Low-income African-American mothers' perception of exposure to racial discrimination and infant birth weight

Public drinking water contaminant estimates for birth cohorts in the Environmental Influences on Child Health Outcomes (ECHO) Cohort

BACKGROUND

The United States Environmental Protection Agency (USEPA) regulates over 80 contaminants in community water systems (CWS), including those relevant to infant health outcomes. Multi-cohort analyses of the association between measured prenatal public water contaminant concentrations and infant health outcomes are sparse in the US.

OBJECTIVE

Our objectives were to (1) develop Zip Code Tabulation Area (ZCTA)-level CWS contaminant concentrations for participants in the Environmental Influences on Child Health Outcomes (ECHO) Cohort and (2) evaluate regional, seasonal, and sociodemographic inequities in contaminant concentrations at the ZCTA-level. The ECHO Cohort harmonizes data from over 69 extant pregnancy and pediatric cohorts across the US.

METHODS

We used CWS estimates derived from the USEPA's Six-Year Review 3 (2006-2011) to develop population-weighted, average concentrations for 10 contaminants across 7640 ZCTAs relevant to the ECHO Cohort. We evaluated contaminant distributions, exceedances of regulatory thresholds, and geometric mean ratios (with corresponding percent changes) associated with ZCTA sociodemographic characteristics via spatial lag linear regression models.

RESULTS

We observed significant regional variability in contaminant concentrations across the US. ZCTAs were most likely to exceed the maximum contaminant level for arsenic (n = 100, 1.4%) and the health-protective threshold for total trihalomethanes (n = 3584, 64.0%). A 10% higher proportion of residents who were American Indian/Alaskan Native and Hispanic/Latino was associated with higher arsenic (11%, 95% CI: 7%, 15%; and 2%, 95% CI: 0%, 3%, respectively) and uranium (15%, 95% CI: 10%, 21%; and 9%, 95% CI: 6%, 12%, respectively) concentrations.

IMPACT

Nationwide epidemiologic analyses evaluating the association between US community water system contaminant concentration estimates and associated adverse birth outcomes in cohort studies are sparse because public water contaminant concentration estimates that can be readily linked to participant addresses are not available. We developed Zip Code Tabulation Area (ZCTA)-level CWS contaminant concentrations that can be linked to participants in the Environmental Influences on Child Health Outcomes (ECHO) Cohort and evaluated regional, seasonal, and sociodemographic inequities in contaminant concentrations for these ZCTAs. Future epidemiologic studies can leverage these CWS exposure estimates in the ECHO Cohort to evaluate associations with relevant infant outcomes.

Social Determinants of Premature Birth

Social determinants of health have received increasing attention in public health, leading to increased understanding of how social factors-individual and contextual-shape the health of the mother and infant. However, racial differences in birth outcomes persist, with incomplete explanation for the widening disparity. Here, we highlight the social determinants of preterm birth, with special attention to the social experiences among African American women, which are likely attributed to structural racism and discrimination throughout life.

Exposure to phthalate metabolites, bisphenol A, and psychosocial stress mixtures and pregnancy outcomes in the Atlanta African American maternal-child cohort

BACKGROUND

Consumer products are common sources of exposure for phthalates and bisphenol A (BPA), which disrupt the endocrine system. Psychosocial stressors have been shown to amplify the toxic effects of endocrine disruptors but, information is limited among African Americans (AAs), who experience the highest rates of adverse pregnancy outcomes and are often exposed to the highest levels of chemical and non-chemical stressors. We examined the association between an exposure mixture of phthalate metabolites, BPA, and psychosocial stressors with gestational age at delivery and birthweight for gestational age z-scores in pregnant AA women.

STUDY DESIGN

Participants were enrolled in the Atlanta African American Maternal-Child Cohort (N = 247). Concentrations of eight phthalate metabolites and BPA were measured in urine samples collected at up to two timepoints during pregnancy (8-14 weeks gestation and 20-32 weeks gestation) and were averaged. Psychosocial stressors were measured using self-reported, validated questionnaires that assessed experiences of discrimination, gendered racial stress, depression, and anxiety. Linear regression was used to estimate individual associations between stress exposures (chemical and psychosocial) and birth outcomes. We leveraged quantile g-computation was used to examine joint effects of chemical and stress exposures on gestational age at delivery (in weeks) and birthweight for gestational age z-scores.

RESULTS

A simultaneous increase in all phthalate metabolites and BPA was associated with a moderate reduction in birthweight z-scores (mean change per quartile increase = -0.22, 95% CI = -0.45, 0.0). The association between our exposure mixture and birthweight z-scores became stronger when including psychosocial stressors as additional exposures (mean change per quantile increase = -0.35, 95% CI = -0.61, -0.08). Overall, we found null associations between exposure to chemical and non-chemical stressors with gestational age at delivery.

CONCLUSIONS

In a prospective cohort of AA mother-newborn dyads, we observed that increased prenatal exposure to phthalates, BPA, and psychosocial stressors were associated with adverse pregnancy outcomes.

Fetal Origins of Health Disparities: Transgenerational Consequences of Racism

Despite advances in perinatal medicine, racial disparity in birth outcomes remains a public health problem in the USA. The underlying mechanisms for this long-standing racial disparity are incompletely understood. This review presents transgenerational risk factors for racial disparities in preterm birth, exploring the impact of interpersonal and structural racism, theoretical models of stress, and biological markers of racial disparities.

The Black-White Disparity in Preterm Birth: Race or Racism?

Policy Points Racism is an upstream determinant of health that influences health through many midstream and downstream factors. This Perspective traces multiple plausible causal pathways from racism to preterm birth. Although the article focuses on the Black-White disparity in preterm birth, a key population health indicator, it has implications for many other health outcomes. It is erroneous to assume by default that underlying biological differences explain racial disparities in health. Appropriate science-based policies are needed to address racial disparities in health; this will require addressing racism.

Improving Postpartum and Long-Term Health After an Adverse Pregnancy Outcome: Examining Interventions From a Health Equity Perspective

Gestational diabetes mellitus and hypertensive disorders in pregnancy are adverse pregnancy outcomes (APOs) that affect 15% of pregnancies in the United States. These APOs have long-term health implications, with greater risks of future cardiovascular and chronic disease later in life. In this manuscript, we review the importance of timely postpartum follow-up and transition to primary care after APOs for future disease prevention. We also discuss interventions to improve postpartum follow-up and long-term health after an APO. In recognizing racial and ethnic disparities in APOs and chronic disease, we review important considerations of these interventions through a health equity lens.

