Stress, Inflammation and Preterm Birth in African American Women

A qualitative exploration of perceptions of the aetiology of preterm birth among pregnant Black women

BACKGROUND

Preterm birth (PTB; <37 weeks completed gestation) is a significant public health problem with both acute and long-term ramifications for individuals and families. Despite decades of research, inequities in health outcomes persist in the United States such that Black women are nearly 1.6 times more likely to experience PTB compared to white women. In order to adequately address persistent inequities in PTB, more must be understood from the nuanced experiences of Black women. The purpose of this qualitative study was to explore how pregnant Black women perceive the aetiology of PTB.

METHODS

Data were collected as part of the Biosocial Impact on Black Birth (BIBB) study which prospectively explored the structural and maternal factors on birth outcomes among self-identified Black women between the ages of 18 and 45 who had singleton pregnancies and were between 8- and 30-weeks' gestation. Semi-structured interviews were conducted remotely using telephone, were anonymized and transcribed, and analysed using thematic analysis.

RESULTS

A total of 61 participants completed interviews. Three main themes developed: (1) Doing Too Much; (2) Black Women Have it Harder; and (3) Patriarchy and Privilege.

CONCLUSION

There is a complex and layered structure in place for Black women which reinforces that the responsibility for PTB belongs to those who experience it the most. Although study participants alluded to the structural vulnerabilities and intersectional stigma, participants turned inward to themselves and to their group identity to explain PTB.

Preterm Birth in African American Women: A Multi-Omic Pilot Study in Early Pregnancy

Preterm birth (PTB; <37 weeks completed gestation) is a devastating problem affecting over 13 million live births worldwide. In the U.S., African Americans experience significantly higher rates of PTB compared to non-Hispanic Whites. PTB disparities have been linked to social determinants of health (e.g., socioeconomic status, discrimination). However, the biological underpinnings related to these associations are unclear. DNA methylation (DNAm) is subject to environmental influences, and DNAm modifications are known to affect gene expression. Using a multi-omic approach, we examined differences in combined DNA methylation (DNAm) and messenger RNA (mRNA) transcriptomic data from 20 pregnant African American women (12 PTB; 8 term birth) early in pregnancy (8-18 weeks gestation). We found that the HLA-DQB2 gene was both differentially methylated (cg12296550; p = .02) and differentially expressed (p = .014; log2FC = 2.5) between women with PTB and term birth. Gene expression analysis showed HLA-DQB2 and HLA-DRB4 (p = .028; log2FC = -3.6) were the two most highly expressed genes. HLA-DQB2 expressed higher in PTB and HLA-DRB4 expressed higher in term birth. However, no genes remained significant (p < .05) after Bonferroni correction. HLA-DRB4 and AKR1C1 were identified as a potential biomarkers in dimensionality reduction models and are also important to immune function and allogenic breakdown. Altered gene expression may lead to inflammatory imbalances or allogenic intolerance resulting in PTB. This study provides proof-of-concept evidence for the feasibility and importance of future multi-omics studies with larger populations to further explore the genes and pathways identified here.

Influence of Mother-Father Relationship on Perceived Stress among Black Pregnant Women

BACKGROUND

Perceived stress during pregnancy has been associated with adverse maternal health and birth outcomes. Compared to White pregnant women, Black pregnant women in the United States report higher levels of perceived stress and experience higher rates of maternal mortality and preterm birth. Mother-father relationship has been associated with perceived stress among pregnant women, though literature among Black pregnant women is limited.

OBJECTIVE

We aimed to examine the associations of mother-father relationship with perceived stress among Black pregnant women.

METHODS

Using a cross-sectional, correlational design, we conducted a secondary analysis of data obtained from 418 Black pregnant women enrolled in the Biosocial Impact on Black Births study. Participants completed questionnaires between 19- and 29 weeks gestation with items related to maternal characteristics, measures of the mother-father relationship, including the level of contact, involvement, closeness, support, and conflict with the father of the baby (FOB), and maternal perceived stress.

