Racial, Ethnic, and Immigrant Generational Disparities in Physically Strenuous and Hazardous Work Conditions.

Despite the importance of work in adult life, research on the social determinants of health often ignores its effects. We examine race/ethnic, immigrant generational, and gender differentials in exposure to work conditions associated with poor health outcomes, using a nationally-representative sample of adults. On average, Latino 1st generation workers are more exposed to strenuous and hazardous work conditions than other workers, even after adjusting for sociodemographic differences. Exposure is lower for 2nd and 3rd generation Latinos. In contrast, Asian 1st generation men often have the lowest exposure levels of all groups and Asian 2nd and 3rd generation men have higher levels of exposure than the first generation, primarily due to intergenerational differences in education. Asian 1st generation women have higher exposures than those in the 2nd or 3rd generation. These results illustrate the importance of considering work conditions in research and policy related to the social determinants of health.

Physical Work Exposures of Older Workers: Does Measurement Make a Difference?

Physically demanding work at later ages, which is especially prevalent among disadvantaged groups, is associated with long-term health outcomes and may contribute to health inequality over the life course. Past studies of these issues have relied on occupational characteristics from the Occupational Information Network (O*NET), but few have assessed how O*NET compares to survey reports when measuring occupational exposures in analyses of socioeconomic status, work conditions, and health. We compare Health and Retirement Study (HRS, N = 16,683 working respondents) and O*NET measurements of general physical activity, frequency of lifting/handling objects, and frequency of stooping-related postures required at work. Pearson correlations between the HRS items and corresponding O*NET items vary from weak to moderate for lifting/handling and stooping-related postures to relatively large for general physical activity. Though they are measured on different scales, both the HRS and O*NET measures of physical demands reveal similar sex, racial/ethnic, and educational differentials in exposure to physically strenuous work. We fit random effects Poisson models to assess how these measures predict accumulation of functional limitations, a potential long-term consequence of strenuous working conditions. Comparable HRS and O*NET measures have similar associations with functional limitations. We also consider an average of physical demand items available in O*NET, finding that this measure has similar associations with functional limitations as the O*NET measure of general physical activity. These results suggest that O*NET characteristics and HRS respondent reports produce comparable disparities in physical work exposures (PWEs) and associations between physically demanding work and declines in physical functioning.

Deportations and departures: Undocumented Mexican immigrants' return migration during three presidential administrations.

This study examines changes in the sociodemographic patterns of deportation and voluntary return of undocumented immigrants from the United States to Mexico during three US presidential administrations (2001 to 2019) with different immigration policies. Most previous studies examining these migration flows for the United States as a whole have relied exclusively on counts of deportees and returnees, thereby ignoring changes over the past 20 y in the characteristics of the undocumented population itself, i.e., the population at risk of deportation or voluntary return. We estimate Poisson models based on two data sources that permit us to compare changes in the sex, age, education, and marital status distributions of both deportees and voluntary return migrants with the corresponding changes in the undocumented population during the Bush, Obama, and Trump administrations: the Migration Survey on the Borders of Mexico-North (Encuesta sobre Migración en las Fronteras de México-Norte) for counts of deportees and voluntary return migrants and the Current Population Survey's Annual Social and Economic Supplement for estimated counts of the undocumented population living in the United States. We find that whereas disparities by sociodemographic characteristics in the likelihood of deportation generally increased beginning in Obama's first term, sociodemographic disparities in the likelihood of voluntary return generally decreased over this period. Despite heightened antiimmigrant rhetoric during the Trump administration, the changes in deportation and voluntary return migration to Mexico among the undocumented during Trump's term were part of a trend that began early in the Obama administration.

Physical work conditions and disparities in later life functioning: Potential pathways.

