Implementation and early effects of medicaid policy interventions to promote racial equity in pregnancy and early childhood outcomes in Pennsylvania: protocol for a mixed methods study.

BACKGROUND: There are large racial inequities in pregnancy and early childhood health within state Medicaid programs in the United States. To date, few Medicaid policy interventions have explicitly focused on improving health in Black populations. Pennsylvania Medicaid has adopted two policy interventions to incentivize racial health equity in managed care (equity payment program) and obstetric service delivery (equity focused obstetric bundle). Our research team will conduct a mixed-methods study to investigate the implementation and early effects of these two policy interventions on pregnancy and infant health equity. METHODS: Qualitative interviews will be conducted with Medicaid managed care administrators and obstetric and pediatric providers, and focus groups will be conducted among Medicaid beneficiaries. Quantitative data on healthcare utilization, healthcare quality, and health outcomes among pregnant and parenting people will be extracted from administrative Medicaid healthcare data. Primary outcomes are stakeholder perspectives on policy intervention implementation (qualitative) and timely prenatal care, pregnancy and birth outcomes, and well-child visits (quantitative). Template analysis methods will be applied to qualitative data. Quantitative analyses will use an interrupted time series design to examine changes over time in outcomes among Black people, relative to people of other races, before and after adoption of the Pennsylvania Medicaid equity-focused policy interventions. DISCUSSION: Findings from this study are expected to advance knowledge about how Medicaid programs can best implement policy interventions to promote racial equity in pregnancy and early childhood health.

The Birth and Beyond (BABY) study: protocol for a birth cohort study investigating the social and environmental determinants of pregnancy-related outcomes in Black American families.

INTRODUCTION: In the USA, Black birthing people and infants experience disproportionately worse pregnancy-related health outcomes. The causes for these disparities are unknown, but evidence suggests that they are likely socially and environmentally based. Efforts to identify the determinants of these racial disparities are urgently needed to elucidate the highest priority targets for intervention. The Birth and Beyond (BABY) study evaluates how micro-level (eg, interpersonal and family) and macro-level (eg, neighbourhood and environmental) risk and resiliency factors transact to shape birth person-infant health, and underlying psychobiological mechanisms. METHODS AND ANALYSIS: The BABY study will follow 350 Black families (birthing parents, non-birthing parents and infants) from pregnancy through the first postpartum year, with research visits during pregnancy and at infant ages 6 and 12 months. Research visits comprise a combination of interview about a range of recent and life course stress and resiliency exposures and supports, psychophysiological (sympathetic, parasympathetic and adrenocortical) assessment and behavioural observations of parent-infant coregulatory behaviours. Spatial analyses are completed by mapping parent current and past residential addresses onto archival public data (eg, about neighbourhood quality and racial segregation). Finally, EMRs are abstracted for information about birthing parent relevant medical history, pregnancy conditions and infant birth outcomes. Analyses will evaluate the risk and resiliency mechanisms that contribute to pregnancy and birth-related outcomes for Black birthing people and their infants, and the protective role of individual, familial, cultural, and community supports. ETHICS AND DISSEMINATION: The BABY study has been approved by the Institutional Review Board at Albany Medical Centre. The study team consulted with local organisations and groups comprised of stakeholders and community leaders and continues to do so throughout the study. Research results will be disseminated with the scientific and local community as appropriate.

Trends and disparities in perinatal health outcomes among women from refugee backgrounds in Victoria, Australia: A population-based study.

BACKGROUND: Women from refugee backgrounds generally experience poorer pregnancy-related outcomes compared to host populations. AIM: To examine the trend and disparities in adverse perinatal outcomes among women of refugee background using population-based data from 2003 to 2017. METHODS: A population-based cross-sectional study of 754,270 singleton births in Victoria compared mothers of refugee backgrounds with Australian-born mothers. Inferential statistics, including Pearson chi-square and binary logistic regression, were conducted. Multiple logistic regression was conducted to explore the relationship between adverse perinatal outcomes and the women's refugee status. FINDINGS: Women of refugee background had higher odds of adverse neonatal and maternal outcomes, including stillbirth, neonatal death, low APGAR score, small for gestational age, postpartum haemorrhage, abnormal labour, perineal tear, and maternal admission to intensive care compared to Australian-born women. However, they had lower odds of neonatal admission to intensive care, pre-eclampsia, and maternal postnatal depression. The trend analysis showed limited signs of gaps closing over time in adverse perinatal outcomes. DISCUSSION AND CONCLUSION: Refugee background was associated with unfavourable perinatal outcomes, highlighting the negative influence of refugee status on perinatal health. This evidences the need to address the unique healthcare requirements of this vulnerable population to enhance the well-being of mothers and newborns. Implementing targeted interventions and policies is crucial to meet the healthcare requirements of women of refugee backgrounds. Collaborative efforts between healthcare organisations, government agencies and non-governmental organisations are essential in establishing comprehensive support systems to assist refugee women throughout their perinatal journey.

The effect of psychosocial stress on prenatal care among Hispanic immigrant women.