RESULTS

Participants who reported lower levels of support (ρ[416] = -0.279, P < .001) and higher levels of conflict (ρ[416] = 0.401, P < .001) with the FOB also reported higher levels of perceived stress. Levels of involvement, closeness, support, and conflict with FOB also predicted levels of maternal perceived stress after controlling for covariates.

CONCLUSIONS

These findings suggest that the mother-father relationship significantly influences perceived stress among Black pregnant women, thus warranting further study and intervention.

Prenatal chronic inflammation and children's executive function development

Fetal inflammation, typically measured indirectly through prenatal maternal cytokine markers, has been shown to impact early childhood executive functions (EFs), which are central to later cognitive and life outcomes. Here, we assessed the impact of prenatal inflammation on EF developmental trajectories using direct placenta histopathology measures in 131 mothers who predominantly self-identified as Black (90.8% Black; 0.8% Asian American, 1.5% biracial, 0.8% Latinx, 3.1% White, 3.1% Missing). We found that placental measures of inflammation were associated with limited gain in EF development from 3 to 5 years old. In follow up analyses, we addressed whether screening questionnaires in infancy might aid in classification of infants as higher risk for subsequent EF problems. We found that parent responses to the Ages & Stages Questionnaire and the Infant/Toddler Sensory Profile at 12 months predict the development of EF abilities in children exposed to chronic inflammation. These findings open promising opportunities for early screening of children at risk for poor executive functioning in children exposed to prenatal inflammation.

A Mixed Methods Approach to Understand Mother-Father Relationship and Perceived Stress Among Black Pregnant Women

BACKGROUND

Black women in the United States report moderate to high levels of perceived stress during pregnancy. Though lower levels of involvement and support from father of the baby (FOB) and higher levels of conflict have been associated with higher levels of maternal perceived stress, it is not clear how Black pregnant women experience the mother-father relationship and its influence on perceived stress.

PURPOSE

To examine and describe the mother-father relationship and its role in experiences of perceived stress from the perspective of Black pregnant women.

METHODS

Using a convergent, mixed methods approach with ideal-type analysis, we conducted a secondary analysis of data among 60 Black pregnant women enrolled in the Biosocial Impact on Black Births study. Women completed online self-report questionnaires and participated in a semi-structured interview by telephone.

RESULTS

Participants who reported more conflict with FOB also reported higher levels of perceived stress (ρ(47) = .431, P= .002). Themes (importance, communication, support, conflict, satisfaction, and stress) emerged from the data. Five distinct mother-father relationship typologies were identified following an ideal-type analysis of the combined dataset: Cared For; Managing Expectations; Just Friends, For the Kids; It's Complicated; and Can't be Bothered.

CONCLUSIONS

These findings are an innovative exemplar of ideal-type analysis and provide a deeper understanding of the nuance and dynamics within the mother-father relationship and how it influences perceived stress among Black pregnant women.

IMPLICATIONS

Clinicians must recognize the significance of the mother-father relationship and, when appropriate, encourage paternal involvement or intervene if there is conflict during pregnancy.

The Social Context of Pregnancy, Respectful Maternity Care, Biomarkers of Weathering, and Postpartum Mental Health Inequities: A Scoping Review

Background: Mental health disorders are the number one cause of maternal mortality and a significant maternal morbidity. This scoping review sought to understand the associations between social context and experiences during pregnancy and birth, biological indicators of stress and weathering, and perinatal mood and anxiety disorders (PMADs). Methods: A scoping review was performed using PRISMA-ScR guidance and JBI scoping review methodology. The search was conducted in OVID Medline and Embase. Results: This review identified 74 eligible English-language peer-reviewed original research articles. A majority of studies reported significant associations between social context, negative and stressful experiences in the prenatal period, and a higher incidence of diagnosis and symptoms of PMADs. Included studies reported significant associations between postpartum depression and prenatal stressors (n = 17), socioeconomic disadvantage (n = 14), negative birth experiences (n = 9), obstetric violence (n = 3), and mistreatment by maternity care providers (n = 3). Birth-related post-traumatic stress disorder (PTSD) was positively associated with negative birth experiences (n = 11), obstetric violence (n = 1), mistreatment by the maternity care team (n = 1), socioeconomic disadvantage (n = 2), and prenatal stress (n = 1); and inverse association with supportiveness of the maternity care team (n = 5) and presence of a birth companion or doula (n = 4). Postpartum anxiety was significantly associated with negative birth experiences (n = 2) and prenatal stress (n = 3). Findings related to associations between biomarkers of stress and weathering, perinatal exposures, and PMADs (n = 14) had mixed significance. Conclusions: Postpartum mental health outcomes are linked with the prenatal social context and interactions with the maternity care team during pregnancy and birth. Respectful maternity care has the potential to reduce adverse postpartum mental health outcomes, especially for persons affected by systemic oppression.