Research in the US on the social determinants of reduced physical functioning at older ages has typically not considered physical work conditions as contributors to disparities. We briefly describe a model of occupational stratification and segregation, review and synthesize the occupational health literature, and outline the physiological pathways through which physical work exposures may be tied to long-term declines in physical functioning. The literature suggests that posture, force, vibration, and repetition are the primary occupational risk factors implicated in the development of musculoskeletal disorders, through either acute injuries or longer-term wear and tear. Personal risk factors and environmental and structural work characteristics can modify this association. In the long-term, these musculoskeletal disorders can become chronic and ultimately lead to functional limitations and disabilities that interfere with one's quality of life and ability to remain independent. We then use data on occupational characteristics from the Occupational Information Network (O*NET) linked to the 2019 American Community Survey (ACS) to examine disparities among sociodemographic groups in exposure to these risk factors. Occupations with high levels of these physical demands are not limited to those traditionally thought of as manual or blue-collar jobs and include many positions in the service sector. We document a steep education gradient with less educated workers experiencing far greater physical demands at work than more educated workers. There are pronounced racial and ethnic differences in these exposures with Hispanic, Black, and Native American workers experiencing higher risks than White and Asian workers. Occupations with high exposures to these physical risk factors provide lower compensation and are less likely to provide employer-sponsored health insurance, making it more difficult for workers to address injuries or conditions that arise from their jobs. In sum, we argue that physical work exposures are likely an important pathway through which disparities in physical functioning arise.

Racial and ethnic differentials in COVID-19-related job exposures by occupational standing in the US.

Researchers and journalists have argued that work-related factors may be partly responsible for disproportionate COVID-19 infection and death rates among vulnerable groups. We evaluate these issues by describing racial and ethnic differences in the likelihood of work-related exposure to COVID-19. We extend previous studies by considering 12 racial and ethnic groups and five types of potential occupational exposure to the virus: exposure to infection, physical proximity to others, face-to-face discussions, interactions with external customers and the public, and working indoors. Most importantly, we stratify our results by occupational standing, defined as the proportion of workers within each occupation with at least some college education. This measure serves as a proxy for whether workplaces and workers employ COVID-19-related risk reduction strategies. We use the 2018 American Community Survey to identify recent workers by occupation, and link 409 occupations to information on work context from the Occupational Information Network to identify potential COVID-related risk factors. We then examine the racial/ethnic distribution of all frontline workers and frontline workers at highest potential risk of COVID-19, by occupational standing and by sex. The results indicate that, contrary to expectation, White frontline workers are often overrepresented in high-risk jobs while Black and Latino frontline workers are generally underrepresented in these jobs. However, disaggregation of the results by occupational standing shows that, in contrast to Whites and several Asian groups, Latino and Black frontline workers are overrepresented in lower standing occupations overall and in lower standing occupations associated with high risk, and thus may be less likely to have adequate COVID-19 protections. Our findings suggest that greater work exposures likely contribute to a higher prevalence of COVID-19 among Latino and Black adults and underscore the need for measures to reduce potential exposure for workers in low standing occupations and for the development of programs outside the workplace.

A Note on "Sequential Neighborhood Effects" by Hicks et al. (2018).

We revisit a novel causal model published in Demography by Hicks et al. (2018), designed to assess whether exposure to neighborhood disadvantage over time affects children's reading and math skills. Here, we provide corrected and new results. Reconsideration of the model in the original article raised concerns about bias due to exposure-induced confounding (i.e., past exposures directly affecting future exposures) and true state dependence (i.e., past exposures affecting confounders of future exposures). Through simulation, we show that our originally proposed propensity function approach displays modest bias due to exposure-induced confounding but no bias from true state dependence. We suggest a correction based on residualized values and show that this new approach corrects for the observed bias. We contrast this revised method with other causal modeling approaches using simulation. Finally, we reproduce the substantive models from Hicks et al. (2018) using the new residuals-based adjustment procedure. With the correction, our findings are essentially identical to those reported originally. We end with some conclusions regarding approaches to causal modeling.

Trajectories of physical functioning among older adults in the US by race, ethnicity and nativity: Examining the role of working conditions.

Latinos in the US live significantly longer than non-Latino whites, but spend more years disabled. Differentials in socioeconomic status account for part, but not all, of the difference in older age disability between Latinos and whites. We hypothesize that a factor often ignored in the literature-the fact that Latinos, on average, have more physically strenuous jobs than non-Latino whites-contributes to the higher Latino risk of functional limitations at older ages. We use longitudinal data from the 1998-2014 Health and Retirement Study (HRS) comprising 17,297 respondents. Compared to US-born whites, Latinos, especially Latino immigrants, report substantially higher levels of physical effort at work. Latino-black differences are much smaller than Latino-white differences. As hypothesized, physical work effort is strongly related to functional limitations. However, differentials in physical work effort for Latinos and whites in their fifties and early sixties are weakly related to Latino-white differentials in FL at later ages.

Racial and ethnic differentials in COVID-19-related job exposures by occupational standing in the US.

