Road to Equity in Maternal and Child Health: Honoring the Past and Blazing New Paths.

PURPOSE: This paper is a historical account of an initiative, as recalled by the authors who were directly involved, that brought to the forefront the long-standing and unjust reproductive health inequities in the United States. It is composed of three distinct but interrelated parts that together map the past, present, and future of addressing racial inequities in Maternal and Child Health. DESCRIPTION: This paper is composed of three distinct but interrelated parts that together map the past, present, and future of addressing racial inequities in Maternal and Child Health. Part I recounts the history and achievements of a Centers for Disease for Control and Prevention initiative in the 1980-90's, led by the Prematurity Research Group in the Division of Reproductive Health, Pregnancy and Infant Health Branch. This initiative stimulated a paradigm shift in how we understand and address black infant mortality and the inequities in this outcome. Part II illustrates examples of some exemplary programmatic and policy legacies that stemmed either directly or indirectly from the Centers for Disease for Control and Prevention paradigm shift. Part III provides a discussion of how effectively the current practice in Maternal and Child Health applies this paradigm to address inequities and proposes a path for accelerating Title V agencies' progress toward birth equity. ASSESSMENT: This CDC initiative was transformative in that it raised the visibility of African American researchers, moved the field from a focus on traditional epidemiologic risks such as personal health promotion and medical interventions, to include racism as a risk factor for inequitable birth outcomes. The paradigm examined the specific roles of historical and structural racism, and the racialized, contextualized, and temporal exposures that are unique to Black women's experiences in the United States. CONCLUSION: The initiative radically changed the narratives about the underlying factors contributing to inequities in birth outcomes of Black women, altered the way we currently approach addressing inequities, and holds the keys for transforming practice to a more holistic and systematic approach to building sustained organizational structures in maternal and child health that accelerate the achievement of birth equity.

REPRINT OF: Racism, Sexism, and Social Class: Implications for Studies of Health, Disease, and Well-being.

Editor's Note: This article is a reprint of a previously published article. For citation purposes, please use the original publication details: Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT. Racism, sexism, and social class: implications for studies of health, disease, and well-being. Am J Prev Med. 1993;9(6 suppl):82-122.

The Other Side of Through: Young Breast Cancer Survivors' Spectrum of Sexual and Reproductive Health Needs.

The long-term reproductive health impact of cancer treatments is a concern for premenopausal women with a history of breast cancer. This study examined the unmet sexual and reproductive health needs of breast cancer survivors, as well as concordances and discordances in needs by childbearing status and race. We interviewed 17 women diagnosed with breast cancer between the ages of 18 and 45 years and living in North Carolina. To analyze these data, we used the Sort and Sift, Think and Shift© method, a multidimensional qualitative analysis approach. We learned that breast cancer survivors (a) received limited reproductive health information, (b) desired realistic expectations of conceiving postcancer, (c) struggled with adjusting to their altered physical appearance, and (d) had menopause symptoms that led to sexual health and quality of life issues. Breast cancer survivors are in need of and desire more education and resources to address their sexual and reproductive health concerns.

DNA methylation of imprinted genes at birth is associated with child weight status at birth, 1 year, and 3 years.

Background: This study assessed the associations between nine differentially methylated regions (DMRs) of imprinted genes in DNA derived from umbilical cord blood leukocytes in males and females and (1) birth weight for gestational age z score, (2) weight-for-length (WFL) z score at 1 year, and (3) body mass index (BMI) z score at 3 years. Methods: We conducted multiple linear regression in n = 567 infants at birth, n = 288 children at 1 year, and n = 294 children at 3 years from the Newborn Epigenetics Study (NEST). We stratified by sex and adjusted for race/ethnicity, maternal education, maternal pre-pregnancy BMI, prenatal smoking, maternal age, gestational age, and paternal race. We also conducted analysis restricting to infants not born small for gestational age. Results: We found an association between higher methylation of the sequences regulating paternally expressed gene 10 (PEG10) and anthropometric z scores at 1 year (ß = 0.84; 95% CI = 0.34, 1.33; p = 0.001) and 3 years (ß = 1.03; 95% CI = 0.37, 1.69; p value = 0.003) in males only. Higher methylation of the DMR regulating mesoderm-specific transcript (MEST) was associated with lower anthropometric z scores in females at 1 year (ß = - 1.03; 95% CI - 1.60, - 0.45; p value = 0.001) and 3 years (ß = - 1.11; 95% CI - 1.98, - 0.24; p value = 0.01). These associations persisted when we restricted to infants not born small for gestational age. Conclusion: Our data support a sex-specific association between altered methylation and weight status in early life. These methylation marks can contribute to the compendium of epigenetically regulated regions detectable at birth, influencing obesity in childhood. Larger studies are required to confirm these findings.