Double Impact: A Dyadic Discrimination Model for Poor, Minority, and Pregnant Couples

Frequent daily discrimination compounds the negative health impacts of those with multiple marginalized identities, including pregnant mothers and their children. We used a dyadic, moderated, mediated model of 296 young, expectant, poor, urban, primarily minority couples. In this study, we explored if a multiple pathway discrimination model explained the relationship between multiple marginalized identities and health (depression and stress). We also examined if a mediated (discrimination moderated by gender) model, within a minority-stress and intersectional framework explained the relationship with depression and stress for couples. We observed that frequent daily discrimination was associated with negative health outcomes (depression and stress). Women reported significantly more depression than men. Frequent daily discrimination mediated the relationship between multiple marginalized identities and depression and stress and having a partner with multiple marginations increased one's personal depression and stress. Our observations suggest that discrimination's impact on health is experienced during pregnancy and the more marginalized identities one carries, the more impact it may have. Further, having a partner with multiple marginalized identities also impacts the depression and stress reported by women. Inventions to address depression and stress outcomes may be strengthened by considering multiple marginalized identities and include couples.

Racial discrimination and adverse pregnancy outcomes: a systematic review and meta-analysis

Introduction

Racial discrimination has been consistently linked to various health outcomes and health disparities, including studies associating racial discrimination with patterns of racial disparities in adverse pregnancy outcomes. To expand our knowledge, this systematic review and meta-analysis assesses all available evidence on the association between self-reported racial discrimination and adverse pregnancy outcomes.

Methods

Eight electronic databases were searched without language or time restrictions, through January 2022. Data were extracted using a pre-piloted extraction tool. Quality assessment was conducted using the Newcastle–Ottawa Scale (NOS), and across all included studies using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Random effects meta-analyses were performed on preterm birth and small for gestational age. Heterogenicity was assessed using Cochran’s χ² test and I² statistic.

Results

Of 13 597 retrieved records, 24 articles were included. Studies included cohort, case–control and cross-sectional designs and were predominantly conducted in the USA (n=20). Across all outcomes, significant positive associations (between experiencing racial discrimination and an adverse pregnancy event) and non-significant associations (trending towards positive) were reported, with no studies reporting significant negative associations. The overall pooled odds ratio (OR) for preterm birth was 1.40 (95% CI 1.17 to 1.68; 13 studies) and for small for gestational age it was 1.23 (95% CI 0.76 to 1.99; 3 studies). When excluding low-quality studies, the preterm birth OR attenuated to 1.31 (95% CI 1.08 to 1.59; 10 studies). Similar results were obtained across sensitivity and subgroup analyses, indicating a significant positive association.

Conclusion

These results suggest that racial discrimination has adverse impacts on pregnancy outcomes. This is supported by the broader literature on racial discrimination as a risk factor for adverse health outcomes. To further explore this association and underlying mechanisms, including mediating and moderating factors, higher quality evidence from large ethnographically diverse cohorts is needed.

Family Educational Attainment and Racial Disparities in Low Birth Weight

OBJECTIVES

To evaluate the effect of grandmother and mother educational attainment on low birth weight (LBW) in children and grandchildren.

METHODS

The National Longitudinal Study of Adolescent to Adult Health is a multigenerational study that collected survey data from 1994 to 2018. Using this database, we constructed a cohort of 2867 non-Hispanic Black (NHB) and non-Hispanic White (NHW) grandmother-mother-grandchild triads to evaluate how education affects the likelihood of having LBW children and grandchildren, while adjusting for socioeconomic and maternal health factors using multivariable logistic regression.

RESULTS

Similar to previous studies, NHB women were more likely to have LBW descendants compared with NHW women in unadjusted and adjusted analyses. The prevalence of LBW descendants was lower in women with college education, regardless of race. Irrespective of race, mother and grandmother college education was associated with decreased odds of LBW children and grandchildren after adjusting for individual variables. When mother and grandmother education were examined together, and after adjusting for all individual, community, and health variables together, mother college education remained associated with lower odds of LBW (adjusted odds ratio, 0.58; 95% confidence interval, 0.44-0.77). There were no statistically significant differences in these effects between NHW and NHB populations.

CONCLUSIONS

Educational attainment in mothers is associated with decreased odds of LBW descendants after adjusting for multiple individual, community, and health covariates, regardless of race. Targeting improvements in education may ameliorate adverse pregnancy outcomes that disproportionately affect minority communities and cause significant lifelong consequences.

Maternal perceived stress and the increased risk of preterm birth in a majority non-Hispanic Black pregnancy cohort

OBJECTIVE

To determine whether perceived stress is associated with preterm birth (PTB) and to investigate racial differences in stress and PTB.

STUDY DESIGN

A secondary analysis of a prospective cohort study of 1911 women with singleton pregnancies examined responses to psychosocial stress questionnaires at 16-20 weeks of gestation.

RESULTS

High perceived stress (19%) and PTB (10.8%) were prevalent in our sample (62% non-Hispanic Black). Women with PTB were more likely to be Black, have chronic hypertension (cHTN), pregestational diabetes, and higher BMI. Women with high perceived stress had more PTBs than those with lower stress (15.2% vs. 9.8%), and stress was associated with higher odds of PTB (aOR: 1.55, 95% CI: 1.09-2.19).

CONCLUSION

The significant association between high perceived stress and PTB suggests that prenatal interventions to reduce maternal stress could improve the mental health of pregnant women and may result in reduced rates of PTB.

Immigrant ancestry and birthweight across two generations born in Sweden: an intergenerational cohort study

INTRODUCTION

Differences in birthweight are often seen between migrants and natives. However, whether migrant-native birthweight inequalities widen, narrow or remain persistent across generations when comparing the descendants of immigrants and natives remains understudied. We examined inequalities in birthweight of mothers (G2) and daughters (G3) of foreign-born grandmothers (G1) compared with those of Swedish-born grandmothers.

METHODS

We used population registers with multigenerational linkages to identify 314 415 daughters born in Sweden during the period 1989-2012 (G3), linked to 246 642 mothers (G2) born in Sweden during 1973-1996, and to their grandmothers (G1) who were Swedish or foreign-born. We classified migrants into non-western, Eastern European, the rest of Nordic and Western. We used multivariable methods to examine mean birthweight and low birthweight (<2500 g; LBW).

RESULTS

Birthweight between individuals with Swedish background (G1) and non-western groups increased from -80 g to -147 g between G2 (mothers) and G3 (daughters), respectively. Furthermore, the odds of LBW increased among the G3 non-western immigrants compared with those with Swedish grandmothers (OR: 1.38, 95% CI 1.12 to 1.69). Birthweight increased in both descendants of Swedes and non-western immigrants, but less so in the latter (83 g vs 16 g).

CONCLUSION

We observed an increase in birthweight inequalities across generations between descendants of non-western immigrants and descendants of Swedes. This finding is puzzling considering Sweden has been lauded for its humanitarian approach to migration, for being one of the most egalitarian countries in the world and providing universal access to healthcare and education.

State Policies, Racial Disparities, and Income Support: A Way to Address Infant Outcomes and the Persistent Black-White Gap?