Researchers and journalists have argued that work-related factors may be partly responsible for disproportionate COVID-19 infection and death rates among vulnerable groups. We evaluate these claims by examining racial and ethnic differences in the likelihood of work-related exposure to COVID-19. We extend previous studies by considering 12 racial and ethnic groups and five types of potential occupational exposure to the virus: exposure to infection, physical proximity to others, face-to-face discussions, interactions with external customers and the public, and working indoors. Most importantly, we stratify our results by occupational standing, defined as the proportion of workers within each occupation with at least some college education. This measure serves as a proxy for whether workplaces and workers employ significant COVID-19-related risk reduction strategies. We use the 2018 American Community Survey to identify recent workers by occupation, and link 409 occupations to information on work context from the Occupational Information Network to identify potential COVID-related risk factors. We then examine the racial/ethnic distribution of all frontline workers and frontline workers at highest potential risk of COVID-19, by occupational standing and by sex. The results indicate that, contrary to expectation, White frontline workers are often overrepresented in high-risk jobs while Black and Latino frontline workers are generally underrepresented in these jobs. However, disaggregation of the results by occupational standing shows that, in contrast to Whites and several Asian groups, Latino and Black frontline workers are overrepresented in lower status occupations overall and in lower status occupations associated with high risk, and are thus less likely to have adequate COVID-19 protections. Our findings suggest that greater work exposures likely contribute to a higher prevalence of COVID-19 among Latino and Black adults and underscore the need for measures to reduce potential exposure for workers in low status occupations and for the development of programs outside the workplace.

Calloused hands, shorter life? Occupation and older-age survival in Mexico.

BACKGROUND: Inequalities in mortality are often attributed to socioeconomic differences in education level, income, and wealth. Low socioeconomic status (SES) is generally related to worse health and survival across the life course. Yet, disadvantaged people are also more likely to hold jobs requiring heavy physical labor, repetitive movement, ergonomic strain, and safety hazards. OBJECTIVE: We examine the link between primary lifetime occupation, together with education and net worth, on survival among older adults in Mexico. METHODS: We use data from four waves (2001, 2003, 2012, and 2015) of the Mexican Health and Aging Study (MHAS). We estimate age-specific mortality rates for ages 50 and over using a hazards model based on a two-parameter Gompertz function. RESULTS: Primary lifetime occupations have a stronger association with survival for women than men. Women with higher socioeconomic status have significantly lower mortality rates than lower status women, whether SES is assessed in terms of schooling, wealth, or occupation. Occupational categories are not jointly related to survival among men, even without controls for education and wealth. There are significant survival differences by wealth among men, but no disparities in mortality by education. CONCLUSIONS: Consistent with recent studies of the Mexican population, we fail to find the expected gradient in the association between some measures of SES and better survival among men. CONTRIBUTION: Our estimates extend this anomalous pattern among Mexican men to another dimension of SES, occupation. SES differentials in mortality are substantially larger for Mexican women, highlighting an important gender disparity.

Longitudinal Determinants of Married Women's Autonomy in Egypt.

This article explores determinants of women's autonomy in Egypt around the beginning of the 'Arab Spring' in 2011. We show that women's autonomy over time is a product not only of their individual characteristics, but also of the household and community environment in which they live. Using the 2006 and 2012 Egyptian Labor Market Panel Survey (ELMPS) and multilevel models, results demonstrate that women's autonomy changes over time. There are large and consistent variations in women's autonomy by household region of residence and wealth. For example, women in the rural and urban Upper Egypt region are less autonomous than women in the Cairo region, and women in wealthier households are less autonomous compared to the poorest households. Programs aiming to increase women's autonomy focus exclusively or primarily on women's own characteristics. These results indicate that strategies to improve women's autonomy should be mindful of the multiple dimensions of autonomy and have a programmatic focus on changing household and social environments.

The effect of adult children living in the United States on the likelihood of cognitive impairment for older parents living in Mexico.