Achieving Breastfeeding Equity: A Study of a National Breastfeeding Initiative.

BACKGROUND: Equity in breastfeeding could reduce excess morbidity and mortality among children and mothers of color. Few programs that support breastfeeding have been evaluated for their capacity to create equity. The aim of this study was to assess the extent to which a diverse set of national breastfeeding programs actively promoted equity. SUBJECTS AND METHODS: Qualitative data collection was conducted between December 2012 and July 2013 by visits to 29 of 58 breastfeeding programs selected by the funder. Programs underwent a site visit with open-ended interviews of staff. Investigators used Atlas.ti software to code data and content analysis of qualitative evaluation data. Key categories and themes were identified to answer the questions: how do the programs conceptualize equity? and how do the organizations operationalize an approach to equity? RESULTS: Programs had widely divergent and often limited conceptualizations of equity. Nine categories describe the equity approaches' programs used. The social, political, and environmental contexts in which programs operated varied in the degree of challenge they pose for implementing equity-focused breastfeeding methods. We found only a few programs that matched the social, cultural, and economic realities and context of women of color. CONCLUSIONS: Breastfeeding equity programs need to explicitly define and envision outcomes, and need to identify equity inhibiting policies and practices. Equity attainment is more likely to emerge from institutional transformational processes that collaborate with the populations at risk. These findings have implications for other programs addressing equity in health.

Dimensionality and R4P: A Health Equity Framework for Research Planning and Evaluation in African American Populations.

Introduction Existing health disparities frameworks do not adequately incorporate unique interacting contributing factors leading to health inequities among African Americans, resulting in public health stakeholders' inability to translate these frameworks into practice. Methods We developed dimensionality and R4P to integrate multiple theoretical perspectives into a framework of action to eliminate health inequities experienced by African Americans. Results The dimensional framework incorporates Critical Race Theory and intersectionality, and includes dimensions of time-past, present and future. Dimensionality captures the complex linear and non-linear array of influences that cause health inequities, but these pathways do not lend themselves to approaches to developing empirically derived programs, policies and interventions to promote health equity. R4P provides a framework for addressing the scope of actions needed. The five components of R4P are (1) Remove, (2) Repair, (3) Remediate, (4) Restructure and (5) Provide. Conclusion R4P is designed to translate complex causality into a public health equity planning, assessment, evaluation and research tool.

Predicting Preterm Birth Among Women Screened by North Carolina's Pregnancy Medical Home Program.

OBJECTIVE: To determine which combination of risk factors from Community Care of North Carolina's (CCNC) Pregnancy Medical Home (PMH) risk screening form was most predictive of preterm birth (PTB) by parity and race/ethnicity. METHODS: This retrospective cohort included pregnant Medicaid patients screened by the PMH program before 24 weeks gestation who delivered a live birth in North Carolina between September 2011-September 2012 (N = 15,428). Data came from CCNC's Case Management Information System, Medicaid claims, and birth certificates. Logistic regression with backward stepwise elimination was used to arrive at the final models. To internally validate the predictive model, we used bootstrapping techniques. RESULTS: The prevalence of PTB was 11 %. Multifetal gestation, a previous PTB, cervical insufficiency, diabetes, renal disease, and hypertension were the strongest risk factors with odds ratios ranging from 2.34 to 10.78. Non-Hispanic black race, underweight, smoking during pregnancy, asthma, other chronic conditions, nulliparity, and a history of a low birth weight infant or fetal death/second trimester loss were additional predictors in the final predictive model. About half of the risk factors prioritized by the PMH program remained in our final model (ROC = 0.66). The odds of PTB associated with food insecurity and obesity differed by parity. The influence of unsafe or unstable housing and short interpregnancy interval on PTB differed by race/ethnicity. CONCLUSIONS: Evaluation of the PMH risk screen provides insight to ensure women at highest risk are prioritized for care management. Using multiple data sources, salient risk factors for PTB were identified, allowing for better-targeted approaches for PTB prevention.