A review of dairy food intake for improving health for black women in the US during pregnancy, fetal development, and lactation

Pregnancy and lactation are special life stages that require regular nutritional and medical attention to help protect the health of the mother and promote the growth and development of the offspring. Despite an increased focus on maternal and fetal health over the last several decades, the rates of pregnancy-related morbidity and mortality are increasing in the United States (US). On average, Black women who are pregnant or lactating face greater health disparities and birth complications than other racial/ethnic groups in the US. The issues contributing to these disparities are multi-faceted and include sociocultural, economic, medical, and dietary factors. For example, Black women face greater rates of food insecurity, worse access to healthcare, and lower nutrient status when compared to White women. A growing body of research suggests that consuming a healthier dietary pattern is one of the most potent modifiable risk factors associated with improved fertility and reducing pregnancy-related complications. Recent publications have also shed light on the role of dairy foods in improving diet quality and nutrient status among Black women and for impacting maternal and fetal health outcomes, such as preeclampsia, spontaneous abortion, preterm birth, and fetal growth. To support healthy pregnancy and lactation, the current national dietary guidelines recommend the consumption of 3 servings of dairy foods per day. However, the vast majority of Black women in the US are falling short of these recommendations and are not meeting nutrient requirements for calcium and vitamin D. Therefore, strategies that target misconceptions surrounding lactose intolerance and focus on the health value of adequate dairy intake among Black women of child-bearing age may benefit both prenatal and postpartum health. This review presents the current evidence on health disparities faced by pregnant and lactating Black women in the US, and the role of dairy foods in supporting healthy pregnancy, fetal development, and lactation outcomes in this population.

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

Background

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

Methods

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

Results

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

Conclusions

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

The effects of experience of discrimination and acculturation during pregnancy on the developing offspring brain

The experience of ethnic, racial, and structural inequalities is increasingly recognized as detrimental to health, and early studies suggest that its experience in pregnant mothers may affect the developing fetus. We characterized discrimination and acculturation experiences in a predominantly Hispanic sample of pregnant adolescent women and assessed their association with functional connectivity in their neonate's brain. We collected self-report measures of acculturation, discrimination, maternal distress (i.e., perceived stress, childhood trauma, and depressive symptoms), and socioeconomic status in 165 women. Then, we performed a data-driven clustering of acculturation, discrimination, perceived stress, depressive symptoms, trauma, and socioeconomic status variables during pregnancy to determine whether discrimination or acculturation clustered into distinct factors. Discrimination and acculturation styles loaded onto different factors from perceived stress, depressive symptoms, trauma, and socioeconomic status, suggesting that they were distinct from other factors in our sample. We associated these data-driven maternal phenotypes (discrimination and acculturation styles) with measures of resting-state functional MRI connectivity of the infant amygdala (n = 38). Higher maternal report of assimilation was associated with weaker connectivity between their neonate's amygdala and bilateral fusiform gyrus. Maternal experience of discrimination was associated with weaker connectivity between the amygdala and prefrontal cortex and stronger connectivity between the amygdala and fusiform of their neonate. Cautiously, the results may suggest a similarity to self-contained studies with adults, noting that the experience of discrimination and acculturation may influence amygdala circuitry across generations. Further prospective studies are essential that consider a more diverse population of minoritized individuals and with a comprehensive assessment of ethnic, racial, and structural factors.