OBJECTIVE: The increased risk for poor physical and mental health outcomes for older parents in Mexico who have an adult child living in the United States may contribute to an increased risk for cognitive impairment in this population. The objective of this study was to examine if older adults in Mexico who have one or more adult children living in the United States are more or less likely to develop cognitive impairment over an 11-year period compared to older adults who do not have any adult children living in the United States. DESIGN: Data for this study came from Wave I (2001) and Wave III (2012) of the Mexican Health and Aging Study. The final sample included 2609 participants aged 60 and over who were not cognitively impaired in 2001 and had one or more adult children (age ≥15). Participants were matched using a propensity score that was estimated with a multivariable logistic regression model that included sociodemographic characteristics and migration history of the older parents. RESULTS: Having one or more adult children living in the United States is associated with lower socioeconomic status and higher number of depressive symptoms, but greater social engagement for older parents living in Mexico. No significant differences in the odds for developing cognitive impairment according to having one or more adult children living in the United States were detected. CONCLUSION: In summary, having one or more adult children living in the United States was associated with characteristics that may increase and decrease the risk for cognitive impairment. This may contribute to the non-significant relationship between migration status of adult children and likelihood for cognitive impairment for older parents living in Mexico.

Sequential Neighborhood Effects: The Effect of Long-Term Exposure to Concentrated Disadvantage on Children's Reading and Math Test Scores.

Prior research has suggested that children living in a disadvantaged neighborhood have lower achievement test scores, but these studies typically have not estimated causal effects that account for neighborhood choice. Recent studies used propensity score methods to account for the endogeneity of neighborhood exposures, comparing disadvantaged and nondisadvantaged neighborhoods. We develop an alternative propensity function approach in which cumulative neighborhood effects are modeled as a continuous treatment variable. This approach offers several advantages. We use our approach to examine the cumulative effects of neighborhood disadvantage on reading and math test scores in Los Angeles. Our substantive results indicate that recency of exposure to disadvantaged neighborhoods may be more important than average exposure for children's test scores. We conclude that studies of child development should consider both average cumulative neighborhood exposure and the timing of this exposure.

Legal Status, Time in the USA, and the Well-Being of Latinos in Los Angeles.

In the USA, undocumented Latino immigrants may have poorer health because of barriers to health care, stressors, and detrimental effects of immigration enforcement. Previous immigrant health research, however, suggests that recently arrived Latino immigrants have better health than US-born Latinos and their health deteriorates over time. Given the current environments that undocumented immigrants face, legal status is a structural factor that likely influences the patterns of immigrant health. Therefore, the aim of this study was to examine the extent to which physical and mental health differed by legal status and duration in the USA for the Latino population in Los Angeles County, California. We conducted analysis of Latino respondents (n = 1396) to the Los Angeles Family and Neighborhood Survey (L.A.FANS) Wave II. We examined self-reported health, depression measured by the Composite International Diagnostic Interview-Short Form, and blood pressure collected by trained interviewers. Respondents reported their legal status, time in the USA, and other sociodemographic characteristics. Regression models were used to test associations between each outcome and 1) legal status and 2) legal status by duration (≤ 15 and > 15 years) in the USA. Without taking duration into account, we found no significant differences in outcomes between undocumented, documented, or US-born Latinos. Taking duration into account, shorter duration undocumented immigrants had worse self-reported health than the US born. Undocumented immigrants, regardless of duration, had higher blood pressure than documented immigrants who had been in the USA for less time and the same level of blood pressure as the US born. In contrast, shorter duration documented immigrants had lower blood pressure compared to longer duration documented immigrants and US-born counterparts, and marginally lower blood pressure than shorter duration undocumented immigrants. The findings suggest that the "health advantage" generally presumed to exist among immigrants may not affect undocumented immigrants.

Association between income trajectories in childhood and psychiatric disorder: a Swedish population-based study.

BACKGROUND: Childhood family income variation is an understudied aspect of households' economic context that may have distinct consequences for children. We identified trajectories of childhood family income over a 12-year period, and examined associations between these trajectories and later psychiatric disorders, among individuals born in Sweden between 1987 and 1991 (n=534 294). METHODS: We used annual income data between the ages of 3-14 years and identified 5 trajectories (2 high-income upward, 1 downward and 2 low-income upward trajectories). Psychiatric disorders in the follow-up period after age 15 were defined from International Classification of Disease (ICD)-codes in a nationwide patient register. Multiadjusted risks for all psychiatric disorders, as well as for specific psychiatric diagnoses, were calculated as HRs with 95% CIs. RESULTS: Of the 5 identified income trajectories, the constant low and the downward trajectories were particularly associated with later psychiatric disorder. Children with these trajectories had increased risks for psychiatric disorder, including mood, anxiety, psychotic disorders and attention deficit/hyperactivity disorder. The association remained, even after adjusting for important variables including parental psychiatric disorder. In contrast, the relationship was reversed for eating disorders, for which children in higher income trajectories had elevated risks. CONCLUSIONS: Findings show that children growing up in a household characterised by low or decreasing family income have an increased risk for psychiatric disorder. Continued work is needed to reduce socioeconomic inequalities in psychiatric disorders. Policies and interventions for psychiatric disorders should consider the socioeconomic background of the family as an important risk or protective factor.

