproductive health inequities, and knowledge of reproductive oppression. Anti-Black racism in the reproductive health care system included subthemes of absence of shared decision making; vicarious reproductive health experiences; stereotyping, invalidation, and dismissal by reproductive health professionals; and medical mistrust. Participants guarded themselves against racism within reproductive health care by engaging in a variety of self-protective actions including seeking a health care professional of color, overpreparing for their appointments, enlisting advocates, seeking care only when desperate, and heightening symptoms to be heard.

CONCLUSION

Personal, vicarious, and historical experiences of racism within reproductive health care triggered participants to perform self-protective actions when interacting with the reproductive health care system. These actions served to promote safety, autonomy and rehumanization within a system that has historically and contemporarily devalued Black reproductive health.

Preterm Birth Among US and Foreign-Born Non-Hispanic Black Birthing Parents in Massachusetts: Variation by Nativity, Region, and Country of Origin

INTRODUCTION

Foreign-born non-Hispanic Black (NHB) birthing parents are less likely to have a preterm birth (PTB) than US-born NHBs. There is further variation by region and country of origin. We update previous studies by examining PTB rates by nativity, region and country of origin among NHBs in Massachusetts, a state with a heterogeneous population of foreign-born NHBs, including communities excluded from previous studies.

METHODS

Using 2011-2015 natality data from the three largest metropolitan areas in Massachusetts, we documented associations between nativity, region, and 18 individual countries of origin and PTB, using multivariable logistic regression to adjust for individual-level risk factors.

RESULTS

PTB was highest among US-born NHBs (9.4%) and lowest among those from Sub-Saharan Africa (SSA) (6.6%). Country-specific rates ranged from 4.0% among Angolans to 12.6% among those from Barbados and Trinidad and Tobago. While NHBs from SSA had significantly lower odds of PTB, risk among those from the Caribbean and Brazil was not different from US-born NHBs. The significantly lower risk among foreign-born NHBs and SSAs, in particular, remained robust in adjusted models.

DISCUSSION

Individual-level factors do not explain observed variation among NHB birthing parents. Future research should investigate explanations for lower PTB risk among SSAs, and congruent risk among foreign-born Caribbeans, Brazilians and US-born NHBs. Exposure to racism, a known risk factor for PTB, likely contributes to these inequities in PTB and merits further exploration. Prenatal care providers should assess place of birth among foreign-born NHBs, as well as exposure to racial discrimination among all NLB birthing parents.

Maternal nativity and risk of adverse perinatal outcomes among Black women residing in California, 2011-2017

OBJECTIVE

Examine the risk of adverse perinatal outcomes among the United States (US)-born and foreign-born Black women in California.

STUDY DESIGN

The study comprised all singleton live births to Black women in California between 2011 and 2017. We defined maternal nativity as US-born or foreign-born. Using Poisson regression, we computed risk ratios (RR) and 95% confidence intervals (CI) for three adverse perinatal outcomes: preterm birth, small for gestational age deliveries, and infant mortality.

RESULTS

Rates of adverse perinatal outcomes were significantly higher among US-born Black women. In adjusted models, US-born Black women experienced an increased risk of preterm birth (RR 1.51, 95% CI 1.39, 1.65) and small for gestational age deliveries (RR 1.52, 95% CI 1.41, 1.64), compared to foreign-born Black women.

CONCLUSIONS

Future studies should consider experiences of racism across the life course when exploring heterogeneity in the risk of adverse perinatal outcomes by nativity among Black women in the US.

Neighborhood Context and the Nativity Advantage in Preterm Birth among Black Women in California, USA

Non-Hispanic Black women remain at increased risk for adverse birth outcomes, yet Black immigrant women are at lower risk than their US-born counterparts. This study examines whether neighborhood context contributes to the nativity advantage in preterm birth (PTB, < 37 weeks) among Black women in California. A sample of live singleton births to non-Hispanic US-born (n = 83,169), African-born (n = 7151), and Caribbean-born (n = 943) Black women was drawn from 2007 to 2010 California birth records and geocoded to urban census tracts. We used 2010 American Community Survey data to measure tract-level Black immigrant density, Black racial concentration, and a neighborhood deprivation index. Risk ratios (RR) and 95% confidence intervals (95%CI) were estimated using log-binomial regression to assess whether neighborhood context partially explained nativity differences in PTB risk. Compared to US-born Black women, African-born Black women had lower PTB risk (RR = 0.65, 95%CI: 0.60-0.71). The difference in PTB risk between US- and Caribbean-born women did not reach statistical significance (RR = 0.87, 95%CI: 0.71-1.05). The nativity advantage in PTB risk was robust to neighborhood social conditions and maternal factors for African-born women (RR = 0.59, 95%CI: 0.51-0.67). This study is one of few that considers area-level explanations of the nativity advantage among Black immigrants and makes a significant contribution by showing that the neighborhood context does not explain the nativity advantage in PTB among Black women in California. This could be due to many factors that should be examined in future research.

Towards a sociological understanding of medical gaslighting in western health care

In recent years, the term 'medical gaslighting' and accompanying accounts of self-identified women experiencing invalidation, dismissal and inadequate care have proliferated in the media. Gaslighting has primarily been conceptualized in the field of psychology as a phenomenon within interpersonal relationships. Following the work of Paige Sweet (American Sociological Review, 84, 2019, 851), I argue that a sociological explanation is necessary. Such an explanation illustrates how medical gaslighting is not simply an interpersonal exchange, but the result of deeply embedded and largely unchallenged ideologies underpinning health-care services. Through an intersectional feminist and Foucauldian analysis, I illuminate the ideological structures of western medicine that allow for medical gaslighting to be commonplace in the lives of women, transgender, intersex, queer and racialized individuals seeking health care. Importantly, these are not mutually exclusive groups, and I use the term bio-Others to highlight and connect how those with embodied differences are treated in medicine. This article indicates the importance of opening a robust discussion about the sociology of medical gaslighting, so that we might better understand what structural barriers people of marginalized social locations face in accessing quality health care and develop creative solutions to challenge health-care inequities.

