Exploring the health consequences of majority-minority neighborhoods: minority diversity and birthweight among native-born and foreign-born blacks

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.

A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms

Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.

Nativity and perinatal outcome disparities in the United States: Beyond the immigrant paradox

In the United States (US), epidemiologists have long documented paradoxically lower rates of adverse perinatal health outcomes among immigrant birthing people than what might be expected in light of socioeconomic and language barriers to healthcare, especially as compared to their US-born racial and ethnic counterparts. However, researchers have also documented significant variability in this immigrant birth paradox when examining within and across racial and ethnic subgroups. This review paper summarizes fifty years of research regarding differences in low, preterm birth, and infant mortality in the US, according to the nativity status of the birthing person. While there is ample evidence of the importance of nativity in delineating a pregnant person's risk of adverse infant outcomes, this review also highlights the relative paucity of research exploring the intersection of acculturation, ethnic enclaves, and structural segregation. We also provide recommendations for advancing the study of perinatal outcomes among immigrants.

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.

A Scoping Review of the Health of African Immigrant and Refugee Children

Migration is a growing phenomenon around the world, including within the African continent. Many migrants, especially African children, face challenges related to health and social inclusion and can face increased health risks. A systematic scoping review of available literature on the health of African migrant children across the globe was conducted to offer insight into these health risks. The review was conducted over a 15-month period from January 2019 to April 2020, yielding 6602 articles once duplicates were removed. This search included electronic databases, reference lists of articles reviewed, and searches of libraries of relevant organisations. A total of 187 studies met the inclusion criteria, of which 159 were quantitative, 22 were qualitative, and 6 used mixed methods. The findings reveal decreased health in this population in areas of nutrition, infectious diseases, mental health, birth outcomes, sexual and reproductive health, physical and developmental health, parasitic infections, oral health, respiratory health, preventative health, endocrine disorders, health care services, and haematological conditions. The findings offer insights into factors influencing the health of African immigrant and refugee children. Further studies, especially qualitative studies, are needed to determine barriers to service access after migration and to investigate other underexplored and overlooked health concerns of African migrant children, including pneumonia and child maltreatment.

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.

The intersectional effect of poverty, home ownership, and racial/ethnic composition on mean childhood blood lead levels in Milwaukee County neighborhoods

Environmental conditions that contribute to childhood lead exposure are spatially patterned. Socioeconomic and racial inequities in childhood lead exposure have been well documented, however childhood lead exposure in Milwaukee is understudied. As a segregated rustbelt metropolitan area with childhood lead exposure concerns, Milwaukee is uniquely positioned to evaluate the synergistic effects of racial and economic drivers of childhood lead exposure. Using surveillance data from the Wisconsin Department of Health Services, Division of Public Health and the US Census Bureau, this cross-sectional study determined the intersectional effect of poverty, home ownership, and racial/ethnic composition on childhood lead exposure in Milwaukee County neighborhoods using linear regression adjusting for average census tract housing age and number of children. The final analytical sample consisted of 48,393 individual childhood blood lead levels aggregated to 215 Milwaukee County census tracts. Census tracts with mean childhood blood lead levels greater than or equal to 5 μg/dL were predominantly low home ownership, high poverty, and majority non-White census tracts. The effects of low home ownership, high poverty, and majority non-White census tracts were synergistic, producing 1.78 (95% CI: 1.44, 2.11) μg/dL higher mean childhood blood lead level than high home ownership, low poverty, and majority White census tracts (referent). This research reveals that social determinants at the neighborhood level co-occur and interact to produce inequities in childhood lead exposure. Lead prevention efforts should align with equity-focused housing and economic policies that target primary prevention in neighborhoods disproportionately burdened by childhood lead exposure.

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.