Neighborhood disinvestment and severe maternal morbidity in the state of California

BACKGROUND

Social determinants of health, including neighborhood context, may be a key driver of severe maternal morbidity and its related racial and ethnic inequities; however, investigations remain limited.

OBJECTIVE

This study aimed to examine the associations between neighborhood socioeconomic characteristics and severe maternal morbidity, as well as whether the associations between neighborhood socioeconomic characteristics and severe maternal morbidity were modified by race and ethnicity.

STUDY DESIGN

This study leveraged a California statewide data resource on all hospital births at ≥20 weeks of gestation (1997-2018). Severe maternal morbidity was defined as having at least 1 of 21 diagnoses and procedures (eg, blood transfusion or hysterectomy) as outlined by the Centers for Disease Control and Prevention. Neighborhoods were defined as residential census tracts (n=8022; an average of 1295 births per neighborhood), and the neighborhood deprivation index was a summary measure of 8 census indicators (eg, percentage of poverty, unemployment, and public assistance). Mixed-effects logistic regression models (individuals nested within neighborhoods) were used to compare odds of severe maternal morbidity across quartiles (quartile 1 [the least deprived] to quartile 4 [the most deprived]) of the neighborhood deprivation index before and after adjustments for maternal sociodemographic and pregnancy-related factors and comorbidities. Moreover, cross-product terms were created to determine whether associations were modified by race and ethnicity.

RESULTS

Of 10,384,976 births, the prevalence of severe maternal morbidity was 1.2% (N=120,487). In fully adjusted mixed-effects models, the odds of severe maternal morbidity increased with increasing neighborhood deprivation index (odds ratios: quartile 1, reference; quartile 4, 1.23 [95% confidence interval, 1.20-1.26]; quartile 3, 1.13 [95% confidence interval, 1.10-1.16]; quartile 2, 1.06 [95% confidence interval, 1.03-1.08]). The associations were modified by race and ethnicity such that associations (quartile 4 vs quartile 1) were the strongest among individuals in the "other" racial and ethnic category (1.39; 95% confidence interval, 1.03-1.86) and the weakest among Black individuals (1.07; 95% confidence interval, 0.98-1.16).

CONCLUSION

Study findings suggest that neighborhood deprivation contributes to an increased risk of severe maternal morbidity. Future research should examine which aspects of neighborhood environments matter most across racial and ethnic groups.

Protective Places: the Relationship between Neighborhood Quality and Preterm Births to Black Women in Oakland, California (2007-2011)

Black women have the highest incidence of preterm birth (PTB). Upstream factors, including neighborhood context, may be key drivers of this increased risk. This study assessed the relationship between neighborhood quality, defined by the Healthy Places Index, and PTB among Black women who lived in Oakland, California, and gave birth between 2007 and 2011 (N = 5418 women, N = 107 census tracts). We found that, compared with those living in lower quality neighborhoods, women living in higher quality neighborhoods had 20-38% lower risk of PTB, independent of confounders. Findings have implications for place-based research and interventions to address racial inequities in PTB.

Examining the Influence of Racial Discrimination on Adverse Birth Outcomes: An Analysis of the Virginia Pregnancy Risk Assessment Monitoring System (PRAMS), 2016-2018

OBJECTIVES

In Virginia, Black women experience higher rates of adverse birth and labor outcomes that may not be explained solely by risky behaviors or social standing. Previous studies have found an association between racial discrimination and adverse birth outcomes; however, their findings may be underpowered due to small sample sizes. The purpose of this study was to examine the relationship between racial discrimination and poor birth outcomes.

METHODS

VA PRAMS (2016-2018) was used for this secondary data analysis of mothers age 15-44. The exposure was measured using two VA PRAMS questions on racial discrimination and information on the outcomes were extracted from birth certificate data. Simple logistic regression was used obtain an association between experiencing racial discrimination and adverse birth outcomes (i.e. preterm birth, low birth weight, and small for gestational age) and to identify risk factors for experiencing racial discrimination. Multivariate logistic regressions were performed after controlling for other covariates.