ABSTRACT: This article explores the effect of psychosocial stress on Hispanic immigrant women, including access to and use of prenatal care and birth outcomes. In addition to highlighting the health effects for this growing population, the article outlines strategies for clinicians to improve access to adequate prenatal care and to cultivate a supportive environment to promote use of prenatal services.

Infant Mortality among Adolescent Mothers in the United States: A 5-Year Analysis of Racial and Ethnic Disparities.

OBJECTIVE: This study was aimed to examine differences in infant mortality outcomes across maternal age subgroups less than 20 years in the United States with a specific focus on racial and ethnic disparities. STUDY DESIGN: Using National Center for Health Statistics cohort-linked live birth-infant death files (2009-2013) in this cross-sectional study, we calculated descriptive statistics by age (<15, 15-17, and 18-19 years) and racial/ethnic subgroups (non-Hispanic white [NHW], non-Hispanic black [NHB], and Hispanic) for infant, neonatal, and postneonatal mortality. Adjusted odds ratios (aOR) were calculated by race/ethnicity and age. Preterm birth and other maternal characteristics were included as covariates. RESULTS: Disparities were greatest for mothers <15 and NHB mothers. The risk of infant mortality among mothers <15 years compared to 18 to 19 years was higher regardless of race/ethnicity (NHW: aOR = 1.40, 95% confidence interval [CI]: 1.06-1.85; NHB: aOR = 1.28, 95% CI: 1.04-1.56; Hispanic: aOR = 1.36, 95%CI: 1.07-1.74). Compared to NHW mothers, NHB mothers had a consistently higher risk of infant mortality (15-17 years: aOR = 1.12, 95% CI: 1.03-1.21; 18-19 years: aOR = 1.21, 95% CI: 1.15-1.27), while Hispanic mothers had a consistently lower risk (15-17 years: aOR = 0.72, 95% CI: 0.66-0.78; 18-19 years: aOR = 0.74, 95% CI: 0.70-0.78). Adjusting for preterm birth had a greater influence than maternal characteristics on observed group differences in mortality. For neonatal and postneonatal mortality, patterns of disparities based on age and race/ethnicity differed from those of overall infant mortality. CONCLUSION: Although infants born to younger mothers were at increased risk of mortality, variations by race/ethnicity and timing of death existed. When adjusted for preterm birth, differences in risk across age subgroups declined and, for some racial/ethnic groups, disappeared. KEY POINTS: · Infant mortality risk was highest for adolescents <15 years old across racial/ethnic groups.. · Racial/ethnic disparities in timing of death were present even among the youngest adolescents.. · Infants of NHB adolescents had greatest risk of mortality, especially as age increased.. · Preterm birth influenced infant mortality risk, especially among NHB adolescents..

Acknowledging and Addressing Allostatic Load in Pregnancy Care.

The USA is one of the few countries in the world in which maternal and infant morbidity and mortality continue to increase, with the greatest disparities observed among non-Hispanic Black women and their infants. Traditional explanations for disparate outcomes, such as personal health behaviors, socioeconomic status, health literacy, and access to healthcare, do not sufficiently explain why non-Hispanic Black women continue to die at three to four times the rate of White women during pregnancy, childbirth, or postpartum. One theory gaining prominence to explain the magnitude of this disparity is allostatic load or the cumulative physiological effects of stress over the life course. People of color disproportionally experience social, structural, and environmental stressors that are frequently the product of historic and present-day racism. In this essay, we present the growing body of evidence implicating the role of elevated allostatic load in adverse pregnancy outcomes among women of color. We argue that there is a moral imperative to assign additional resources to reduce the effects of elevated allostatic load before, during, and after pregnancy to improve the health of women and their children.

Improving the health of young African American women in the preconception period using health information technology: a randomised controlled trial.

BACKGROUND: Preconception care focuses on improving women's health before pregnancy as a means to improve their health and future pregnancy outcomes. How to effectively deliver such care is unknown. The aim of this research was to assess the impact of an embodied conversational agent system on preconception risks among African American and Black women. METHODS: We did an open-label, randomised controlled trial of women aged 18-34 years, self-identified as African American or Black, or both, and not pregnant, recruited from 35 states in the USA. Sealed allocation envelopes (in permuted blocks of six and eight, prepared using a random number generator) were opened after enrolment. Intervention participants received an online conversational agent called Gabby that assessed 102 preconception risks and delivered 12 months of tailored dialogue using synthesised speech, non-verbal behaviour, visual aids, and health behaviour change techniques such as motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk with a clinician. The primary outcome was the proportion of identified risks at the action or maintenance stage of change at months 6 and 12. The study is registered with ClinicalTrials.gov, NCT01827215. FINDINGS: From March 11, 2014, through July 8, 2018, 528 women recruited from 35 states and 242 cities across the USA received the Gabby intervention (n=262) or were assigned to the control group (n=266). Participants identified a mean of 21 preconception risks per woman (SD 9·9). In the intention-to-treat analysis, at 6 months, intervention women reported reaching the action or maintenance stage of change for 50·0% (SD 28·9) of those preconception risks identified compared with 42·7% (28·3) in the control group (incidence rate ratio 1·16, 95% CI 1·07-1·26; p=0·0004). This result persisted at 12 months. INTERPRETATION: The Gabby system has the potential to improve women's preconception health. Further research is needed to determine if improving preconception risks impacts outcomes such as preterm delivery. FUNDING: National Institute for Minority Health and Health Disparities.