Inequities in Adverse Maternal and Perinatal Outcomes: The Effect of Maternal Race and Nativity

OBJECTIVES

To evaluate the effect of race and ethnicity on differences in maternal and perinatal outcomes among U.S.-born and foreign-born women, as well as racial and ethnic disparities in outcomes within these groups.

METHODS

This retrospective study analyzed singleton pregnancies (n = 11,518) among women delivering at Boston Medical Center from January 2010-March 2015. Outcomes of interest included preterm birth, early preterm birth, cesarean delivery, hypertensive disorders, diabetes, low birth weight at term (LBW, < 2500 g), NICU admission and intrauterine fetal demise (IUFD). Prevalence ratios and 95% confidence intervals comparing outcomes between U.S.- and foreign-born women were calculated and stratified by race. Obstetric outcomes among Black and Hispanic women were compared to those of white women within both U.S.- and foreign-born groups.

RESULTS

Preterm birth, hypertensive disorders, LBW and NICU admission were more likely to occur among U.S.-born women and their neonates compared to foreign-born women. Controlling for sociodemographic characteristics did not significantly impact these disparities. Among foreign-born women, Black women had a higher prevalence of many maternal and neonatal complications, while Hispanic women had a lower prevalence of some complications compared to white women. Black woman and infants consistently exhibit worse outcomes regardless of their nativity, while Hispanic women foreign-born women experience less disparate outcomes.

CONCLUSIONS FOR PRACTICE

Overall, women born in the United States are at higher risk of several adverse perinatal outcomes compared to foreign-born women. Racial and ethnic disparities in birth outcomes exist in both groups. However, the complex interplay between biopsychosocial influences that mediate these inequities appear to have different effects among U.S- and foreign- born women. A better understanding of these factors can be used to combat disparities and improve outcomes for all women.

Addressing Obstetric Health Disparities among Refugee Populations: Training the Next Generation of Culturally Humble OB/GYN Medical Providers

Issue: The burden of increasing obstetric morbidity and mortality in the United States disproportionately affects marginalized and vulnerable populations, including refugees. Many factors have been attributed to this disparity in birth outcomes, such as linguistic, cultural, and health system limitations. However, refugee health disparities have received little attention in the U.S., especially as it relates to the training of healthcare providers. Evidence: Poor obstetric outcomes among refugee communities have been historically attributed to delayed initiation of prenatal care, failure to detect co-morbidities, as well as higher rates of Cesarean sections in comparison to host-country mothers. These inequities are often linked to poor communication due to cultural misunderstandings, which ultimately leads to mistrust and reduced utilization of healthcare services. In 2017, a Midwest academic hospital, refugee community, and health system came together to form the Congolese Health Partnership (CHP). The CHP was formed to improve access to quality healthcare for expecting Congolese mothers and their families experiencing poor quality of obstetric care. Discussions that arose from this partnership identified issues of mistrust in healthcare providers within the community, worry about misjudgment and overuse of C-sections, and a lack of understanding about health insurance during pregnancy and childbirth. Therefore, it is apparent that understanding the contextual nuances that play a role in these poor outcomes among refugee communities in the U.S. is critical in order to narrow the healthcare gap. Implications: Since pregnancy and its surrounding events are intricately tied to the ways in which different societies define culture, we argue for a focus on culture when training future healthcare providers to work with refugees in the U.S. Specifically, we focus on the necessity of cultural humility, rather than cultural competence, when caring for obstetric patients from diverse backgrounds. Cultural humility forces providers to think about power imbalances that exist between a patient and provider when cultural differences exist. We describe specific barriers to care among Congolese refugees living in eastern Iowa and explore ways to utilize community-provider partnership and cultural humility training to address obstetric morbidity. Finally, we propose ways to incorporate cultural humility training among OB/GYN residents to address community-identified barriers to improve overall health outcomes locally with implications for refugee communities across the U.S.

Multiethnic PDX models predict a possible immune signature associated with TNBC of African ancestry

PURPOSE

Triple-negative breast cancer (TNBC) is an aggressive subtype most prevalent among women of Western Sub-Saharan African ancestry. It accounts for 15-25% of African American (AA) breast cancers (BC) and up to 80% of Ghanaian breast cancers, thus contributing to outcome disparities in BC for black women. The aggressive biology of TNBC has been shown to be regulated partially by breast cancer stem cells (BCSC) which mediate tumor recurrence and metastasis and are more abundant in African breast tumors.

METHODS

We studied the biological differences between TNBC in women with African ancestry and those of Caucasian women by comparing the gene expression of the BCSC. From low-passage patient derived xenografts (PDX) from Ghanaian (GH), AA, and Caucasian American (CA) TNBCs, we sorted for and sequenced the stem cell populations and analyzed for differential gene enrichment.

RESULTS

In our cohort of TNBC tumors, we observed that the ALDH expressing stem cells display distinct ethnic specific gene expression patterns, with the largest difference existing between the GH and AA ALDH+ cells. Furthermore, the tumors from the women of African ancestry [GH/AA] had ALDH stem cell (SC) enrichment for expression of immune related genes and processes. Among the significantly upregulated genes were CD274 (PD-L1), CXCR9, CXCR10 and IFI27, which could serve as potential drug targets.

CONCLUSIONS

Further exploration of the role of immune regulated genes and biological processes in BCSC may offer insight into developing novel approaches to treating TNBC to help ameliorate survival disparities in women with African ancestry.

The Excess Preterm Birth Rate Among US-Born (Compared to Foreign-Born) Black Women: The Role of Father's Education

OBJECTIVE

To ascertain the component of the excess preterm birth (< 37 weeks, PTB) rate among US-born (compared to foreign-born) Black women attributable to differences in acknowledged father's education attainment.

METHODS

Stratified analyses and Oaxaca-Blinder decomposition methods were performed on the 2013 National Center for Health Statistics birth certificate files of singleton infants with acknowledged fathers.