RESULTS

Virginia women (N = 2634) who experienced racial discrimination had statistically significant increased odds of having a low birth weight infant (OR 2.27; 95% CI 1.18, 4.38); however, when stratified by race, only non-Hispanic Black (n = 540) women had statistically significant increased odds of preterm birth and low birth weight (PTB OR 7.18; 95% CI 2.28, 22.65; LBW OR 3.56; 95% CI 1.28, 9.91).

CONCLUSIONS

Non-Hispanic Black women in Virginia who experience racial discrimination are more likely to have low birth weight and preterm births. Efforts to effectively reduce adverse birth outcomes and eliminate racial inequities must consider upstream, holistic approaches beyond the biomedical model.

Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization

OBJECTIVE

To examine maternal childhood adversity in relation to increased risk for maternal and infant perinatal complications and newborn Neonatal Intensive Care Unit (NICU) admittance.

METHODS

A sample of 164 women recruited at their first prenatal appointment participated in a longitudinal study through 6 weeks postdelivery. Participants self-reported on their adverse childhood experiences (ACEs), negative health risks (overweight/obesity, smoking, and alcohol use), adverse infant outcomes, NICU admittance, and maternal perinatal complications across three pregnancy assessments and one post-birth assessment. Logistic binomial regression analyses were used to examine associations between maternal ACEs and adverse infant outcomes, NICU admittance, and maternal perinatal complications, controlling for pregnancy-related health risks.

RESULTS

Findings showed that women with severe ACEs exposure (6+ ACEs) had 4 times the odds of reporting at least one adverse infant outcome (odds ratio [OR] = 4.33, 95% CI: 1.02-18.39), almost 9 times the odds of reporting a NICU admission (OR = 8.70, 95% CI: 1.34-56.65), and 4 times the odds of reporting at least one maternal perinatal outcome (OR = 4.37, 95% CI: 1.43-13.39).

CONCLUSIONS

The findings demonstrate the extraordinary risk that mothers' ACEs pose for infant and maternal health outcomes over and above the associations with known maternal health risks during pregnancy, including overweight/obesity, smoking, and alcohol use. These results support a biological intergenerational transmission framework, which suggests that risk from maternal adversity is perpetuated in the next generation through biophysical and behavioral mechanisms during pregnancy that negatively affect infant health outcomes.

Power and Efficacy of Maternal Voice in Neonatal Intensive Care Units: Implicit Bias and Family-Centered Care

INTRODUCTION

Implicit bias can lead medical professionals in Neonatal Intensive Care Units (NICUs) to disregard mothers who are Black and economically disadvantaged as they advocate for their infants' health. Disregard can weaken underlying communication principles within the Family-Centered Care (FCC) model of pediatric health in NICUs and increase maternal distress. This study is the first to address communication disregard by examining mothers' perceived power and efficacy of voice with NICU doctors and nurses. We hypothesized that mothers who are Black and economically disadvantaged would report lower efficacy of voice and higher levels of distress as compared to White mothers with higher income.

METHODS

During pre-assessment within a small clinical trial of a parenting intervention, 33 racially and economically diverse mothers, from three Midwest NICUs serving the urban poor, responded to a 14-item measure of maternal power and efficacy of voice and measures of somatization, depression, anxiety and eating/sleeping disorders. Nonparametric examinations assessed the relation of power and efficacy of voice to maternal race, income, and distress.

RESULTS

In contrast to White, higher-income mothers, Black, economically disadvantaged mothers reported lower perceived efficacy of voice with doctors (U = 74.5, d = 0.65) and nurses (U = 74.0; d = .0.66). These mothers with lower perceived efficacy with doctors and nurses, reported higher levels of somatization (U = 16.5, d = 1.14; U = 13.5, d = 1.38, respectively) and eating disorders (U = 14.0, d = 1.29; U = 12.0, d = 1.48, respectively).

DISCUSSION

Study results are discussed within the framework of implicit bias in FCC in the NICU, expanding our understanding of effective communication with economically stressed, Black mothers.