Low birth weight and preterm births vary by state, and Black mothers typically face twice the risk that their white counterparts do. This gap reflects an accumulation of psychosocial and material exposures that include interpersonal racism, differential experience with area-level deprivation such as residential segregation, and other harmful exposures that the authors refer to as "institutional" or "structural" racism. The authors use logistic regression models and a dataset that includes all births from 1994 to 2017 as well as five state policies from this period-Aid to Families with Dependent Children/Temporary Aid for Needy Families, housing assistance, Medicaid, minimum wage, and the earned income tax credit (EITC)-to examine whether these state social policies, designed to provide a financial safety net, are associated with risk reduction of low birth weight and preterm birth to Black and white mothers, and whether variations in state generosity attenuate the racial inequalities in birth outcomes. The authors also examine whether the relationship between state policies and racial inequalities in birth outcomes is moderated by the education level of the mother. We find that the EITC reduces the risk of low birth weight and preterm birth for Black mothers. The impact is much less consistent for white mothers. For both Black and white mothers, the benefits to birth outcomes are larger for mothers with less education.

"Black Nurses in the Home is Working": Advocacy, Naming, and Processing Racism to Improve Black Maternal and Infant Health

OBJECTIVES

1) To explore how racism-related stress impacts Black women's health, pregnancy, and parenting. 2) To explore how a culturally-specific program affects the relationship between racism-related stress and Black women's health, pregnancy, and parenting.

METHODS

This qualitative study uses a Black Feminist approach to center the lived experiences and perspectives of Black women. Focus groups were conducted with clients and staff of a culturally-specific program that provides perinatal care for Black families. A thematic analysis was conducted using a Reproductive Justice framework as a guide.

RESULTS

Participants consisted of 23 program clients and staff who all identified as Black women. Four themes emerged from the analysis: 1) The pervasive reach of structural racism, 2) Shared identities facilitate trust and healing, 3) Racism directly impacts mental health, and 4) Advocacy on macro and micro levels is a vital service.

CONCLUSIONS FOR PRACTICE

Results show the chronicity and toxicity of structural racism on Black women's physical and mental health. The presence of overt and subtle forms of racism occur in multiple systems and require interventions on macro- and micro-levels. Culturally-specific perinatal care programs that prioritize racial concordance between providers and clients/patients are well-received and effective models of care. Black perinatal care should include culturally-specific approaches, advocacy on behalf of and alongside Black people, mental health support with attention to racism-related stress, and interrogation of implicit bias. Multipronged interventions guided by Reproductive Justice principles provide a holistic framework to address interpersonal and systemic racial oppression.

Developing Tools to Report Racism in Maternal Health for the CDC Maternal Mortality Review Information Application (MMRIA): Findings from the MMRIA Racism & Discrimination Working Group

PURPOSE

The purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form.

DESCRIPTION

In the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality.

ASSESSMENT

Charged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs.

CONCLUSION

The working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form.

Stress-Related Mental Health Disorders and Inflammation in Pregnancy: The Current Landscape and the Need for Further Investigation

Many studies have focused on psychoimmunological mechanisms of risk for stress-related mental health disorders. However, significantly fewer studies have focused on understanding mechanisms of risk for stress-related disorders during pregnancy, a period characterized by dramatic changes in both the innate and adaptive immune systems. The current review summarizes and synthesizes the extant literature on the immune system during pregnancy, as well as the sparse existing evidence highlighting the associations between inflammation and mood, anxiety, and fear-related disorders in pregnancy. In general, pregnant persons demonstrate lower baseline levels of systemic inflammation, but respond strongly when presented with an immune challenge. Stress and trauma exposure may therefore result in strong inflammatory responses in pregnant persons that increases risk for adverse behavioral health outcomes. Overall, the existing literature suggests that stress, trauma exposure, and stress-related psychopathology are associated with higher levels of systemic inflammation in pregnant persons, but highlight the need for further investigation as the existing data are equivocal and vary based on which specific immune markers are impacted. Better understanding of the psychoimmunology of pregnancy is necessary to reduce burden of prenatal mental illness, increase the likelihood of a successful pregnancy, and reduce the intergenerational impacts of prenatal stress-related mental health disorders.

State-Level Regulations Regarding the Protection of Sexual Minorities and Birth Outcomes: Results From a Population-Based Cohort Study

OBJECTIVE

We leverage state-level variability in social policies that confer legal protections for sexual minorities (e.g., employment nondiscrimination acts) and examine their association with birth outcomes among sexual minority women.

METHODS

We link measures of structural protections (i.e., social policies) to a prospective, population-based cohort of US adults-the National Longitudinal Study of Adolescent to Adult Health ( n = 7913 total singleton births, n = 274 singleton births to bisexual women, n = 53 singleton births to lesbian women)-which includes measurement of key risk factors for birth outcomes over the life course.

RESULTS

Lesbian, gay, bisexual (LGB) policy protections were associated with better birth outcomes for lesbian women. For example, among lesbian women, the predicted birth weight for infants in states with no policy protections was 3.01 kg (95% confidence interval = 2.71-3.30) but was 3.71 kg (95% confidence interval = 3.46-3.96) in states with three or four policy protections. In negative control analyses, there was no association between LGB policy protections and birth outcomes among the nonstigmatized group (i.e., heterosexual women), providing evidence of specificity. Furthermore, in states with the most LGB policy protections, lesbian women were at lower risk for preterm births and had infants with higher birth weights than heterosexual and bisexual women. These associations remained robust after adjusting for 13 risk factors, including demographics, prior and current indicators of socioeconomic status, preconception and perinatal risk factors, and neighborhood characteristics.

CONCLUSIONS

These results provide novel evidence that sexual orientation-related policy protections, measured at the state level, are associated with a decreased risk for adverse birth outcomes among lesbian women.

Examination of maternal near-miss experiences in the hospital setting among Black women in the United States

INTRODUCTION

The high rate of maternal mortality among Black women in the United States continues to gain attention; yet research has not yet fully illuminated the precursors to these events, most impactful among them being "maternal near misses." A maternal near miss occurs when a woman nearly dies but survives a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy. Researchers have focused on reviewing patient medical records after sentinel maternal events to help determine major contributors to them; however, qualitative studies with near-miss survivors, especially among Black women, may be a more useful approach.

METHODS

Using a qualitative methodology, we conducted semi-structured interviews with 12 Black women to explore how they perceived the care provided to them during their near-miss experiences. Our study also employed a phenomenology framework to understand the lived experience of Black women who had a maternal near miss in the context of a hospital setting.

RESULTS

We interviewed 12 women between October 2020 and March 2021. All participants had a maternal near miss between the years 2010 and 2020 and were aged between 19 and 41 years when they had their near-miss experience. These women identified communication, patient-provider relationship, skills/competency of staff, provider discrimination, systems issues, and emotional distress as major contributors to their experiences.

CONCLUSION

Maternal near misses serve as a precursor to maternal mortality events. By listening to patients and their families recount their perspectives on what leads up to these near misses, we can unearth valuable lessons that can aid in the development of strategies and interventions to decrease the numbers of pregnancy-related deaths; especially among Black women who suffer disproportionately from maternal morbidity and mortality. Based on these findings, we recommend that hospitals and OB-GYN practices consider the unique predispositions of their Black patients; account for their own personal biases, revisit the near-miss experiences of past patients to keep patients central to care and build rapport between patients and hospital birthing support staff; and center discussions about improvements in care around racist structures and systems.