RESULTS

US-born Black women (N = 196,472) had a PTB rate of 13.3%, compared to 10.8% for foreign-born Black women (N = 51,334; Risk Difference (95% confidence interval) = 2.5 (2.3, 2.8). Infants of US-born black women had a greater a percentage of fathers with a high school diploma or less and a lower percentage of fathers with bachelor's degrees or higher than their counterparts of foreign-born women. In both subgroups, PTB rates tended to decline as the level of paternal education attainment rose. In an Oaxaca model (controlling for maternal age, education, marital status, parity, adequacy of prenatal care utilization, and chronic medical conditions), differences in paternal education attainment explained 15% of the maternal nativity disparity in PTB rates. In contrast, maternal education attainment accounted for approximately 4% of the disparity in PTB rates.

CONCLUSIONS FOR PRACTICE

Acknowledged father's low level of education attainment, or something closely related to it, explains a notable proportion of the disparity in PTB rates between US-born and foreign-born Black women.

Infant Health for Arab and Non-Arab Mothers Identifying as White, Black, or Other in Massachusetts

INTRODUCTION

This study quantifies the differences in infant outcomes by mother's self-identified race among Arab Americans and by self-identified race and ethnicity for Arabs and non-Arabs.

METHODS

This study used data from the Standard Certificate of Live Birth on 8,204 infants born to Arab and 325,354 infants born to non-Arab mothers between 2012 and 2016 in Massachusetts; data were analyzed between 2019 and 2020. Mothers' race was categorized as White, Black, or Other. Mothers' ethnicity was categorized as Arab or non-Arab. Outcomes included birth weight, preterm birth, low-birth weight, small for gestational age, and large for gestational age. Linear and logistic regression models assessed the association between race and infant health outcomes.

RESULTS

Black Arab mothers had higher odds of preterm birth (AOR=1.37, 95% CI=1.07, 1.76) and low-birth weight (AOR=1.35, 95% CI=0.99, 1.84) than White Arab mothers. Arab mothers who self-identified as Other had babies that were 51.4 grams lighter than babies born to White Arab mothers. White Arab mothers had higher odds of low birth weight (AOR=1.19, 95% CI=1.06, 1.34) and small-for-gestational-age babies (AOR=1.22, 95% CI=1.11, 1.36) but lower odds of large-for-gestational-age babies (AOR=0.77, 95% CI=0.70, 0.86) than White non-Arab mothers.

CONCLUSIONS

Both ethnicity and race are important determinants of the health of Arab American infants. Arab ethnicity may play a negative role in the infant health of Arab Americans who identify as White. A better understanding of the lived experiences of Arab American mothers, with regard to their racial and ethnic identity, may help better inform clinical practice.

Pregnancy-related weight among immigrant and US-born mothers: The role of nativity, maternal duration of residence, and age at arrival

OBJECTIVES

The goals of this study were to examine the associations between nativity and pregnancy-related weight and to assess the associations between maternal duration of residence and age at arrival in the United States on pregnancy-related weight among immigrants.

METHODS

Using logistic regression and data from the Early Childhood Longitudinal Study-Birth Cohort, we assessed differences in preconception weight and gestational weight gain between US-born and immigrant women (N = 7000). We then analyzed differences in both outcomes by duration of residence among immigrants (n = 1850) and examined whether the identified relationships varied by age at arrival in the United States.

RESULTS

Compared to US-born mothers, immigrants were less likely to be classified as obese prior to pregnancy (odds ratio 0.435, 95% confidence interval, 0.321-0.590) or experience excessive gestational weight gain (odds ratio 0.757, 95% confidence interval, 0.614-0.978). Among the immigrant sub-sample, living in the United States for 10-15 years (odds ratio 2.737, 95% confidence interval, 1.459-5.134) or 16+ years was positively associated with both preconception obesity (odds ratio 2.918, 95% confidence interval, 1.322-6.439) and excessive gestational weight gain (odds ratio 1.683, 95% confidence interval, 1.012-2.797, 16+ years only). There was some evidence that the duration of residence was positively associated with preconception obesity, but only among women who had moved to the United States at age 18 years and older.

CONCLUSION

In sum, while immigrants are less likely than US-born mothers to experience preconception obesity or excessive gestational weight gain, these outcomes vary among the former group by duration of US residence.

A tale of two generations: Maternal skin color and adverse birth outcomes in Black/African American women

We examined how sociopolitical context (marked by generational cohort) and maternal skin color interacted to influence preterm delivery (PTD) rates in sample of Black women. Data were from 1410 Black women, ages 18-45 years, residing in Metropolitan Detroit, MI enrolled (2009-2011) in the Life-course Influences on Fetal Environments (LIFE) Study. Because we hypothesized that generational differences marked by changes in the sociopolitical context would influence exposure to racism, we categorized women into two cohorts by maternal birth year: a) Generation X, 1964-1983 and b) Millennial, 1984-1993. Descriptive results showed similar PTD rates by generational cohort, Generation X: 16.3% vs. Millennials: 16.1%. Yet, within each generation, PTD rates varied by women's skin tone (categorized: light, medium, and dark brown). Poisson regression models confirmed a significant interaction between generational cohort and maternal skin tone predicting PTD (P = 0.001); suggesting a salubrious association between light brown skin tone (compared to medium and dark) and PTD for Generation X. However, Millennials with medium and dark brown skin experienced lower PTD rates than their light Millennial counterparts. Research should consider sociopolitical context and the salience of skin tone bias when investigating racial health disparities, including those in perinatal health.

Preterm birth and nativity among Black women with gestational diabetes in California, 2013-2017: a population-based retrospective cohort study

Background

Despite the disproportionate prevalence of gestational diabetes (GDM) and preterm birth (PTB) and their associated adverse perinatal outcomes among Black women, little is known about PTB among Black women with GDM. Specifically, the relationship between PTB by subtype (defined as indicated PTB and spontaneous PT labor) and severity, GDM, and nativity has not been well characterized. Here we examine the risk of PTB by severity (early < 34 weeks, late 34 to 36 weeks) and early term birth (37 to 38 weeks) by nativity among Black women with GDM in California.