Discrimination and systemic inflammation: A critical review and synthesis

Exposure to discrimination or unfair treatment has emerged as an important risk factor for illness and disease that disproportionately affects racial and ethnic minorities. Discriminatory experiences may operate like other stressors in that they activate physiological responses that adversely affect the maintenance of homeostasis. Research suggests that inflammation plays a critical role in the pathophysiology of stress-related diseases. Recent findings on discrimination and inflammation are discussed. We highlight limitations in the current evidence and provide recommendations for future studies that seek to examine the association between discrimination and inflammation.

Understanding the Steps Toward Mobile Early Intervention for Mothers and Their Infants Exiting the Neonatal Intensive Care Unit: Descriptive Examination

Background

Neonatal intensive care unit (NICU) history, combined with systemic inequities for mothers of nondominant cultures and mothers who are socioeconomically disadvantaged, places infants at an extraordinary risk for poor developmental outcomes throughout life. Although receipt of early intervention (EI) is the best single predictor of developmental outcomes among children with and at risk for early developmental delays, mothers and infants with the greatest needs are least likely to receive EI. Mobile internet-based interventions afford substantial advantages for overcoming logistical challenges that often prevent mothers who are economically disadvantaged from accessing EI. However, the bridge from the NICU to a mobile internet intervention has been virtually unexplored.

Objective

This study aims to examine progression flow from NICU exit referral to an early mobile internet intervention to increase EI access and promote parent mediation of infant social-emotional and communication development.

Methods

Three NICUs serving the urban poor in a Midwestern city were provided support in establishing an electronic NICU exit referral mechanism into a randomized controlled trial of a mobile internet intervention for mothers and their infants. Measurement domains to reflect the bridge to service included each crucial gateway required for navigating the path into Part C EI, including referral, screening, assessment, and intervention access. An iterative process was used and documented to facilitate each NICU in establishing an individualized accountability plan for sharing referral materials with mothers before their NICU exit. Subsequent to the referral, progression flow was documented on the basis of a real-time electronic recording of service receipt and contact records. Mother and infant risk characteristics were also assessed. Descriptive analyses were conducted to summarize and characterize each measurement domain.

Results

NICU referral rates for EI were 3 to 4 times higher for open-shared versus closed-single gatekeeper referral processes. Of 86 referred dyads, 67 (78%) were screened, and of those screened, 51 (76%) were eligible for assessment. Of the 51 assessment-eligible mothers and infants, 35 dyads (69%) completed the assessment and 31 (89%) went on to complete at least one remote coaching intervention session. The dyads who accessed and engaged in intervention were racially and ethnically diverse and experiencing substantial adversity.

Conclusions

The transition from the NICU to home was fraught with missed opportunities for an EI referral. Beyond the referral, the most prominent reason for not participating in screening was that mothers could not be located after exiting the NICU. Stronger NICU referral mechanisms for EI are needed. It may be essential to initiate mobile interventions before exiting the NICU for maintaining post-NICU contact with some mothers. In contrast to a closed, single point of referral gatekeeper systems in NICUs, open, shared referral gating systems may be less stymied by individual service provider biases and disruptions.

How Depressive Symptoms among African American Women Relate to Measures of Social Disorder in Her Childhood and Pregnancy Neighborhood