The impact of social disadvantage on preconception health, illness, and well-being: an intersectional analysis.

PURPOSE: To understand how social and structural contexts shape individual risk, vulnerability, and interconception health-related behaviors of African-American women. APPROACH OR DESIGN: A longitudinal ethnographic study was conducted. SETTING: The study was conducted in Philadelphia, Pennsylvania. PARTICIPANTS: The sample included 19 African-American women who were participants in the intervention group of a randomized clinical trial of interconceptional care. METHOD: Data were collected through interaction with participants over a period of 6 to 12 months. Participant observation , structured and unstructured interviews, and Photovoice were used to obtain data; grounded theory was used for analysis. The analysis was guided by intersectional theory. RESULTS: Social disadvantage influenced health and health care-seeking behaviors of African-American women, and the disadvantage centered on the experience of racism. The authors identify seven experiences grounded in the interactions among the forces of racism, class, gender, and history that may influence women's participation in and the effectiveness of preconception and interconception health care. CONCLUSION: African-American women's health and wellness behaviors are influenced by an experience of racism structurally embedded and made more virulent by its intersection with class, gender, and history. These intersecting forces create what may be a unique exposure that contributes significantly to the proximal determinants of health inequities for African-American women. Health promotion approaches that focus on the individual as the locus of intervention must concomitantly unravel and address the intertwining structural forces that shape individual circumstance in order to improve women's interconceptional health and to reduce disparities.

Contextualized stress, global stress, and depression in well-educated, pregnant, African-American women.

PURPOSE: Well-educated, pregnant, African-American women are disproportionately at risk for adverse birth outcomes and depression linked to stress has been established as a significant contributor to poor birth outcomes. Since racial and gendered stress have been identified as threats to birth outcomes, a cross-sectional study was conducted that utilized the Jackson, Hogue, Phillips Contextualized Stress Measure (JHP), a measurement of racial and gendered stress, and the Perceived Stress Scale (PSS), an assessment of global stress, to detect their associations and predictions for depression as measured by the Beck Depression Inventory II (BDI-II). METHOD: We recruited 101 pregnant, well-educated, African-American women from ob-gyn offices who were administered the JHP, the PSS, and the BDI-II. Correlational, chi-square, and stepwise regression analyses were conducted with the measures and the demographic variables of relationship status, the presence of other children, and annual household income. FINDINGS: The results revealed significant linear and covariate associations for the JHP, PSS, and BDI-II. Correspondingly, chi-square analysis found significant associations for the JHP and the BDI-II and the presence of other children, relationship status, and annual household income. Results from the regression models found that the contextualized and global stress measures were both predictive of depression. Demographic characteristics did not predict depression. CONCLUSION: The results argue for prenatal depression and stress screening. Furthermore, the link between contextualized stress and depression alerts health care providers and local communities to be responsive to the particular stressors that pose risks for pregnant African-American women and their babies.

Disparities in infant mortality and effective, equitable care: are infants suffering from benign neglect?