Methods

This retrospective cohort study used linked birth certificate and hospital discharge data for 8609 of the 100,691 self-identifying non-Hispanic Black women with GDM who had a singleton live birth between 20 and 44 weeks gestation in California in 2013–2017. Adjusted odds ratios (aOR) and 95% confidence intervals (CIs) were examine risks for PTB, by severity and subtype, and early term birth using multivariate regression modeling.

Results

Approximately, 83.9% of Black women with GDM were US-born and 16.1% were foreign-born. The overall prevalence of early PTB, late PTB, and early term birth was 3.8, 9.5, and 29.9%, respectively. Excluding history of prior PTB, preeclampsia was the greatest overall risk factor for early PTB (cOR = 6.7, 95%, CI 5.3 to 8.3), late PTB (cOR = 4.3, 95%, CI 3.8 to 5.0), and early term birth (cOR = 1.8, 95%, CI 1.6 to 2.0). There was no significant difference in the prevalence of PTB by subtypes and nativity (p = 0.5963). Overall, 14.2% of US- compared to 8.9% of foreign-born women had a PTB (early PTB: aOR = 0.56, 95%, CI 0.38 to 0.82; late PTB: aOR = 0.57, 95%, CI 0.45 to 0.73; early term birth: aOR = 0.67, 95%, CI 0.58 to 0.77).

Conclusions

Foreign-born status remained protective of PTB, irrespective of severity and subtype. Preeclampsia, PTB, and GDM share pathophysiologic mechanisms suggesting a need to better understand differences in perinatal stress, chronic disease, and vascular dysfunction based on nativity in future epidemiologic studies and health services research.

Racial/ethnic minority segregation and low birth weight in five North American cities

Comparisons of communities across cities are rare in social epidemiology. Our prior work exploring racial/ethnic segregation and the prevalence of low birth weight (LBW) in communities from two large urban cities showed a strong relationship in Chicago and a very weak relationship in Toronto. This study extends that work by examining the association between racial/ethnic minority segregation and LBW in total of 307 communities in five North American cities: Baltimore, Boston, Chicago, Philadelphia, and Toronto. We used Pearson correlation coefficients and OLS regression models to examine potential variability in the association between racial/ethnic minority segregation and LBW, controlling for community-level unemployment. In a combined model with community-level data from all cities, a 10% increase in minority composition is associated with a 0.7% increase in LBW. While racial/ethnic minority segregation and unemployment are not associated with LBW in Toronto, these social determinants have strong and significant associations with LBW across communities in the four US cities in the analysis. Subsequent models revealed opposite effects for percentage non-Hispanic Black and percentage Hispanic. Across communities in the US cities in this analysis, there is considerable similarity in the strength of the effect of racial/ethnic segregation on LBW. Future work should incorporate communities from additional cities, looking to identify community assets and public policies that allow some minority communities to thrive, while other minority communities suffer from a high prevalence of LBW. More work is also needed on the generalizability of these patterns to other health outcomes.

Intergenerational Change in Birthweight: Effects of Foreign-born Status and Race/Ethnicity

BACKGROUND

Foreign-born women have heavier infants than US-born women, but it is unclear whether this advantage persists across generations for all races and ethnicities.

METHODS

Using 1971-2015 Florida birth records, we linked records of female infants within families to assess intergenerational changes in birthweight and prevalence of low birthweight by grandmother's race/ethnicity and foreign-born status. We also assessed educational gradients in low birthweight in two generations.

RESULTS

Compared with daughters of US-born black women, daughters of foreign-born black women had substantially higher birthweights (3,199 vs. 3,083 g) and lower prevalence of low birthweight (7.8% vs. 11.8%). Daughters of foreign-born Hispanic women had moderately higher birthweights (3,322 vs. 3,268 grams) and lower prevalence of low birthweight (4.5% vs. 6.2%) than daughters of US-born Hispanic women. In the next generation, a Hispanic foreign-origin advantage persisted in low birthweight prevalence (6.1% vs. 7.2%), but the corresponding black foreign-origin advantage was almost eliminated (12.2% vs. 13.1%). Findings were robust to adjustment for sociodemographic and medical risk factors. In contrast to patterns for other women, the prevalence of low birthweight varied little by maternal education for foreign-born black women. However, a gradient emerged among their US-born daughters.

CONCLUSIONS

The convergence of birthweight between descendants of foreign-born and US-born black women is consistent with theories positing that lifetime exposure to discrimination and socioeconomic inequality is associated with adverse health outcomes for black women. The emergence of a distinct educational gradient in low birthweight prevalence between generations underscores hypothesized adverse effects of multiple dimensions of disadvantage.

A review of maternal prenatal exposures to environmental chemicals and psychosocial stressors-implications for research on perinatal outcomes in the ECHO program

Exposures to environmental chemicals and psychosocial stressors during pregnancy have been individually associated with adverse perinatal outcomes related to birthweight and gestational age, but are not often considered in combination. We review types of psychosocial stressors and instruments used to assess them and classes of environmental chemical exposures that are known to adversely impact perinatal outcomes, and identify studies relevant studies. We discuss the National Institutes of Health's Environmental influences on Child Health Outcomes (ECHO) program that has combined existing longitudinal cohorts that include more than 50,000 children across the U.S. We describe future opportunities for investigators to use this important new resource for addressing relevant and critical research questions to maternal health. Of the 84 cohorts in ECHO, 38 collected data on environmental chemicals and psychosocial stressors and perinatal outcomes. The diverse ECHO pregnancy cohorts provide capacity to compare regions with distinct place-based environmental and social stressors.