Pockets of progress amidst persistent racial disparities in low birthweight rates

Racial disparities persist in adverse perinatal outcomes such as preterm birth, low birthweight (LBW), and infant mortality across the U.S. Although pervasive, these disparities are not universal. Some communities have experienced significant improvements in black (or African American) birth outcomes, both in absolute rates and in rate ratios relative to whites. This study assessed county-level progress on trends in black and white LBW rates as an indicator of progress toward more equal birth outcomes for black infants. County-level LBW data were obtained from the 2003 to 2013 U.S. Natality files. Black LBW rates, black-white rate ratios and percent differences over time were calculated. Trend lines were first assessed for significant differences in slope (i.e., converging, diverging, or parallel trend lines). For counties with parallel trend lines, intercepts were tested for statistically significant differences (sustained equality vs. persistent disparities). To assess progress, black LBW rates were compared to white LBW rates, and the trend lines were tested for significant decline. Each county's progress toward black-white equality was ultimately categorized into five possible trend patterns (n = 408): (1) converging LBW rates with reductions in the black LBW rate (decreasing disparities, n = 4, 1%); (2) converging LBW rates due to worsening white LBW rates (n = 5, 1%); (3) diverging LBW rates (increasing disparities, n = 9, 2%); (4) parallel LBW rates (persistent disparities, n = 373, 91%); and (5) overlapping trend lines (sustained equality, n = 18, 4%). Only four counties demonstrated improvement toward equality with decreasing black LBW rates. There is significant county-level variation in progress toward racial equality in adverse birth outcomes such as low birthweight. Still, some communities are demonstrating that more equitable outcomes are possible. Further research is needed in these positive exemplar communities to identify what works in accelerating progress toward more equal birth outcomes.

Pregnancy and Birth Outcomes Among Immigrant Women in the US and Europe: A Systematic Review

Human migration is not a new phenomenon, but it has changed significantly with the advance of globalization. We focus on differences in the published literature concerning migration and health (EU vs the US), centering specifically on reproductive health outcomes. We conducted a literature search in the Pubmed and Embase databases. We reviewed papers that contrast migrants to native-born populations and analyzed differences between countries as well as challenges for future research. The prevalence of low birthweight among migrants varies by the host country characteristics as well as the composition of migrants to different regions. The primary driver of migrant health is the migrant "regime" in different countries at specific periods of time. Future health outcomes of immigrants will depend on the societal characteristics (legal protections, institutions and health systems) of host countries.

Ethnic enclaves and birth outcomes of immigrants from India in a diverse U.S. state

Sociological theory suggests that ethnic enclaves promote immigrant health. Existing studies of ethnic enclaves and immigrant birth outcomes have generally focused on blacks and Hispanics, while few have focused on immigrants from India - the second largest immigrant group in the U.S., after Mexicans. Paradoxically, this group generally exhibits worse birth outcomes than non-Hispanic whites, despite their high levels of education. This study investigates associations between residence in South Central Asian ethnic enclaves and both birth outcomes and prenatal behaviors of immigrant mothers from India, using population-level birth record data from the state of New Jersey in the U.S. (1999-2012; n = 64,375). Results indicate that residence in a South Central Asian enclave is associated with less prenatal smoking and earlier prenatal care, but not with birthweight- or gestational-age related outcomes, among immigrant mothers from India. These findings are consistent with theory suggesting that social support, social capital, and social norms transmitted through the social networks present in ethnic enclaves foster health-promoting behaviors. Notably, the prenatal behaviors of non-Hispanic white mothers were not associated to a large degree with living in South Central Asian enclaves, which is also consistent with theory and bolsters our confidence that the observed associations for immigrant mothers from India are not spurious.

Ethnic density of regions and psychiatric disorders among ethnic minority individuals

BACKGROUND

Ethnic minorities form an increasingly large proportion of Canada's population. Living in areas of greater ethnic density may help protect mental health among ethnic minorities through psychosocial pathways such as accessibility to culturally appropriate provision of mental health care, less discrimination and a greater sense of belonging. Mood and anxiety disorders are common psychiatric disorders.