Embedding Population Health in Physical Therapist Professional Education

The future of health care professional education is moving from a focus on the individual to embrace the health of the larger society. The COVID-19 pandemic has further highlighted the connection between social determinants and the health of populations. There are frameworks and competencies to support the delivery of population health content in the entry-level Doctor of Physical Therapy (DPT) curriculum. Three options for integrating population health content into the DPT curriculum are presented: (1) threading the content throughout the curriculum, (2) concentrating the content in 1 or 2 identified courses, and (3) offering elective courses. Each of these strategies has benefits and challenges, but threading the content throughout the curriculum provides the best opportunity to reinforce population health competencies across populations and practice settings. Experiential learning using authentic scenarios provides an ideal opportunity for students to understand population health concepts in a real-world context. Activities that incorporate interaction with other health professions broaden students' perspectives of the role of different professions for achieving population health goals. Examples of learning activities are included in 3 competency areas, Foundations of Population Health, Prevention and Health Promotion, and Health Policy. Current societal issues provide an opportunity to enhance population health education from a meaningful perspective for students. The topic of health equity presents an opportunity to tie social and political factors of population health to social justice and health outcomes. Similarly, the COVID-19 pandemic puts issues of mental health, health disparities, and health systems front and center in our understanding of population health.

IMPACT

Health care practitioners are looking at health through the lens of health equity and acknowledging the impact of social and political determinants on health to address health disparities, decrease health care expenditures, and respond to changes necessitated by pandemics such as COVID-19. As health care systems and practices are rethought and reconstructed, the intentional integration of population health principles woven into the fabric of professional education is a critical component of preparing future providers. This article describes how population health concepts can be meaningfully embedded into the DPT curriculum along with providing realistic examples and activities.

Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

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.

Direct and Vicarious Racial Discrimination at Three Life Stages and Preterm Labor: Results from the African American Women's Heart & Health Study

INTRODUCTION

Health disparities research has demonstrated a negative relationship between racial discrimination and African American women's maternal health outcomes. Yet, the relationship between racial discrimination and preterm labor, a key measure of maternal health, remains understudied. This study sought to examine the associations between preterm labor and direct and vicarious racial discrimination among African American women at three life stages: childhood, adolescence, and adulthood.

METHODS

Logistic regression methods were used to analyze cross-sectional data from the African American Women's Heart & Health Study (AAWHHS; N = 173). The AAWHHS includes detailed maternal health information on a community sample of African American women residing in the San Francisco Bay Area.

RESULTS

Findings indicated each unit increase in adolescent direct racial discrimination was associated with a 48% increase in the odds of preterm labor (OR: 1.480, 95% CI 1.002-2.187, p < 0.05) and each unit increase in childhood vicarious racial discrimination was associated with a 45% increase in the odds of preterm labor (OR: 1.453, 95% CI 1.010-2.092, p < 0.05) after adjusting for number of pregnancies and socioeconomic variables.

DISCUSSION

This study provides evidence of an association between life-stage racial discrimination and preterm labor risk among African American women, underscoring a need to consider how both directly and vicariously experienced racial discrimination at different developmental periods impact racial disparities in birth outcomes.

Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action

BACKGROUND

Many pregnant people find no bridge to ongoing specialty or primary care after giving birth, even when clinical and social complications of pregnancy signal need. Black, indigenous, and all other women of color are especially harmed by fragmented care and access disparities, coupled with impacts of racism over the life course and in health care.

METHODS

We launched the initiative "Bridging the Chasm between Pregnancy and Health across the Life Course" in 2018, bringing together patients, advocates, providers, researchers, policymakers, and systems innovators to create a National Agenda for Research and Action. We held a 2-day conference that blended storytelling, evidence analysis, and consensus building to identify key themes related to gaps in care and root causes of inequities. In 2019, more than 70 stakeholders joined six working groups to reach consensus on strategic priorities based on equity, innovation, effectiveness, and feasibility.

FINDINGS

Working groups identified six key strategic areas for bridging the chasm. These include: 1) progress toward eliminating institutional and interpersonal racism and bias as a requirement for accreditation of health care institutions, 2) infrastructure support for community-based organizations, 3) extension of holistic team-based care to the postpartum year and beyond, with integration of doulas and community health workers on the team, 4) extension of Medicaid coverage and new quality and pay-for-performance metrics to link maternity care and primary care, 5) systems to preserve maternal narratives and data across providers, and 6) alignment of research with women's lived experiences.

CONCLUSIONS

The resulting agenda presents a path forward to remedy the structural chasms in women's health care, with key roles for advocates, policymakers, researchers, health care leaders, educators, and the media.

The Racial Configuration of Parent Couples and Premature Birth: an Analysis of the Utah Population Database

In this paper, we analyze detailed maternal and paternal race information in a 25-year time series of birth record data to consider racial inequities in premature births experienced by women of color and women within interracial parent couples. We analyze birth outcomes within Utah, a historically racially homogeneous state experiencing growing racial diversity and interracial marriage over the past two decades. Our analyses consider disparities in preterm birth according to maternal race and the interracial status of couples for all birth certificate records within the Utah Population Database from 1989 to 2015 (N = 1,148,818). Our results, consistent with a dyadic perspective on minority stress, indicate that maternal race and interracial parent-couple status are each significantly associated with heightened risk of premature birth. The odds of preterm birth are significantly greater among all four racialized groups in the analyses (African Americans, Asians, Native Americans, and Native Hawaiian or Pacific Islanders) as compared to White women. Furthermore, we find that mothers in mixed-race parent couples with either a white or a black father experience a greater risk of preterm birth than mothers parenting with a father of the same race. Our results suggest that in order to capture the complete perspective on racial-ethnic disparities in adverse birth outcomes, outcomes pivotal for subsequent health outcomes over the life course, it is critical to address racism's toxic effects across multiple levels of lived experience-from the individual level, to the parent dyad, to the local community and beyond.

The Association between Maternal Experiences of Interpersonal Discrimination and Adverse Birth Outcomes: A Systematic Review of the Evidence

In the present systematic review, we argue that maternal experiences of interpersonal discrimination at least partially account for the disproportionate rates of adverse birth outcomes in minority populations. Since the 1990s, research in this area has slowly, but steadily increased, shedding more light on the insidious nature of interpersonal discrimination and its toxic health effects. With the aim of bringing this topic to the fore in academic as well as clinical settings, this paper provides a state-of-the-art review of the empirical knowledge on the relationship between maternal experiences of discrimination and birth outcomes. Of 5901 articles retained in the literature search, 28 met the predefined inclusion criteria. Accounting for a range of health and behavioral factors, the vast majority of these studies support the notion that maternal experiences of interpersonal discrimination predict a range of adverse birth outcomes, including preterm birth, low birth weight, and various physiological markers of stress (allostatic load) in both mother and child pre- and postpartum. Several moderators and mediators of this relationship were also identified. These related primarily to the type (first-hand and vicarious), timing (childhood, adolescence, and adulthood), frequency, and pervasiveness of discrimination experienced, as well as to maternal mental health and coping. More research into these factors, however, is required to definitively determine their significance. We discuss these findings as they relate to the general health repercussions of interpersonal discrimination, as well as in terms of applied prenatal care and interventions. Ultimately, we argue that assessing maternal experiences of interpersonal discrimination in prenatal care may represent a considerable asset for mitigating existing majority-minority disparities in adverse birth outcomes.