An Examination of Preterm Birth and Residential Social Context among Black Immigrant Women in California, 2007-2010

The foreign-born black population contributes a considerable amount of heterogeneity to the US black population. In 2005, black immigrants accounted for 20% of the US black population. Compared to native-born black women, black immigrant women are at lower risk for adverse birth outcomes, including preterm birth. Some scholars posit that differential exposures to socioeconomic disadvantage and structural racism in the residential context may account for this advantage. However, to date, few studies offer comprehensive examinations of the black immigrant residential social context, particularly in settlement regions beyond predominantly black and historically segregated regions. Further, studies examining the black immigrant residential context typically use a single indicator, which limits discussion of the intersecting domains that simultaneously increase or decrease risk among black immigrants. We addressed these gaps by examining black immigrant neighborhoods in the state of California, where racial residential segregation of the black population is low. We operationalized the residential context of black immigrant women using three distinct attributes: immigrant co-ethnic density, black racial concentration, and neighborhood deprivation. We linked 2007-2010 California birth records of black immigrant women and 2010 census data on tract-level social attributes (N = 6930). OLS regression analyses showed that immigrant co-ethnic density, black racial concentration and neighborhood deprivation were not associated with preterm birth among black immigrants. Our findings indicate that in California, residential social context has little relation to black immigrant preterm birth-a finding that is unique compared to residential settings of other settlement contexts.

Skin Tone Matters: Racial Microaggressions and Delayed Prenatal Care

INTRODUCTION

Literature posits that discrimination can be a barrier to racial and ethnic minorities' healthcare use. This study examines the relationship between perceived discrimination in the form of racial microaggressions and delayed prenatal care in African American women. It also investigates whether this relationship is modified by women's shade of skin color owing to societal attitudes and beliefs tied to colorism (also known as skin-tone bias).

METHODS

Data were collected from a cohort of 1,410 black, African American women in metropolitan Detroit, Michigan, enrolled in 2009-2011 (analyzed between August 2017 and July 2018). Perceived racial microaggressions were assessed using the 20-item Daily Life Experiences of Racism and Bother scale. Logistic regression modeled the relationship between the Daily Life Experiences of Racism and Bother scale and delayed prenatal care, defined as third trimester or no prenatal care entry.

RESULTS

Nearly a quarter (24.8%) of women had delayed prenatal care. Logistic regression models showed that a Daily Life Experiences of Racism and Bother score above the median was associated with delayed prenatal care (AOR=1.31, 95% CI=1.00, 1.71). This association was moderated by self-reported maternal skin tone (interaction p=0.03). A higher Daily Life Experiences of Racism and Bother score was associated with delayed prenatal care among African-American women at either end of the color continuum (light brown: AOR=1.64, 95% CI=1.02, 2.65; dark brown: AOR=2.30, 95% CI=1.20, 4.41) but not in the middle (medium brown women).

CONCLUSIONS

Skin tone-based mistreatment in tandem with racial discrimination in the form of racial microaggressions may influence African American women's use of prenatal care. These findings have implications related to the engagement of women of color, particularly African American women, in healthcare systems and maternal and child health programs.

Awareness of High Blood Pressure by Nativity Among Black Men: Implications for Interpreting the Immigrant Health Paradox

Introduction

Differences in the social determinants of health and cardiovascular health outcomes by nativity have implications for understanding the immigrant health paradox among black immigrants. We aimed to understand whether blood pressure awareness, a precursor to achieving blood pressure control among hypertensive patients, varied by nativity among a sample of black men.

Methods

Data were collected from 2010 through 2014. In 2016, we conducted logistic regression models using data from a large sample of urban-dwelling middle-aged and older black men. All men in the study had measured high blood pressure at the time of enrollment and were also asked whether they were aware of having high blood pressure. Independent variables included demographics, socioeconomic status, access to care, and health-related behaviors.

Results

Foreign-born participants were significantly less likely than US-born participants to report awareness of having high blood pressure (P < .001). We observed a significant positive relationship between proportion of life spent in the US and being aware of having hypertension (β = 0.863; 95% CI, 0.412–1.314; P < .001). This relationship remained after adjusting the model for salient independent variables (β = 0.337; 95% CI, 0.041–0.634; P = .03).

Conclusions

Difference in hypertension awareness by nativity may skew surveillance estimates used to track health disparities by large heterogeneous racial categories. Our results also indicate that prior health care experience and circumstances should be considered when studying the immigrant health paradox.

From the West Indies to Africa: A universal generational decline in health among blacks in the United States

Research shows that foreign-born blacks have better health profiles than their U.S.-born counterparts. Less is known, however, regarding whether black immigrants' favorable health outcomes persist across generations or whether these patterns differ across the diverse sending regions for black immigrants. In this study, we use data from the 1996-2014 waves of the March Current Population Survey (CPS) to investigate generational differences in self-rated health among blacks with West Indian, Haitian, Latin American, and African ancestry. We show that first-generation black immigrants have a lower probability of reporting fair/poor health than third/higher generation blacks. The health advantage of the first generation over the third/higher generation is slightly more prounced among the foreign-born who migrated to the United States after age 13. Second-generation immigrants with two foreign-born parents are generally less likely to report their health as fair/poor than the third/higher generation. However, we find no evidence that self-reported fair/poor health varies between second-generation immigrants with mixed nativity parents (only one foreign-born parent) and the third/higher generation. These general patterns hold across each of the ancestral subgroups in the study sample. In summary, our findings highlight a remarkable convergence in health across immigrant generations among blacks in the United States.

Hypertension among US-born and foreign-born non-Hispanic Blacks: National Health and Nutrition Examination Survey 2003-2014 data

OBJECTIVES

Non-Hispanic Blacks in the United States have the highest reported prevalence of hypertension (44%) worldwide. However, this does not consider the heterogeneity of Blacks within the United States, particularly comparing US-born to long-standing or recent (foreign-born) immigrants. The objective of this study is to compare odds of hypertension between US-born and foreign-born Blacks in the United States.

METHODS

We assessed the prevalence of hypertension among US-born (n = 4511) vs. foreign-born (n = 522) non-Hispanic Black adults aged 22-79 years, based on pooled nationally representative data (2003-2014); as well by length of US residency among immigrants. Multivariable-adjusted logistic regression was used to investigate the association between nativity and hypertension odds.

RESULTS

Nearly half (42.8%) of US-born Blacks but only 27.4% of foreign-born Blacks had hypertension. After adjusting for major covariates, foreign-born Blacks were 39.0% less likely (odds ratio 0.61 95% confidence interval 0.49, 0.77) to have hypertension than their US-born counterparts. Among foreign-born Blacks, length of US residency was not significantly associated with odds of hypertension.