Quality care for infant mortality disparity elimination requires services that improve health status at both the individual and the population level. We examine disparity reduction due to effective care and ask the following question: Has clinical care ameliorated factors that make some populations more likely to have higher rates of infant mortality compared with other populations? Disparities in postneonatal mortality due to birth defects have emerged for non-Hispanic black and Hispanic infants. Surfactant and antenatal steroid therapy have been accompanied by growing disparities in respiratory distress syndrome mortality for black infants. Progesterone therapy has not reduced early preterm birth, the major contributor to mortality disparities among non-Hispanic black and Puerto Rican infants. The Back to Sleep campaign has minimally reduced SIDS disparities among American Indian/Alaska Native infants, but it has not reduced disparities among non-Hispanic black infants. In general, clinical care is not equitable and contributes to increasing disparities.

The Healthy African American Families (HAAF) project: from community-based participatory research to community-partnered participatory research.

During the past two decades, there has been an increased use of community-based participatory research in public health activities, especially as part of efforts to understand health disparities affecting communities of color. This article describes the history and lessons learned of a long-standing community participatory project, Healthy African American Families (HAAF), in Los Angeles, California. HAAF evolved from a partnership formed by a community advisory board, university, and federal health agency to an independent, incorporated community organization that facilitates and brokers research and health promotion activities within its community. HAAF created mechanisms for community education and networks of community relationships and reciprocity through which mutual support, research, and interventions are integrated. These sustained, institutionalized relationships unite resources and both community and scientific expertise in a community-partnered participatory research model to address multiple health problems in the community, including preterm birth, HIV, asthma, depression, and diabetes. The HAAF participatory process builds on existing community resiliency and resources and on centuries of self-help, problem-solving, cooperative action, and community activism within the African American community. HAAF demonstrates how community-partnered participatory research can be a mechanism for directing power, collective action, system change, and social justice in the process of addressing health disparities at the community level.

Where is the F in MCH? Father involvement in African American families.

OBJECTIVES: To: 1) review the historical contexts and current profiles of father involvement in African American families; 2) identify barriers to, and supports of, involvement; 3) evaluate the effectiveness of father involvement programs; and 4) recommend directions for future research, programs, and public policies. METHODS: Review of observational and interventional studies on father involvement. RESULTS: Several historical developments (slavery, declining employment for Black men and increasing workforce participation for Black women, and welfare policies that favored single mothers) led to father absence from African American families. Today, more than two thirds of Black infants are born to unmarried mothers. Even if unmarried fathers are actively involved initially, their involvement over time declines. We identified multiple barriers to, and supports of, father involvement at multiple levels. These levels include intrapersonal (eg, human capital, attitudes and beliefs about parenting), interpersonal (eg, the father's relationships with the mother and maternal grandmother), neighborhoods and communities (eg, high unemployment and incarceration rates), cultural or societal (eg, popular cultural perceptions of Black fathers as expendable and irresponsible, racial stratification and institutionalized racism), policy (eg, Earned Income Tax Credit, Temporary Assistance for Needy Families, child support enforcement), and life-course factors (eg, father involvement by the father's father). We found strong evidence of success for several intervention programs (eg, Reducing the Risk, Teen Outreach Program, and Children's Aid Society - Carrera Program) designed to prevent formation of father-absent families, but less is known about the effectiveness of programs to encourage greater father involvement because of a lack of rigorous research design and evaluation for most programs. CONCLUSION: A multi-level, life-course approach is needed to strengthen the capacity of African American men to promote greater involvement in pregnancy and parenting as they become fathers.

Utilization of joint arthroplasty: racial and ethnic disparities in the Veterans Affairs Health Care System.

Studies within the Veterans Administration health care system have been very useful in identifying the existence of racial and ethnic disparities with regard to patient utilization of hip and knee joint arthroplasty. Existing studies have focused on three factors: estimates of joint arthroplasty utilization,postoperative outcomes, and patient-related variables (eg, expectations of and familiarity with the procedure, religious beliefs). Although Veterans Administration-based studies have produced helpful data, these data are limited because the populations studied are not representative of the larger US population. Specifically, studies from the Veterans Administration health care system are composed of a predominantly male patient demographic;in addition, patients are more likely to have lower income and education levels than the US population as a whole.