Application of the Weathering Framework: Intersection of Racism, Stigma, and COVID-19 as a Stressful Life Event among African Americans

The disproportionate impact of coronavirus disease 2019 (COVID-19) on African American communities necessitates an increased focus on the intersectional roles of racism, stigma, and other social determinants of health in influencing disease and mortality risk. The Weathering Framework is applied to demonstrate the dynamic interrelationships between these factors and to conceptualize COVID-19 as a stressful life event that will have profound health implications over the life course for African Americans. Recommendations for population health research, interventions and policies aimed at reducing COVID-19 incidence and mortality, and mitigation of the long-term impacts of the pandemic on communities of color are discussed.

Phenotyping stress exposures related to perinatal health disparities

Black American women living in low-resource environments are exposed to multiple stressors and are at high risk for perinatal complications. Stress exposure likely impacts pregnancy and birth complications via alterations in health systems that are engaged in regulating the stress response. Stressors may vary in terms of magnitude and pattern of effect on such health systems. In the present study, we test associations between three types of stress exposure: perceived stress, negative life events, and discrimination stress on neuroendocrine and cardiac response to a controlled laboratory stressor during the first trimester of pregnancy. In all, 100 pregnant Black women with Medicaid insurance completed a laboratory assessment during which salivary cortisol and heart rate variability (HRV) were used to measure stress response to the Trier Social Stress Test (TSST). Results revealed that only discrimination stress was significantly associated with cortisol and HRV in response to the TSST. High levels of discrimination stress were associated with lower levels of cortisol reactivity and higher levels of HRV across the visit. These results highlight the differential impact of domains of stress exposure on stress regulation during pregnancy and provide further evidence of the impact of discrimination stress on Black American women's health.

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.

Exposures to structural racism and racial discrimination among pregnant and early post-partum Black women living in Oakland, California

Research supports that exposure to stressors (e.g., perceived stress and racism) during pregnancy can negatively impact the immune system, which may lead to infection and ultimately increases the risk for having a preterm or low-birthweight infant. It is well known that Black women report higher levels of stressors at multiple timepoints across pregnancy compared with women of all other racial and ethnic groups. This study addresses gaps in the literature by describing pregnant and early post-partum Black women's exposures to structural racism and self-reported experiences of racial discrimination, and the extent to which these factors are related. We used a cross-sectional study design to collect data related to exposures to racism from pregnant and early post-partum Black women residing in Oakland, California, from January 2016 to December 2017. Comparative analysis revealed that living in highly deprived race + income neighborhoods was associated with experiencing racial discrimination in three or more situational domains (p = .01). Findings show that Black women are exposed to high levels of racism that may have negative impacts on maternal health outcomes.

Multiple forms of discrimination and postpartum depression among indigenous Palestinian-Arab, Jewish immigrants and non-immigrant Jewish mothers

Background

While discrimination takes multiple forms, racial or ethnic discrimination is a root cause of this health-damaging social phenomenon. We drew on intersectionality theory, which offers an account of discrimination’s multiple effects, to consider associations between women’s experiences of discrimination and postpartum depression (PPD) using four measures: single forms of discrimination (SFD); multiple forms of discrimination (MFD); ethnic discrimination combined with MFD (E-MFD); and a composite MFD that interacted with women’s identity (C-MFD).

Methods

We interviewed a stratified sample of 1128 mothers face to face in 2014–2015 during mothers’ visits to maternal and child health clinics. The mothers belonged to three groups in Israel: Palestinian-Arab minority, Jewish immigrant, and non-immigrant Jewish. We conducted unadjusted and adjusted logistic regressions for PPD, measured on the Edinburgh Postnatal Depression Scale, in associations with SFD (experiencing discrimination based on any of the following: age, sex, class, ethno-national identity, religiosity level and skin color); MFD (experiencing 0,1, 2 or ≥ 3 of SFD); E-MFD (ethnic discrimination combined with other MFD); and finally, C-MFD (interaction between MFD and women’s identity).

Results

Palestinian-Arab mothers had higher PPD and reported higher SFD (based on ethnicity, religiosity level, and socioeconomic status), as well as higher MFD and E-MFD. This was followed by Jewish immigrant mothers, and lastly by non-immigrant Jewish mothers. However, both MFD and E-MFD had a strong association with PPD among non-immigrant Jewish mothers reporting 2MFD and ≥ 3MFD, and Palestinian-Arab mothers reporting ≥3MFD, but no significant association among immigrant Jewish mothers. When we used C-MFD, we found a dose-response association in which Palestinian-Arab mothers experiencing more MFD (2MFD and ≥ 3MFD) were more likely to experience PPD. This was followed by immigrant Jewish mothers (reporting 2MFD and ≥ 3MFD), and lastly by non-immigrant Jewish mothers.

Conclusions

MFD should be considered in relation to women’s identity (being part of a minority, immigrant, or non-immigrant majority group) in maternal mental health research and practice. Otherwise, we risk underestimating the effects of MFD on PPD, especially in minority and immigrant mothers, who are more likely to face interlocking forms of discrimination.

Maternal experiences of ethnic discrimination and subsequent birth outcomes in Aotearoa New Zealand

Background

Interpersonal discrimination experience has been associated with adverse birth outcomes. Limited research has evaluated this relationship within multicultural contexts outside the United States where the nature and salience of discrimination experiences may differ. Such research is important in order to help identify protective and risk factors that may mediate the relationship between discrimination experience and adverse birth outcomes.

Methods

Evaluated the relationship between perceived discrimination, as measured in pregnancy, with birth weight and gestation length among Māori, Pacific, and Asian women from Aotearoa New Zealand (N = 1653).

Results

Thirty percent of the sample reported some type of unfair treatment that they attributed to their ethnicity. For Māori women specifically, unfair treatment at work (β = − 243 g) and in acquiring housing (β = − 146 g) were associated with lower birth weight when compared to Māori women not experiencing these types of discrimination, while an ethnically motivated physical attack (β = − 1.06 week), and unfair treatment in the workplace (β = − 0.95 week), in the criminal justice system (β = − 0.55 week), or in banking (β = − 0.73 week) were associated with significantly shorter gestation.

Conclusions

Despite a high prevalence of discrimination experience among women from all ethnic groups, discrimination experience was a strong predictor of lower birth weight and shorter gestation length among indigenous Māori women only. Additional research is needed to better understand the risk and protective factors that may moderate the relationship between discrimination experience and adverse birth outcomes among women from different ethnic groups.