CONCLUSION

Foreign-born vs. US-born non-Hispanic Blacks have substantially lower prevalence of hypertension. Considering nativity among US Blacks in clinical research and public health efforts may improve accuracy of characterizing health disparities and facilitate development of targeted interventions to reduce hypertension in this diverse population.

Deconstructing a disparity: explaining excess preterm birth among U.S.-born black women

PURPOSE

To determine components of excess preterm birth (PTB) rates for U.S.-born black women relative to both foreign-born black women and U.S.-born white women attributable to differences in observed sociodemographic, behavioral, and medical risk factors.

METHODS

Using the 2013 U.S. natality files, we used Oaxaca-Blinder decomposition on the absolute scale to estimate the contribution of the group differences in the prevalence of PTB predictors between U.S.- and foreign-born black women and U.S.-born black and U.S.-born white women.

RESULTS

U.S.-born blacks had a 3.2 (95% confidence interval: 3.0-3.5) and 4.4 (95% confidence interval: 4.3-4.5) percentage point higher risk of PTB than foreign-born blacks and U.S.-born whites, respectively. The variables in the models explained between 18% and 27% of the PTB disparities. Differences in paternal acknowledgment (about 12%), maternal hypertension (about 7%-11%), and maternal education (about 6%-10%) explained the largest proportion of these disparities.

CONCLUSIONS

Programs and policies that address both distal and proximate factors, including the social determinants of health and the prevention and management of hypertension, may reduce the higher rates of PTB among U.S.-born black women compared to foreign-born black women and U.S.-born white women.

Worry about racial discrimination: A missing piece of the puzzle of Black-White disparities in preterm birth?

OBJECTIVES

The causes of the large and persistent Black-White disparity in preterm birth (PTB) are unknown. It is biologically plausible that chronic stress across a woman's life course could be a contributor. Prior research suggests that chronic worry about experiencing racial discrimination could affect PTB through neuroendocrine, vascular, or immune mechanisms involved in both responses to stress and the initiation of labor. This study aimed to examine the role of chronic worry about racial discrimination in Black-White disparities in PTB.

METHODS

The data source was cross-sectional California statewide-representative surveys of 2,201 Black and 8,122 White, non-Latino, U.S.-born postpartum women with singleton live births during 2011-2014. Chronic worry about racial discrimination (chronic worry) was defined as responses of "very often" or "somewhat often" (vs. "not very often" or "never") to the question: "Overall during your life until now, how often have you worried that you might be treated or viewed unfairly because of your race or ethnic group?" Prevalence ratios (PRs) with 95% Confidence Intervals (CI) were calculated from sequential logistic regression models, before and after adjustment for multiple social/demographic, behavioral, and medical factors, to estimate the magnitude of: (a) PTB risks associated with chronic worry among Black women and among White women; and (b) Black-White disparities in PTB, before and after adjustment for chronic worry.

RESULTS

Among Black and White women respectively, 36.9 (95% CI 32.9-40.9) % and 5.5 (95% CI 4.5-6.5) % reported chronic worry about racial discrimination; rates were highest among Black women of higher income and education levels. Chronic worry was significantly associated with PTB among Black women before (PR 1.73, 95% CI 1.12-2.67) and after (PR 2.00, 95% CI 1.33-3.01) adjustment for covariates. The unadjusted Black-White disparity in PTB (PR 1.59, 95%CI 1.21-2.09) appeared attenuated and became non-significant after adjustment for chronic worry (PR 1.30, 95% CI 0.93-1.81); it appeared further attenuated after adding the covariates (PR 1.17, 95% CI 0.85-1.63).

CONCLUSIONS

Chronic worry about racial discrimination may play an important role in Black-White disparities in PTB and may help explain the puzzling and repeatedly observed greater PTB disparities among more socioeconomically-advantaged women. Although the single measure of experiences of racial discrimination used in this study precluded examination of the role of other experiences of racial discrimination, such as overt incidents, it is likely that our findings reflect an association between one or more experiences of racial discrimination and PTB. Further research should examine a range of experiences of racial discrimination, including not only chronic worry but other psychological and emotional states and both subtle and overt incidents as well. These dramatic results from a large statewide-representative study add to a growing-but not widely known-literature linking racism-related stress with physical health in general, and shed light on the links between racism-related stress and PTB specifically. Without being causally definitive, this study's findings should stimulate further research and heighten awareness of the potential role of unmeasured social variables, such as diverse experiences of racial discrimination, in racial disparities in health.

Residential segregation, political representation, and preterm birth among U.S.- and foreign-born Black women in the U.S. 2008-2010

Although racial residential segregation is associated with preterm birth (PTB) among non-Hispanic black (NHB) women in the U.S., prior work suggests that increased black political power arising from segregation may be protective for infant health. We examined associations between residential segregation, black political representation, and preterm birth (PTB) among U.S- and foreign-born NHB women in major U.S. cities using birth certificate data from 2008 to 2010 (n=861,450). Each 10-unit increase in segregation was associated with 3-6% increases in odds of PTB for both U.S.- and foreign-born NHB women. Black political representation was not associated with PTB and did not moderate the association between residential segregation and PTB.

The Role of Racial Identity and Implicit Racial Bias in Self-Reported Racial Discrimination: Implications for Depression Among African American Men

Racial discrimination is conceptualized as a psychosocial stressor that has negative implications for mental health. However, factors related to racial identity may influence whether negative experiences are interpreted as instances of racial discrimination and subsequently reported as such in survey instruments, particularly given the ambiguous nature of contemporary racism. Along these lines, dimensions of racial identity may moderate associations between racial discrimination and mental health outcomes. This study examined relationships between racial discrimination, racial identity, implicit racial bias, and depressive symptoms among African American men between 30 and 50 years of age (n = 95). Higher racial centrality was associated with greater reports of racial discrimination, while greater implicit anti-Black bias was associated with lower reports of racial discrimination. In models predicting elevated depressive symptoms, holding greater implicit anti-Black bias in tandem with reporting lower racial discrimination was associated with the highest risk. Results suggest that unconscious as well as conscious processes related to racial identity are important to consider in measuring racial discrimination, and should be integrated in studies of racial discrimination and mental health.

