Racism and perinatal health inequities research: where we have been and where we should go.

For more than a century, substantial racial and ethnic inequities in perinatal health outcomes have persisted despite technical clinical advances and changes in public health practice that lowered the overall incidence of morbidity. Race is a social construct and not an inherent biologic or genetic reality; therefore, racial differences in health outcomes represent the consequences of structural racism or the inequitable distribution of opportunities for health along racialized lines. Clinicians and scientists in obstetrics and gynecology have a responsibility to work to eliminate health inequities for Black, Brown, and Indigenous birthing people, and fulfilling this responsibility requires actionable evidence from high-quality research. To generate this actionable evidence, the research community must realign paradigms, praxis, and infrastructure with an eye directed toward reproductive justice and antiracism. This special report offers a set of key recommendations as a roadmap to transform perinatal health research to achieve health equity. The recommendations are based on expert opinion and evidence presented at the State of the Science Research Symposium at the 41st Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in 2021. Recommendations fall into 3 broad categories-changing research paradigms, reforming research praxis, and transforming research infrastructure-and are grounded in a historic foundation of the advances and shortcomings of clinical, public health, and sociologic scholarship in health equity. Changing the research paradigm requires leveraging a multidisciplinary perspective on structural racism; promoting mechanistic research that identifies the biologic pathways perturbed by structural racism; and utilizing conceptual models that account for racism as a factor in adverse perinatal outcomes. Changing praxis approaches to promote and engage multidisciplinary teams and to develop standardized guidelines for data collection will ensure that paradigm shifts center the historically marginalized voices of Black, Brown, and Indigenous birthing people. Finally, infrastructure changes that embed community-centered approaches are required to make shifts in paradigm and praxis possible. Institutional policies that break down silos and support true community partnership, and also the alignment of institutional, funding, and academic publishing objectives with strategic priorities for perinatal health equity, are paramount. Achieving health equity requires shifting the structures that support the ecosystem of racism that Black, Brown, and Indigenous birthing people must navigate before, during, and after childbearing. These structures extend beyond the healthcare system in which clinicians operate day-to-day, but they cannot be excluded from research endeavors to create the actionable evidence needed to achieve perinatal health equity.

Development and validation of statewide survey-based measures of livability in Connecticut.

Livability, or how a place and its systems (e.g., housing, transportation) supports the ability to lead a livable life, is a determinant of health. There is a lack of standard, validated measures to assess livability in the US. This study employed factor analytic methods to create measures of livability in Connecticut using data from the DataHaven Community Wellbeing Survey (DCWS) (n = 32,262). Results identified a 3-factor model (safety, opportunity, and infrastructure) as the best fit, explaining 69% of the variance in survey items. Newly created livability measures had high internal consistency, in addition to high convergent validity with other area-level measures.

Investigating the measurement properties of livability: a scoping review.

Connecting evidence-based public health recommendations to livability, a popular and relatable construct, can increase the policy relevance of research to improve community design. However, there are many different definitions and conceptualizations of livability and little consensus about its measurement. Improved measurement, including standardization, is needed to increase understanding of livability's influence on health and to facilitate comparisons across contexts. This study sought to review existing livability measures, how they were created, and evidence regarding their reliability and validity. A scoping review of three databases (PubMed, Google Scholar, and Web of Science) identified 744 eligible studies. After screening, 24 studies, 15 from the original search and 9 through backward citation searches, were included in the review. Most studies were carried out in an urban context. There was minimal consensus across studies on the conceptualization of livability. However, measure domains and indicators overlapped significantly. While the process used to validate the measures varied, most studies reported high levels of reliability and found that livability was correlated with similar measures (e.g. place satisfaction, neighborhood safety, and sense of place) and self-reported health and wellbeing. Further research is needed to develop parsimonious, standardized measures of livability in order to create and sustain livable communities worldwide.

Health care utilization among women of reproductive age living in public housing: Associations across six public housing sites in San Francisco.