Childhood social adversity and risk of depressive symptoms in adolescence in a US national sample.

OBJECTIVE: Childhood social adversity has been associated with an increased risk of depression and other psychiatric disorders in adolescence and early adulthood. However, the role of timing and accumulation of adversities has not yet been established in longitudinal studies. We examined the association between childhood adversities and adolescent depressive symptoms, and the impact of timing and accumulation of adversity. METHOD: Longitudinal data were obtained from the Child Development Supplement to the Panel Study of Income Dynamics (n=2223), a nationally representative survey of US families that incorporates data from parents and their children. Negative binomial regression analysis was used to estimate effects of childhood social adversity on adolescent depressive symptoms, presented as Incidence Rate Ratios with 95% confidence intervals. RESULTS: Children exposed to social adversity reported higher levels of adolescent depressive symptoms captured by two depression scales. Single-parent household and residential instability were particularly associated with depressive symptoms. A positive relationship was found between cumulative adversity and the risk of adolescent depression. The timing of exposure appeared to have little effect on the risk of adolescent depressive symptoms. LIMITATIONS: The structure of the data implies that alternative causal pathways cannot be fully discounted. The self- or parent-reported data is subject to recall bias. CONCLUSION: Our findings support the long-term negative impact of childhood adversity on adolescent depressive symptoms, regardless of when in childhood the adversity occurs. Policies and interventions to reduce adolescent depressive symptoms need to consider the social background of the family as an important risk or protective factor.

The unhealthy food environment does not modify the association between obesity and participation in the Supplemental Nutrition Assistance Program (SNAP) in Los Angeles County.

BACKGROUND: Participation in the Supplemental Nutrition Assistance Program (SNAP) has been linked to an increased risk of obesity, but not much is known about the mechanisms behind this association. The objective of this study was to determine if the neighborhood density of unhealthy food outlets modifies the association between obesity and participation in SNAP. METHODS: Data comes from the first wave of the Los Angeles Family and Neighborhood Survey; included are a subsample of adults (18+ years) who were SNAP participants or eligible non-participants (N = 1,176). We carried out multilevel analyses with obesity (BMI ≥ 30 Kg/m2), SNAP participation, and the neighborhood density of unhealthy food outlets as dependent, independent and modifying variables, respectively, controlling for age, gender, race/ethnicity, marital status, working status, mental health, and neighborhood poverty. RESULTS: SNAP participants had double the odds of obesity compared to eligible non-participants (OR = 2.02; 95%CI = 1.44-2.83). However, the neighborhood density of unhealthy food outlets did not modify this association. CONCLUSIONS: SNAP participation was associated with higher odds of obesity in our primarily Hispanic sample in Los Angeles County, with no effect modification found for the unhealthy portion of the food environment. More research is needed with additional food environment measures to confirm our null findings. Additional research is needed to elucidate the mechanisms linking SNAP participation and obesity as they remain unclear.

Maternal health care seeking by rural Tibetan women: characteristics of women delivering at a newly-constructed birth center in western China.

BACKGROUND: Increasing skilled birth attendance at delivery is key to reducing maternal mortality, particularly among marginalized populations. Despite China's successful rollout of a national policy to promote facility deliveries, challenges remain among rural and ethnic minority populations. In response, a Tibetan Birth and Training Center (TBTC) was constructed in 2010 to provide high-quality obstetric care in a home-like environment to a predominantly Tibetan population in Tso-ngon (Qinghai) province in western China to improve maternal care in the region. This study examines if and how first users of the TBTC differ from women in the broader community, and how this information may inform subsequent maternal health care interventions in this area. METHODS: Trained, Tibetan interviewers administered a face-to-face, quantitative questionnaire to two groups of married, Tibetan women: women who had delivered at the TBTC between June 2011-June 2012 (n = 114) and a non-equivalent comparison group of women from the same communities who had delivered in the last two years, but not at the TBTC (n = 108). Chi-squared and ANOVA tests were conducted to detect differences between the samples. RESULTS: There were no significant differences between the samples in education or income; however, women from the TBTC sample were significantly younger (25.55 vs. 28.16 years; p < 0.001) and had fewer children (1.54 vs. 1.70; p = 0.05). Items measuring maternity health care-seeking and perceived importance of health facility amenities indicated minimal differences between the samples. However, as compared to the community sample, the TBTC sample had a greater proportion of women who reported having the final say regarding where to deliver (26% vs. 14%; p = 0.02) and having a friend or family member who delivered at home (50% vs. 28%; p < 0.001). CONCLUSIONS: Findings did not support the hypothesis that the TBTC attracts lower-income, less-educated women. Minimal differences in women's characteristics and perceptions regarding delivery care between the two samples suggest that the TBTC is serving a broad cross-section of women. Differences between the samples with respect to delivery care decision-making and desire for skilled birth care underscore areas that may be further explored and supported in subsequent efforts to promote facility delivery in this population, and similar populations, of women.