Racial Discrimination and Adverse Birth Outcomes: An Integrative Review

INTRODUCTION

This article presents an integrative review of the literature examining the relationship between racial discrimination and adverse birth outcomes.

METHODS

Searches for research studies published from 2009 to 2015 were conducted using PubMed, CINAHL, Scopus, PsycINFO, Web of Science, and Embase. Articles were assessed for potential inclusion using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2009 framework.

RESULTS

Fifteen studies met criteria for review. The majority of the studies found a significant relationship between racial discrimination and low birth weight, preterm birth, and small for gestational age. Each of the studies that examined more proximal variables related to birth outcomes such as entry into prenatal care, employment opportunities, neighborhood characteristics, or inflammatory markers found significant associations between the specific variables examined and racial discrimination. Participants in qualitative studies discussed experiences of institutional racism with regard to several components of prenatal care including access and quality of care.

DISCUSSION

Racial discrimination is a significant risk factor for adverse birth outcomes. To best understand the mechanisms by which racial discrimination impacts birth outcomes, and to inform the development of effective interventions that eliminate its harmful effects on health, longitudinal research that incorporates comprehensive measures of racial discrimination is needed. Health care providers must fully acknowledge and address the psychosocial factors that impact health outcomes in minority racial/ethnic women.

Place of birth effects on self-reported discrimination: Variations by type of discrimination

Researchers have suggested that perceptions of discrimination may vary depending on place of birth and the length of time spent living in the U.S., variables related to acculturation. However, the existing literature provides a mixed picture, with data suggesting that the effects of acculturation on perceptions of discrimination vary by race and other sociodemographic factors. This study evaluated the role of place of birth (POB: defined as U.S.-born vs. foreign-born), age at immigration, and length of residence in the U.S. on self-reported discrimination in a sample of urban-dwelling Asian and Black adults (n= 1454). Analyses examined POB effects on different types of discrimination including race-related stigmatization, exclusion, threat, and workplace discrimination. Sociodemographic variables (including age, gender, employment status and education level) were tested as potential moderators of the relationship between POB and discrimination. The results revealed a significant main effect for POB on discrimination, with U.S.-born individuals reporting significantly more discrimination than foreign-born individuals, although the effect was reduced when sociodemographic variables were controlled. Across the sample, POB effects were seen only for race-related stigmatization and exclusion, not for threat and workplace discrimination. With the exception of limited effects for gender, sociodemographic variables did not moderate these effects. Younger age at immigration and greater years of residence in the U.S. were also positively associated with higher levels of perceived discrimination. These findings suggest increasing acculturation may shape the experience and perception of racial and ethnic discrimination.

Health among Black children by maternal and child nativity

OBJECTIVES

We examined 5 health outcomes among Black children born to US-born and foreign-born mothers and whether differences by mother's region of birth could be explained by maternal duration of US residence, child's place of birth, and familial sociodemographic characteristics.

METHODS

Data were from the 2000-2011 National Health Interview Surveys. We examined 3 groups of children, based on mother's region of birth: US origin, African origin, and Latin American or Caribbean origin. We estimated multivariate regression models.

RESULTS

Children of foreign-born mothers were healthier across all 5 outcomes than were children of US-born mothers. Among children of foreign-born mothers, US-born children performed worse on all health outcomes than children born abroad. African-origin children had the most favorable health profile. Longer duration of US residence among foreign-born mothers was associated with poorer child health. Maternal educational attainment and other sociodemographic characteristics did little to explain these differences.

CONCLUSIONS

Further studies are needed to understand the role of selective migration and the behavioral, cultural, socioeconomic, and contextual origins of the health advantage of Black children of foreign-born mothers.

Variation in birth outcomes by mother's country of birth among non-Hispanic black women in the United States

Rates of prematurity (PTB) and small-for-gestational age (SGA) were compared between US-born and foreign-born non-Hispanic black women. Comparisons were also made between Sub-Saharan African-born and Caribbean-born black women and by maternal country of birth within the two regions. Comparisons were adjusted for sociodemographic, health behavioral and medical risk factors available on the birth record. Birth record data (2008) from all states (n = 27) where mother's country of birth was recorded were used. These data comprised 58 % of all singleton births to non-Hispanic black women in that year. Pearson Chi square and logistic regression were used to investigate variation in the rates of PTB and SGA by maternal nativity. Foreign-born non-Hispanic black women had significantly lower rates of PTB (OR 0.727; CI 0. 726, 0.727) and SGA (OR 0.742; CI 0.739-0.745) compared to US-born non-Hispanic black women in a fully adjusted model. Sub-Saharan African-born black women compared to Caribbean-born black women had significantly lower rates of PTB and SGA. Within each region, the rates of PTB and SGA varied by mother's country of birth. These differences could not be explained by adjustment for known risk factors obtained from vital records. Considerable heterogeneity in rates of PTB and SGA among non-Hispanic black women in the US by maternal nativity was documented and remained unexplained after adjustment for known risk factors.