Housing is a key social determinant of health and health care utilization. Although stigmatized due to poor quality, public housing may provide stability and affordability needed for individuals to engage in health care utilization behaviors. For low-income women of reproductive age (15-44 y), this has implications for long-term reproductive health trajectories. In a sample of 5,075 women, we used electronic health records (EHR) data from 2006 to 2011 to assess outpatient and emergency department (ED) visits across six public housing sites in San Francisco, CA. Non-publicly housed counterparts were selected from census tracts surrounding public housing sites. Multivariable regression models adjusted for age and insurance status estimated incidence rate ratios (IRR) for outpatient visits (count) and odds ratios (OR) for ED visit (any/none). We obtained race/ethnicity-specific associations overall and by public housing site. Analyses were completed in December 2020. Public housing was consistently associated with health care utilization among the combined Asian, Alaskan Native/Native American, Native Hawaiian/Pacific Islander, and Other (AANHPI/Other) group. Public housing residents had fewer outpatient visits (IRR: 0.86; 95% Confidence Interval [CI]: 0.81, 0.93) and higher odds of an ED visit (OR: 1.81; 95% CI: 1.32, 2.48). Black women had higher odds of an ED visits (OR: 1.32; 95% CI: 1.07, 1.63), but this was driven by one public housing site (site-specific OR: 2.34; 95% CI: 1.12, 4.88). Variations by race/ethnicity and public housing site are integral to understanding patterns of health care utilization among women of reproductive age to potentially improve women's long-term health trajectories.

Maternal Childhood Adversity, Prepregnancy Obesity, and Gestational Weight Gain.

INTRODUCTION: Growing evidence suggests that exposure to childhood adversity may influence obesity across the life course. High maternal weight complicates pregnancy and increases the risk of child obesity. This study examined the association between maternal childhood adversity and pregnancy-related weight in a large U.S. METHODS: Data on 6,199 pregnancies from 2,873 women followed from 1979 to 2012 by the National Longitudinal Survey of Youth 1979 were analyzed in 2014. Associations between three adversity exposures before age 18 years (history of physical abuse, alcohol problems, or mental illness in the household) and two maternal weight outcomes (prepregnancy obesity and excessive gestational weight gain) were modeled separately using survey-adjusted log-binomial models. RESULTS: After adjusting for race/ethnicity and early-life socioeconomic factors, childhood physical abuse was associated with a 60% increase in the risk of prepregnancy obesity (adjusted risk ratio=1.6, 95% CI=1.1, 2.2). Household alcohol abuse was associated with a 30% increase in prepregnancy obesity (adjusted risk ratio=1.3, 95% CI=1.0, 1.7), as was household mental illness (adjusted risk ratio=1.3, 95% CI=0.8, 1.9), but the mental illness exposure was not significant. Physical abuse and household alcohol abuse were associated with a significant 20% increase in the risk of excessive gestational weight gain; mental illness was not. CONCLUSIONS: Adversity in early life may affect maternal weight before and during pregnancy. Screening and treating women of reproductive age for childhood adversity and its negative effects could significantly reduce obesity-related health outcomes for women and their children.

Racial-ethnic differences in pregnancy-related weight.

This review examines published literature to answer 2 questions: 1) Are there racial-ethnic differences in excessive or inadequate gestational weight gain (GWG) and postpartum weight retention (PPWR)? and 2) Is there evidence that approaches to promote healthy weight during and after pregnancy should vary by race-ethnicity? We identified a limited number of articles that explicitly looked at racial-ethnic differences in either GWG or PPWR after controlling for relevant covariates. These studies suggest that black and Hispanic women are more likely to gain inadequately based on the Institute of Medicine's pregnancy weight gain guidelines compared to white women. Black women are more likely to retain considerable amounts of weight postpartum compared to both Hispanic and white mothers. Studies were inconclusive as to whether Hispanic women retained more or less weight postpartum, so more research is needed. Interventions to increase GWG were few and those designed to reduce GWG and PPWR showed mixed results. Future studies should address the methodological and conceptual limitations of prior research as well as investigate biological mechanisms and behavioral risk factors to determine the reasons for the racial-ethnic differences in pregnancy-related weight outcomes. Interventions would benefit from a mixed-methods approach that specifically identifies race-relevant barriers to weight management during and after pregnancy. Attention to the greater social context in which pregnancy-related weight exists is also needed.