Identifying the Key Elements of Racially Concordant Care in a Freestanding Birth Center

INTRODUCTION

There is empirical evidence that the quality of interpersonal care patients receive varies dramatically along racial and ethnic lines, with African American people often reporting much lower quality of care than their white counterparts. Improving the interpersonal relationship between clinicians and patients has been identified as one way to improve quality of care. Specifically, research has identified that patients feel more satisfied with the care that they receive from clinicians with whom they share a racial identity. However, little is known about how clinicians provide racially concordant care. The goal of this analysis was to identify the key components of high-quality care that were most salient for African American birthworkers providing perinatal care to African American patients.

METHODS

We conducted semistructured interviews (30 to 90 minutes) with clinicians (N = 10; midwives, student midwives, and doulas) who either worked at or worked closely with an African American-owned birth center in North Minneapolis, Minnesota. We used inductive coding methods to analyze data and to identify key themes.

RESULTS

Providing racially concordant perinatal care to African American birthing individuals required clinicians to acknowledge and center the sociocultural realities and experiences of their patients. Four key themes emerged in our analysis. The first overarching theme identified was the need to acknowledge how cultural identity of patients is fundamental to the clinical encounter. The second theme that emerged was a commitment to racial justice. The third and fourth themes were agency and cultural humility, which highlight the reciprocal nature of the clinician-patient relationship.

DISCUSSION

The most salient aspect of the care that birthworkers of color provide is their culturally centered approach. This approach and all subsequent themes suggest that achieving birth equity for pregnant African American people starts by acknowledging and honoring their sociocultural experiences.

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

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

Obstetric Racism: The Racial Politics of Pregnancy, Labor, and Birthing

In this article, I analyze the birth stories of Black women living in the United States. Their birth stories describe various forms of racism during medical encounters while they were pregnant or during labor and delivery. In the global women's health arena, the issues raised are viewed as obstetric violence. However, obstetric racism-as both an occurrence and analytic-best captures the particularities of Black women's reproductive care during the pre- and post-natal period. Obstetric racism is a threat to positive birth outcomes. I argue that birth workers including midwives and doulas, mediate obstetric racism and stratified reproductive outcomes.

Racial discrimination and leukocyte glucocorticoid sensitivity: Implications for birth timing

RATIONALE

Psychological stress-induced cortisol elevations appear to contribute to preterm birth. Yet, some studies suggest that the biological ramifications of racial discrimination-associated stress are unique and may involve development of decreased glucocorticoid sensitivity despite normalized cortisol levels.

OBJECTIVE

In this study, we examined the effects of racial discrimination on maternal cortisol output, leukocyte glucocorticoid sensitivity, and the degree of correspondence between cortisol levels and birth timing in an African American cohort.

METHOD

A generally healthy prospective cohort was enrolled at 28-32 weeks gestation (n = 91). The Experiences of Discrimination scale was administered, whole blood collected, and plasma cortisol levels, cytokine levels, and leukocyte counts quantified for examination of patterns of endogenous feedback.

RESULTS

Racial discrimination in the mid-tertile was associated with greater maternal cortisol levels than the bottom tertile among women reporting internalizing responses (b* = 0.68, p = 0.001). Decreased leukocyte glucocorticoid sensitivity was witnessed at greater frequencies of experiences of racial discrimination, as evidenced by decreased correspondence between maternal cortisol levels and plasma IL-8 levels, monocyte counts, and lymphocyte counts (p values ≤ 0.043). The association between maternal cortisol levels and birth timing differed by discrimination tertile (p values ≤ 0.005), with greater cortisol levels predictive of earlier birth among women without (b* = -0.59, p < 0.001) but not with racial discrimination (ps ≥ 0.497).

CONCLUSION

We provide novel evidence of decreased glucocorticoid sensitivity at increasing frequency of exposure to racial discrimination. Our findings suggest that the biology of preterm birth may depend upon racial discriminatory exposures, favoring pathways dependent upon glucocorticoid-induced increases in leukocyte tissue surveillance versus glucocorticoid resistance-associated inflammatory aberrations at increasing levels of exposure. Precision approaches to prenatal care are sorely needed to combat preterm birth, particularly among African American women, with efforts dependent upon further research examining the pathways contributing to the syndrome dependent upon the totality of an individual's exposures.

Is Perceived Discrimination in Pregnancy Prospectively Linked to Postpartum Depression? Exploring the Role of Education

Objectives The role of perceived discrimination in postpartum depression is largely unknown. We investigate whether perceived discrimination reported in pregnancy contributes to postpartum depression, and whether its impact varies by education level. Methods Prospective data are a part of European Longitudinal Study of Pregnancy and Childhood, the Czech Republic. Surveys were collected in mid-pregnancy and at 6 months after delivery. Depression was measured using Edinburgh Postnatal Depression Scale. Generalized linear models were estimated to test the effects of perceived discrimination on postpartum depression. Results Multivariate models revealed that among women with low education, discrimination in pregnancy was prospectively associated with 2.43 times higher odds of postpartum depression (p < .01), after adjusting for antenatal depression, history of earlier depression, and socio-demographic background. In contrast, perceived discrimination was not linked to postpartum depression among women with high education. Conclusions Perceived discrimination is a risk factor for postpartum depression among women with low education. Screening for discrimination and socio-economic disadvantage during pregnancy could benefit women who are at risk for mental health problems.

Black/White disparities in pregnant women in the United States: An examination of risk factors associated with Black/White racial identity

This paper explores racial disparities and risk factors of adverse pregnancy outcomes in Black and White pregnant women in the US. The study uses a cross-sectional approach to explore Black and White disparities using data from the 2012 National Survey on Drug Use and Health (NSDUH), which collects interview data from approximately 70,000 randomly selected participants. We included several self-reported conditions that we categorised as individual and social stressors (e.g. measures of institutionalised racism, individual health behaviours, access to quality care and social context factors). We used descriptive statistics, univariate and multivariate analyses in risk factors of adverse pregnancy outcomes between Black and White women. Black women who were pregnant had a lower socioeconomic status and experienced more measures of institutionalised racism compared to White women who were pregnant. More white women who were pregnant were married, had higher levels of educational attainment, higher income levels, and greater employment opportunities. White pregnant women also had higher levels of private health insurance and less dependency on government programmes for access to healthcare. Results from the regressions indicated that Black pregnant women were less likely to be married (OR = 0.01), less likely to have higher income levels (OR = 0.31) and less likely to be employed (OR = 0.52). However, Black pregnant women were more likely to be younger (OR = 1.82). For the health-eroding behaviours, Black pregnant women were less likely to smoke (OR = 0.53) and use alcohol (0.52). After assessing the SES Household-level stressors (access to healthcare), Black pregnant women were more likely to have Medicaid/CHIP (OR = 3.21) and health coverage through government assistant programmes (OR = 3.80); however, less likely to have private health insurance (OR = 0.38). There are differences in risk factors of adverse pregnancy outcomes between White and Black pregnant women based on measures of individual level/social stressors, institutionalised racism, health behaviours and access to care.