Differing first year mortality rates of term births to White, African-American, and Mexican-American US-born and foreign-born mothers

To determine whether maternal nativity (US-born versus foreign-born) is associated with the first year mortality rates of term births. Stratified and multivariable binomial regression analyses were performed on the 2003-2004 National Center for Health Statistics linked live birth-infant death cohort files. Only term (37-42 weeks) infants with non-Latina White, African-American, and Mexican-American mothers were studied. The infant mortality rate (<365 days, IMR) of births to US-born non-Latina White mothers (n = 3,684,569) exceeded that of births to foreign-born White mothers (n = 226,621): 2.4/1,000 versus 1.3/1,000, respectively; relative risk (RR) = 1.8 [95 % confidence interval (CI) 1.6-2.0]. The IMR of births to US-born African-American mothers (n = 787,452) exceeded that of births to foreign-born African-American mothers (n = 118,246): 4.1/1,000 versus 2.2/1,000, respectively; RR = 1.8 (1.6-2.1). The IMR of births to US-born Mexican-American mothers (n = 338,337) exceeded that of births to Mexican-born mothers (n = 719,837): 2.4/1,000 versus 1.8/1,000, respectively; RR = 1.3 (1.2-1.4). These disparities were not limited to a singular cause of death and were widest among deaths due to Sudden Infant Death Syndrome. In multivariable binomial regression models, the adjusted RR of infant mortality for non-LBW, term births to US-born (compared to foreign-born) for White, African-American, and Mexican-American mothers equaled 1.5 (1.3-1.7), 1.7 (1.5-2.1) and 1.6 (1.4-1.8), respectively. The IMR of term births to White, African-American, and Mexican-American mothers exceeds that of their counterparts with foreign-born mothers independent of traditional individual level risk factors.

Pathways between perceived discrimination and health among immigrants: evidence from a large national panel survey in Germany

OBJECTIVE

Discrimination is an important determinant of health, and its experience may contribute to the emergence of health inequalities between immigrants and nonimmigrants. We examine pathways between perceived discrimination and health among immigrants in Germany: (1) whether perceptions of discrimination predict self-reported mental and physical health (SF-12), or (2) whether poor mental and physical health predict perceptions of discrimination, and (3) whether discrimination affects physical health via mental health.

DESIGN

Data on immigrants come from the German Socio-Economic Panel (SOEP) from the years 2002 to 2010 (N = 8,307), a large national panel survey. Random and fixed effects regression models have been estimated.

RESULTS

Perceptions of discrimination affect mental and physical health. The effect of perceived discrimination on physical health is mediated by its effect on mental health. Our analyses do not support the notion that mental and physical health predict the subsequent reporting of discrimination. Different immigrant groups are differentially exposed to perceived discrimination.

CONCLUSION

In spite of anti-discrimination laws, the health of immigrants in Germany is negatively affected by perceived discrimination. Differential exposure to perceived discrimination may be seen as a mechanism contributing to the emergence of health inequalities in Germany.

Stigma, discrimination, or symptomatology differences in self-reported mental health between US-born and Somalia-born Black Americans

OBJECTIVES

We examined differences in self-reported mental health (SRMH) between US-born and Somalia-born Black Americans compared with White Americans. We tested how SRMH was affected by stigma toward seeing a mental health provider, discrimination in the health care setting, or symptoms of depression.

METHODS

Data were from a 2008 survey of adults in Minnesota and were limited to US-born and Somalia-born Black and White Americans (n = 938).

RESULTS

Somalia-born adults were more likely to report better SRMH than either US-born Black or White Americans. They also reported lower levels of discrimination (18.6%) than US-born Black Americans (33.4%), higher levels of stigma (23.6% vs 4.7%), and lower levels of depressive symptoms (9.1% vs 31.6%). Controlling for stigma, discrimination, and symptomatology, Somalia-born Black Americans reported better SRMH than White and Black Americans (odds ratio = 4.76).

CONCLUSIONS

Mental health programming and health care providers who focus on Black Americans' mental health might be missing important sources of heterogeneity. It is essential to consider the role of race and ethnicity, but also of nativity, in mental health policy and programming.

Maternal familism predicts birthweight and asthma symptoms three years later

There are marked ethnic and socioeconomic differences in birthweight and childhood asthma, conditions which may be linked causally or via a third variable. Cultural resources are often credited with diminished health disparities in infancy and childhood among subsets of poor and minority populations; yet direct empirical tests of this hypothesis are needed. In this study, ethnicity, lifespan family socioeconomic position (FSEP), and the cultural resource of familism were compared as predictors of birthweight and expression of asthma symptoms (AE) by age three. Familism and lifespan FSEP were assessed in 4633 socioeconomically disadvantaged African Americans, White Americans, and Latinas upon giving birth, as was offspring birthweight. AE was assessed in offspring through age three. Asthma diagnosis by age three was likelier in very low (≤ 1500 g) and low (≤ 2500 g) birthweight infants compared to infants born at average (2501-3999 g) or larger (≥ 4000 g) birthweights. Asthma risk associated with lower birthweight was higher for Latinos (17-35%) and African Americans (19-23%) than for White Americans (13-14%). As predicted, maternal familism was higher among White Americans than among African Americans and Latinas, an effect that was largely driven by ethnic disparities in lifespan FSEP. Familism predicted continuous birthweight (p = .003) and AE (p = .001) by age three independently of ethnicity and lifespan FSEP accounting for appropriate control variables, including maternal biomedical risk, maternal acculturation, parental marital status, and infant sex. There was a 71-g gain in birthweight for every one-unit increase in familism. The protective effect of familism on AE by age three was strongest for participants of lower lifespan FSEP. Maternal familism is one cultural resource that may reduce reproductive and intergenerational health disparities in both U.S.- and foreign-born Americans. Consistent with our previous work, familism and other nonmaterial resources covary with material resources. Nevertheless, culture is distinguishable from lifespan FSEP and ethnicity, and has health implications beyond associations to ethnicity, lifespan FSEP, and related biomedical and sociodemographic factors.

African American Women's Preparation for Childbirth From the Perspective of African American Health-Care Providers

Preparation for birthing has focused primarily on Caucasian women. No studies have explored African American women's birth preparation. From the perceptions of 12 African American maternity health-care providers, this study elicited perceptions of the ways in which pregnant African American women prepare for childbirth. Focus group participants answered seven semistructured questions. Four themes emerged: connecting with nurturers, traversing an unresponsive system, the need to be strong, and childbirth classes not a priority. Recommendations for nurses and childbirth educators include: (a) self-awareness of attitudes toward African Americans, (b) empowering of clients for birthing, (c) recognition of the role that pregnant women's mothers play, (d) tailoring of childbirth classes for African American women, and (e) research on how racism influences pregnant African American women's preparation for birthing.