Return Migration to Mexico: Does Health Matter?

We use data from three rounds of the Mexican Family Life Survey to examine whether migrants in the United States returning to Mexico in the period 2005-2012 have worse health than those remaining in the United States. Despite extensive interest by demographers in health-related selection, this has been a neglected area of study in the literature on U.S.-Mexico migration, and the few results to date have been contradictory and inconclusive. Using five self-reported health variables collected while migrants resided in the United States and subsequent migration history, we find direct evidence of higher probabilities of return migration for Mexican migrants in poor health as well as lower probabilities of return for migrants with improving health. These findings are robust to the inclusion of potential confounders reflecting the migrants' demographic characteristics, economic situation, family ties, and origin and destination characteristics. We anticipate that in the coming decade, health may become an even more salient issue in migrants' decisions about returning to Mexico, given the recent expansion in access to health insurance in Mexico.

Cumulative exposure to childhood stressors and subsequent psychological distress. An analysis of US panel data.

Research has shown that childhood stress increases the risk of poor mental health later in life. We examined the effect of childhood stressors on psychological distress and self-reported depression in young adulthood. Data were obtained from the Child Development Supplement (CDS) to the national Panel Study of Income Dynamics (PSID), a survey of US families that incorporates data from parents and their children. In 2005 and 2007, the Panel Study of Income Dynamics was supplemented with two waves of Transition into Adulthood (TA) data drawn from a national sample of young adults, 18-23 years old. This study included data from participants in the CDS and the TA (n = 2128), children aged 4-13 at baseline. Data on current psychological distress was used as an outcome variable in logistic regressions, calculated as odds ratios (OR) with 95% confidence intervals (CI). Latent Class Analyses were used to identify clusters based on the different childhood stressors. Associations were observed between cumulative exposure to childhood stressors and both psychological distress and self-reported depression. Individuals being exposed to three or more stressors had the highest risk (crude OR for psychological distress: 2.49 (95% CI: 1.16-5.33), crude OR for self-reported depression: 2.07 (95% CI: 1.15-3.71). However, a large part was explained by adolescent depressive symptoms. Findings support the long-term negative impact of cumulative exposure to childhood stress on psychological distress. The important role of adolescent depression in this association also needs to be taken into consideration in future studies.

Tibetan women's perspectives and satisfaction with delivery care in a rural birth center.

OBJECTIVE: To identify sociodemographic characteristics and factors involved in Tibetan women's decisions to deliver at the Tibetan Birth and Training Center (TBTC) in rural western China. METHODS: In the present mixed-methods study, a random sample of married women who delivered at the TBTC between June 2011 and June 2012 were surveyed. Additionally, four focus group discussions were conducted among married women living in the TBTC catchment area. Descriptive analyses were conducted, and dominant themes were identified. RESULTS: In focus group discussions, women (n=33) reported that improved roads and transportation meant that access to health facilities was easier than in the past. Although some of the 114 survey participants voiced negative perceptions of healthcare facilities and providers, 99 (86.8%) indicated that they chose to deliver at the TBTC because they preferred to have a doctor present. Most women (75 [65.8%]) said their mother/mother-in-law made the final decision about delivery location. Women valued logistic and cultural aspects of the TBTC, and 108 (94.7%) said that they would recommend the TBTC to a friend. CONCLUSION: Study participants preferred delivery care that combines safety and comfort. The findings highlight avenues for further promotion of facility delivery among populations with lower rates of skilled deliveries.