Adjustment Profiles of Low-Income Caregivers from the United States and South Africa: Contrasts and Commonalities

Although low-income parents living in under-resourced communities in the United States and around the world face challenges, many do well while others struggle in one or more areas of functioning. The present study examined patterns of adjustment among maternal caregivers living in the United States (US) (N = 320) and South Africa (SA) (N = 324). Cluster analyses across four domains of functioning representing both positive and negative adjustment and conducted within country revealed similar patterns of adjustment, with a majority of caregivers (37.8% in the US; 47.5% in SA) landing in a "holding steady" pattern, exhibiting good but not exceptional adjustment. Other patterns of adjustment (three additional in the US sample; two additional in the SA sample) showed elevated impairment in somatic complaints, problems with alcohol, or life satisfaction. In both the US and SA, support from family, friends, and neighbors differentiated the adjustment profiles. Further, both current stressors within and outside of the family and previous stressors including direct and indirect exposure to violence discriminated caregivers who were "holding steady" from those who were struggling in one or more domains. Additionally, across both countries, caregivers who were "holding steady" evidenced less avoidant coping. Implications of this work for fostering resilience among caregivers and their children are discussed.

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.

A review of recent literature on materialist and psychosocial models for racial and ethnic disparities in birth outcomes in the US, 2000-2014

OBJECTIVE

Material and psychosocial factors exacerbate racial disparities in health outcomes. This review sought to ascertain recent knowledge of the effects of materialist and psychosocial factors on differences in low birthweight (LBW) and preterm delivery (PTD) outcomes between Black and White mothers.

DESIGN

Search and review was conducted for studies that examined: (a) neighborhood-level deprivation as an indicator of material conditions, and (b) racial discrimination or occupational stressors as indicators of psychosocial stress. The outcomes of interest were LBW and PTD.

RESULTS

Material and psychosocial factors significantly and negatively affected Blacks more than Whites, and were associated with increased adverse outcomes. Of five studies with a homogeneous Black study sample, three reported no effect on outcomes in women exposed to material or psychosocial factors.

CONCLUSION

Through this review we find that in comparison to White women, Black women are at higher risk of adverse outcomes due to both psychosocial stress and meso-level deprivation, after accounting for personal factors. A better understanding of effects on health outcomes of material and psychosocial factors in Black women is needed. Further investigation into materialist and psychosocial factors, will allow us to better understand the factors driving PTD and LBW disparities in the US.

County-level racial prejudice and the black-white gap in infant health outcomes

OBJECTIVE

Black mothers are 60 percent more likely than white mothers to have preterm births and twice as likely to have a baby with low birth weight. We examine whether these black-white gaps in birth outcomes are larger in counties with higher levels of racial prejudice.

METHOD

We use data from the restricted-use natality files in the United States, which provide information on birth weight, gestation, and maternal characteristics for over 31 million births from 2002 to 2012, combined with county-level data measures of both explicit and implicit racial prejudice from Project Implicit from over a million individuals who took the Implicit Association Test during this same period. We compare counties that are one standard deviation above the mean (high prejudice) with those that are one standard deviation below the mean (low prejudice) in terms of their average level of racial prejudice.

RESULTS

The black-white gap in low birth weight is 14 percent larger in counties with high implicit racial prejudice compared to counties with low prejudice. The black-white gap in preterm births is 29 percent larger in the high prejudice counties. The gaps are even larger when we use explicit measures of racial prejudice with high prejudice counties having a black-white gap that is 22 percent larger for low birth weight and 36 percent larger for preterm births. These relationships do not appear to be biased by the way the prejudice sample is constructed, since the racial gap in birth outcomes is unrelated to other county-level biases such as those based on gender or sexual orientation.

CONCLUSION

The black-white gap in United States' birth outcomes is larger in those counties that have the highest levels of racial prejudice. This is true for both implicit and explicit racial prejudice, though the strength of the relationship is strongest for explicit racial prejudice.

Intimate partner violence screening and the comparative effects of screening mode on disclosure of sensitive health behaviours and exposures in clinical settings

OBJECTIVE

Detecting sensitive health information in clinical settings is of scientific and practical importance. The purpose of this study was to determine whether mode of screening influenced disclosure of intimate partner violence (IPV) in patterns similar to other forms of sensitive information.

STUDY DESIGN

This cross sectional study was designed to compare effects of face-to-face vs computer self-assessment for sensitive health information on disclosure rates. Multivariate logistic regression was used for the analysis.

METHODS

Data were collected in 2012 from 639 eligible African American consenting women receiving services in women, infants and children (WIC) clinics. Women were randomized to complete assessments of sensitive exposures via computer-assisted self-interview (CASI) or face-to-face interview (FTFI). Those with complete information were included in the analysis (n = 616).

RESULTS

Of 39 sensitive health exposures, reporting was higher for FTFI than CASI for exposure to IPV (7 of 7 outcomes), tobacco use (2 of 3 outcomes) and reproductive health care (2 of 3 outcomes). For example, face-to-face improved disclosure of IPV in the last year (adjusted odds ratios [aOR] = 2.27; 95% CI = 1.60-3.21) and any drug, tobacco or alcohol in the last week (aOR = 1.39; 95% CI = 1.00-1.93).

CONCLUSION

Trained personnel may enhance disclosure above computer-based assessments for IPV for African American women receiving public assistance through The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Propensities to disclose sexual health behaviour and drug use by CASI may not apply to IPV in this population. The context and personal motivations influence women's decision to disclose IPV.

Infant mortality in the United States

The infant mortality rate (IMR) of 6.0 per 1000 live births in the United States in 2013 is nearly the highest among developed countries. Moreover, the IMR among blacks is >twice that among whites-11.11 versus 5.06 deaths per 1000 live births.This higher IMR and racial disparity in IMR is due to a higher preterm birth rate (11.4% of live births in 2013) and higher IMR among term infants. The United States also ranks near the bottom for maternal mortality and life expectancy among the developed nations-despite ranking highest in the proportion of gross national product spent on health care. This suggests that factors other than health care contribute to the higher IMR and racial disparity in IMR. One factor is disadvantaged socioeconomic status. All of the actionable determinates that negatively impact health-personal behavior, social factors, heath-care access and quality and the environment-disproportionately affect the poor. Addressing disadvantaged socioeconomic status by improving access to quality health care and increasing social expenditures would have the greatest impact on the USA's IMR and racial disparity in IMR.

The association between maternal and partner experienced racial discrimination and prenatal perceived stress, prenatal and postnatal depression: findings from the growing up in New Zealand cohort study

BACKGROUND

A growing number of studies document the association between maternal experiences of racial discrimination and adverse children's outcomes, but our understanding of how experiences of racial discrimination are associated with pre- and post-natal maternal mental health, is limited. In addition, existent literature rarely takes into consideration racial discrimination experienced by the partner.