Pregnant African American women who report higher levels of social disorder (e.g., vacant housing, drug dealing) in their neighborhoods also report higher levels of depressive symptoms. The effects of social disorder in the neighborhood during childhood on depressive symptoms during pregnancy are not known. Also unknown is the interaction between social disorders in the neighborhood during childhood and during pregnancy regarding depressive symptoms during pregnancy. The purpose of this study was to examine whether higher levels of social disorder in the neighborhood during pregnancy buffered the association of social disorder in the neighborhood during childhood (at age 10 as reference) with depressive symptoms during pregnancy among African American women. We conducted a secondary data analysis of 1383 African American women from the Life-course Influences on Fetal Environments (LIFE) Study (Detroit, Michigan, 2009-2011). Women were interviewed in the hospital 24-72 h after the births. The Center for Epidemiological Studies-Depression (CES-D) scale measured depressive symptoms. Scales measuring social disorder in the neighborhood both during childhood and during pregnancy were also included in the interviews. Women with CES-D scores ≥ 16 were younger, were more likely to be single, and had lower levels of education and household income compared with women with CES-D < 16. There was a significant association between women who report social disorder in their neighborhoods during childhood and depressive symptoms during pregnancy. This effect was moderated by measures of social disorder in the neighborhood during pregnancy (p = .037). Women who reported both low levels of social disorder in their neighborhoods during childhood and during pregnancy had the lowest CES-D scores after controlling for maternal age, marital status, years of education, and family income. The model had a good fit to the data (χ²₍₆₎ = 6.36, p = .38). Health care providers should inquire about neighborhood conditions during childhood and during pregnancy and provide referrals for appropriate professional and community support for women who report social disorder in their neighborhoods and depressive symptoms.

Neighborhood Environment and DNA Methylation: Implications for Cardiovascular Disease Risk

Exposure to chronic stress such as living in disadvantaged neighborhoods has been related to cardiovascular disease (CVD). Chronic stress may increase the risk for CVD by increasing levels of systemic inflammation (e.g., higher levels of pro-inflammatory cytokines). Differential DNA methylation of inflammation-related candidate genes is also related to higher risk for CVD. Thus, the purpose of this review was to examine the association of neighborhood disadvantage with DNA methylation. A search of literature was conducted using Scopus, CINAHL, PubMed, Medline, and Embase databases. The keywords neighborhood, neighborhood disorder, neighborhood crime, neighborhood violence, neighborhood safety, built environment, and housing vacancy were combined with the keywords DNA methylation and epigenetics. Five studies were included in this review (n = 3 adult blood samples and n = 2 fetal blood samples). Four of the five studies reported an association of neighborhood socioeconomic status, social environment, and crime with either global or gene-specific DNA methylation. Only two studies examined the association of neighborhood disadvantage with inflammation-related candidate genes. One of these studies found a significant association of neighborhood socioeconomic disadvantage and social environment with DNA methylation in inflammation-related candidate genes. Thus, data are limited on the association between neighborhood disadvantage and DNA methylation of inflammation-related candidate genes, as well as genes in other potential mechanistic pathways including psychosocial stress, toxin response, and adiposity. Future studies should examine these associations and the potential epigenetic mechanisms by which neighborhood disadvantage increases the risk for CVD.

Symptoms of Depression Predict Negative Birth Outcomes in African American Women: A Pilot Study

INTRODUCTION

African American women have higher rates of preterm birth and low-birth-weight infants compared with non-Hispanic white women. Symptoms of depression have also been related to these negative birth outcomes. Lower levels of social support and higher levels of avoidance coping and cortisol have been related to more symptoms of depression in pregnant women. The purpose of this pilot study was to examine the relationships among symptoms of depression, social support, avoidance coping, cortisol, and negative birth outcomes (ie, preterm birth, low-birth-weight infants) in a sample of African American women.

METHODS

This study used a prospective design. A convenience sample of 90 African American women completed questionnaires and had blood drawn in the second trimester of pregnancy. Birth data were collected from medical records.

RESULTS

Based on the Center for Epidemiological Studies-Depression (CES-D) Scale scores, 28% of women were at increased risk for clinical depression (CES-D ≥ 16). Compared to women who gave birth at term, women who had preterm birth had higher CES-D scores (11.67 and 19.0, respectively) and used avoidance coping more often (7.98 and 13.14, respectively). Compared to women with normal-birth-weight infants, women with low-birth-weight infants had higher levels of cortisol (61.75 mcg/dL and 89.72 mcg/dL, respectively). Women at increased risk for clinical depression were 16 times more likely to have preterm birth and 4 times more likely to have low-birth-weight infants. Women with plasma cortisol levels in the top 25th percentile were 7 times more likely to have low-birth-weight infants. Preeclampsia during pregnancy also predicted preterm birth and low-birth-weight infants.