AIM

This study examined whether ethnic density of regions was related to mood and anxiety disorders among ethnic minorities in Canada.

METHOD

Responses by ethnic minority individuals to the 2011-2014 administrations of the Canadian Community Health Survey ( n =  33,201) were linked to health region ethnic density data. Multilevel logistic regression was employed to model the odds of having mood and/or anxiety disorders associated with increasing region-level ethnic density and to examine whether sense of community belonging helped explain variance in such associations. Analyses were adjusted for individual-level demographic factors as well as region-level socio-economic factors.

RESULTS

Higher ethnic density related to lower odds of mood and/or anxiety disorders for Canadian-born (but not foreign-born) ethnic minorities. Sense of community belonging did not help explain such associations, but independently related to lower odds of mood and/or anxiety disorders. These findings remained after adjusting for regional population density and after excluding (rural/remote) regions of very low ethnic density.

CONCLUSION

Ethnic density of regions in Canada may be an important protective factor against mental illness among Canadian-born ethnic minorities. It is important to better understand how, and for which specific ethno-cultural groups, ethnic density may influence mental health.

Addressing reproductive health disparities as a healthcare management priority: pursuing equity in the era of the Affordable Care Act

PURPOSE OF REVIEW

To summarize the newest available evidence on maternal and reproductive health disparities, and to describe elements of the Affordable Care Act most likely to impact these disparities.

RECENT FINDINGS

Significant racial and ethnic disparities in maternal and reproductive health outcomes have persisted in recent years, contributing to poor outcomes and increasing costs. Pregnancy-related mortality ratios are up to three times higher in Black women compared with non-Hispanic White women, with the risk of severe maternal morbidity also significantly higher in Black and Hispanic women. Unintended pregnancy is twice as likely in minority women. Insurance status, socioeconomic status, and broader social determinants of health are implicated in these disparities. Coverage changes associated with the Affordable Care Act may provide some opportunities to reach communities most at risk. Delivery innovation, payment reform, and further public financing of key services are examples of further management approaches that can be used to address reproductive health disparities.

SUMMARY

The Affordable Care Act offers important opportunities to address persistent reproductive health disparities, but significant gaps remain. Efforts must be made to reduce the negative outcomes and high financial and human costs associated with disparities in reproductive health.

Mortality of New York children with sickle cell disease identified through newborn screening

PURPOSE

Long-term follow-up of newborn screening for conditions such as sickle cell disease can be conducted using linkages to population-based data. We sought to estimate childhood sickle cell disease mortality and risk factors among a statewide birth cohort with sickle cell disease identified through newborn screening.

METHODS

Children with sickle cell disease identified by newborn screening and born to New York residents in 2000-2008 were matched to birth and death certificates. Mortality rates were calculated (using numbers of deaths and observed person-years at risk) and compared with mortality rates for all New York children by maternal race/ethnicity. Stratified analyses were conducted to examine associations between selected factors and mortality.

RESULTS

Among 1,911 infants with sickle cell disease matched to birth certificates, 21 deaths were identified. All-cause mortality following diagnosis was 3.8 per 1,000 person-years in the first 2 years of life and 1.0 per 1,000 person-years at ages 2-9 years. The mortality rate was significantly lower among children of foreign-born mothers and was significantly higher among preterm infants with low birth weight. The mortality rates were not significantly higher for infants after 28 days with sickle cell disease than for all New York births, but they were 2.7-8.4 times higher for children 1 through 9 years old with homozygous sickle cell disease than for those of all non-Hispanic black or Hispanic children born to New York residents.

CONCLUSION

Estimated mortality risk in children with homozygous sickle cell disease remains elevated even after adjustment for maternal race/ethnicity. These results provide evidence regarding the current burden of child mortality among children with sickle cell disease despite newborn screening.Genet Med 17 6, 452-459.