METHODS

We analysed data from the Growing Up in New Zealand study to examine the burden of lifetime and past year experiences of racial discrimination on prenatal and postnatal mental health among Māori, Pacific, and Asian women in New Zealand (NZ), and to study the individual and joint contribution of mother's and partner's experiences of lifetime and past year racial discrimination to women's prenatal and postnatal mental health.

RESULTS

Our findings show strong associations between lifetime and past year experiences of ethnically-motivated interpersonal attacks and unfair treatment on mother's mental health. Māori, Pacific, and Asian women who had experienced unfair treatment by a health professional in their lifetime were 66 % more likely to suffer from postnatal depression, compared to women who did not report these experiences. We found a cumulative effect of lifetime experiences of ethnically-motivated personal attacks on poor maternal mental health if both the mother and the partner had experienced a racist attack.

CONCLUSIONS

Experiences of racial discrimination have severe direct consequences for the mother's mental health. Given the importance of mother's mental health for the basic human needs of a healthy child, racism and racial discrimination should be addressed.

Unintended Pregnancy, Depression, and Hazardous Drinking in a Community-Based Sample of Sexual Minority Women

CONTEXT

Unintended pregnancy is a stressful life event with important implications for women's health. Little research has examined sexual minority women's (SMW; lesbian, bisexual, mostly heterosexual) experiences of unintended pregnancy, and no studies have examined the relationship between unintended pregnancy, mental health, and negative coping behaviors in this population.

METHODS

We used the Chicago Health and Life Experiences of Women (CHLEW) Study (n = 454), a diverse sample of SMW, to examine the relationship between self-reported unintended pregnancy, depressive symptoms, and hazardous drinking. We used generalized linear model-building techniques and adjusted for key sociodemographic controls, as well as unintended pregnancy risk factors, including childhood physical and sexual abuse and age of sexual debut.

RESULTS

Twenty-four percent of the sample reported an unintended pregnancy. SMW who reported unintended pregnancies also reported significantly more depressive symptoms and greater risk of hazardous drinking. Adjusting for childhood abuse explained the relationship between unintended pregnancy and depressive symptoms, but not the relationship between unintended pregnancy and hazardous drinking.

CONCLUSIONS

Unintended pregnancy among SMW is an understudied topic. Our results suggest that unintended pregnancy is not uncommon among SMW and highlight the need for more research to investigate the mechanisms that link unintended pregnancy to depression and to hazardous drinking within this population.

Do Physical Activity Patterns Across the Lifecourse Impact Birth Outcomes?

The significant impact of physical activity during, or immediately prior to pregnancy on a range of pregnancy and birth outcomes has been established. However, lifecourse theory posits that the antecedents of poor outcomes occur across a larger trajectory of time. The objective of this study was to examine whether physical activity patterns over the lifecourse impact birth outcomes. The sample (n = 1,713) was derived from Waves I, III, and IV of the National Longitudinal Study of Adolescent Health and limited to women who had their first, singleton live birth between Waves III and IV; respondents who had missing data were excluded. Outcome variables included preterm birth (<37 weeks) and low birth weight (<5.5 pounds). Physical activity was categorized as follows: long-term physically active (active at Waves I and III); short-term physically active (active at only Wave I or III); and not physically active (not active at Waves I and III). Survey-weighted logistic regression controlled for socio-demographic and established predictors of poor birth outcomes. Women categorized as long-term physically active had lower rates of preterm births (12.2 vs. 18.7 %) and low birth weight (9.1 vs. 11.1 %) compared to women categorized as not physically active. However, when controlling for covariates, adjusted analysis revealed that physical activity consistency only predicted preterm birth (aOR = 0.55, 95 % CI = 0.33-0.91). Findings suggest that physical activity patterns across the lifecourse may decrease risk of preterm birth. Implications include efforts supporting patterns of physical activity over longer periods of time prior to pregnancy.

A Comparison of Birth Outcomes Among Black, Hispanic, and Black Hispanic Women

BACKGROUND

While non-Hispanic Black populations tend to be disproportionately affected by adverse reproductive outcomes, Hispanic populations tend to demonstrate healthier birth outcomes, regardless of socioeconomic background. Little is known about birth outcomes for women who are both Black and Hispanic. We examined whether birth outcomes and risk factors for women who are both Black and Hispanic most closely resemble those of women who are only Black or Hispanic and also compared these outcomes to those for Whites.

METHODS

Using the 2013 US natality files, we examined 2,970,315 singleton births to Black Hispanic, Hispanic, Black, and White mothers. We used logistic regression to calculate predicted probabilities of low birth weight (LBW), preterm birth (PTB), or small for gestational age (SGA). Race-stratified regression analysis was used to identify the factors that significantly predicted risk for each outcome for each racial/ethnic group.

RESULTS

Black mothers had the highest prevalence and predicted probabilities of experiencing all three outcomes. Black Hispanic mothers were less likely than Black mothers and more likely than Hispanic mothers to experience each of the adverse outcomes. We also found support for racial variation in risk and protective factors for mothers in the different groups. Factors like age and education inconsistently predicted risk of experiencing the birth outcomes for all groups. Overall, Black Hispanic mothers had birth outcomes and risk factor profiles like Hispanic mothers, although they had sociodemographic characteristics and health behaviors like Black mothers.

CONCLUSIONS

Patterning of birth outcomes among Black Hispanic women suggest an intersection of risk and protective factors associated with their respective racial and ethnic identities. Additional information about sociodemographic context is needed to develop a more complete picture of how factors related to race and ethnic group membership influence Black Hispanic women's birth outcomes.

Racism in the form of micro aggressions and the risk of preterm birth among black women

PURPOSE

This study sought to examine whether perceived interpersonal racism in the form of racial micro aggressions was associated with preterm birth (PTB) and whether the presence of depressive symptoms and perceived stress modified the association.

METHODS

Data stem from a cohort of 1410 black women residing in Metropolitan Detroit, Michigan, enrolled into the Life-course Influences on Fetal Environments (LIFE) study. The Daily Life Experiences of Racism and Bother (DLE-B) scale measured the frequency and perceived stressfulness of racial micro aggressions experienced during the past year. Severe past-week depressive symptomatology was measured by the Centers for Epidemiologic Studies-Depression scale (CES-D) dichotomized at ≥ 23. Restricted cubic splines were used to model nonlinearity between perceived racism and PTB. We used the Perceived Stress Scale to assess general stress perceptions.

RESULTS

Stratified spline regression analysis demonstrated that among those with severe depressive symptoms, perceived racism was not associated with PTB. However, perceived racism was significantly associated with PTB among women with mild to moderate (CES-D score ≤ 22) depressive symptoms. Perceived racism was not associated with PTB among women with or without high amounts of perceived stress.

CONCLUSIONS

Our findings suggest that racism, at least in the form of racial micro aggressions, may not further impact a group already at high risk for PTB (those with severe depressive symptoms), but may increase the risk of PTB for women at lower baseline risk.