DISCUSSION

Symptoms of depression in pregnancy may predict adverse birth outcomes. Interventions that have the potential to improve the mental health of pregnant women and ultimately birth outcomes need to be explored.

Neighborhood Context and Preterm Delivery among African American Women: the Mediating Role of Psychosocial Factors

Preterm delivery (PTD), or birth before 37 completed weeks of gestation, is a serious public health issue, and racial disparities persist. In a recently published study, perceptions of the residential environment (or neighborhood context) were associated with PTD rates among urban African American women with low educational attainment (≤12 years); however, the mechanisms of these associations are unknown. Given this gap in the literature, we used data from the Life Influences on Fetal Environments Study of postpartum African American women from Metropolitan Detroit, Michigan (2009-2011; n = 399), to examine whether psychosocial factors (depressive symptomology, psychological distress, and perceived stress) mediate associations between perceptions of the neighborhood context and PTD. Validated scales were used to measure women's perceptions of their neighborhood safety, walkability, healthy food availability (higher=better), and social disorder (higher=more disorder). The psychosocial indicators were measured with the Center for Epidemiologic Studies-Depression Scale, Kessler's Psychological Distress Scale (K6), and Cohen's Perceived Stress Scale. Statistical mediation was assessed using an unadjusted logistic regression-based path analysis for estimating direct and indirect effects. The associations between perceived walkability, food availability, and social disorder were not mediated by psychosocial factors. However, perceptions of neighborhood safety were inversely associated with depressive symptoms which were positively associated with PTD rates. Also, higher perceived neighborhood social disorder was associated with higher PTD rates, net of the indirect paths through psychosocial factors. Future research should identify other mechanisms of the perceived neighborhood context-PTD associations, which would inform PTD prevention efforts among high-risk groups.

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.

Exploring the Experience of Life Stress Among Black Women with a History of Fetal or Infant Death: a Phenomenological Study

INTRODUCTION

Disparate birth outcomes among Black women continue to be a major public health problem. Whereas prior research has investigated the influence of stress on Black women's birth outcomes, few studies have explored how stress is experienced among Black women across the life course. The objectives of this study were to describe the experience of stress across the life course among Black women who reported a history of fetal or infant death and to identify stressful life events (SLE) that may not be represented in the widely used SLE inventory.

METHODS

Using phenomenological, qualitative research design, in-depth interviews were conducted with six Black women in Kansas who experienced a fetal or infant death.

RESULTS

Analyses revealed that participants experienced multiple, co-occurring stressors over the course of their lives and experienced a proliferation of stress emerging in early life and persisting into adulthood. Among the types of stressors cited by participants, history of sexual assault (trauma-related stressor) was a key stressful life event that is not currently reflected in the SLE inventory.

CONCLUSION

Our findings highlight the importance of using a life-course perspective to gain a contextual understanding of the experiences of stress among Black women, particularly those with a history of adverse birth outcomes. Further research investigating Black women's experiences of stress and the mechanisms by which stress impacts their health could inform efforts to reduce disparities in birth outcomes. An additional focus on the experience and impact of trauma-related stress on Black women's birth outcomes may also be warranted.

Racial discrimination predicts greater systemic inflammation in pregnant African American women

PURPOSE

Chronic exposure to racial discrimination by pregnant African American women may lead to allostatic overload; thereby, predisposing women to systemic inflammation. Thus, the goal of this study was to examine if experiences of racial discrimination are related to systemic inflammation in pregnant African Americans.

METHODS

A sample of 96 African American women from Chicago completed questionnaires and had blood drawn during the second trimester of pregnancy (19.7±2.5 weeks).

RESULTS

Experiences of racial discrimination were associated with higher cytokine levels of interleukin (IL)-4 (B=2.161, 95% CI = 1.02-3.30, p<.001) and IL-6 (B=1.859, 95% CI=.61-3.11, p=.004) when controlling for covariates.

CONCLUSION

These findings suggest that experiences of racial discrimination may cause physiological wear and tear on the body leading to alteration of immune functions. Nurses should inquire about women's experiences of racial discrimination and make referrals for community or church support groups for women who report racial discrimination.