Adverse perinatal outcomes among children in Switzerland: the impact of national origin and socio-economic group.

OBJECTIVES: We examined the effect of the mother's origin and socio-economic characteristics on adverse perinatal outcomes in Switzerland. METHODS: Births occurring from 2011 to 2017 were identified in the Swiss population register and merged with the Swiss civil register and the Register of the first pillar to obtain information on the migration origin and socio-economic level. Four indicators of adverse perinatal outcomes were defined. RESULTS: Logistic regressions show that both the migration origin and the socio-economic level are measured by the parents' income, influence risk. Compared to the children of mothers born in Switzerland, those of mothers from EU/EFTA countries have a lower risk of infant mortality, low birth weight and extreme prematurity. The highest risk is observed for children born to mothers from the rest of the world. High levels of risk consistently characterize children with low-income parents (first decile). CONCLUSIONS: Our results justify further investigations at the level of health services to better identify the factors causing differences in the prevalence of adverse outcomes and to take them into account in adapted health policies.

Evaluating the Health Outcomes of the Healthy Women Healthy Babies Program in Delaware.

OBJECTIVES: The Delaware Healthy Women Healthy Babies Program (HWHB) was developed in response to increasing rates of infant mortality (IMR) and widening racial disparity. The primary aim of this study was to examine birth outcomes of enrolled and non-enrolled black and Hispanic women in the program whose payer was Medicaid. METHODS: We utilized a retrospective cohort of linked birth certificate and HWHB program participant data during 2011-2015. Our primary outcome variables (dependent variables) of interest included cigarette use, low birth weight, preterm birth and neonatal mortality. We utilized inverse probability of treatment weighting (IPTW) and estimated crude odds ratios (COR) and adjusted odds ratio (AOR) with 95% confidence intervals (CI) using IPTW as a weight variable. RESULTS: HWHB enrolled women were 10% less likely to smoke during pregnancy COR 0.89 (95% CI 0.82-0.96); were 9% less likely to deliver a low birth weight infant (AOR 0.91; 95% CI 0.84-0.99; p = 0.023); were 15% less likely to deliver a preterm infant (AOR 0.85; 0.78-0.92; p < .0001) as compared with non-HWHB women. Infants delivered by HWHB enrolled women had 27% less likelihood (AOR 0.73; 95% CI 0.54-0.98; p = 0.035) of experiencing a neonatal death (i.e., < 28 days) as compared with infants of non-enrolled HWHB women. CONCLUSION: The primary goal of this evaluation was to assess the effectiveness of the HWHB program on modifiable risk factors of IMR among HWHB enrolled and non-enrolled women. We found that HWHB program is a promising practice in improving the outcomes of infants born to participating black and Hispanic mothers.

Estimating racial health disparities among adverse birth outcomes as deviations from the population rates.

BACKGROUND: Despite significant research, the reasons for racial health disparities among adverse birth outcomes (ABO) remain largely unknown. The bulk of research into racial health disparities among ABO in the United States has concentrated on the risk of race and ethnic groups relative to the specific sub-population of non-Hispanic white women and their children. The objective of this study was to estimate the racial and ethnic risks among a set of neonatal and maternal health disparities while minimizing bias attributable to how the baseline risk was established. METHODS: All birth records were obtained from the United States Natality database for the years 2014 to 2017. A Bayesian modeling approach was used to estimate the risk disparity for disorders by race. The estimation of the race-specific risks used a sum-to-zero constraint for the race regression coefficients. RESULTS: Estimating racial health disparities relative to the overall population rate yielded novel results and identified perinatal health disparities for all the race groups studied. CONCLUSIONS: Unbiased risk estimates for racial disparities among ABO are now available for stimulating and initiating more complex causal modeling that can lead to understanding how racial health disparities for ABO are mediated and how they can be prevented.

Social and economic factors, maternal behaviours in pregnancy and neonatal adiposity in the PANDORA cohort.

BACKGROUND: Australian Indigenous women experience high rates of social disadvantage and type 2 diabetes (T2D) in pregnancy, but it is not known how social factors and maternal behaviours impact neonatal adiposity in offspring of women with hyperglycaemia in pregnancy. METHODS: Participants were Indigenous (n = 404) and Europid (n = 240) women with gestational diabetes mellitus (GDM) or T2D in pregnancy and their offspring in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) study. Social, economic factors, and maternal behaviours were measured in pregnancy and six neonatal anthropometric outcomes were examined after birth. RESULTS: On univariate analysis, maternal education < 12 years (p = 0.03), unemployment (p = 0.001), welfare income vs no welfare income (p = 0.001), lower area based socio-economic score (p < 0.001), and fast food intake > 2 times/week (p = 0.002) were associated with increased sum of skinfolds (SSF) in offspring. Smoking was significantly associated with a reduction in anthropometric measures, except SSF. In multivariable models adjusted for ethnicity, BMI and hyperglycaemia, social and economic factors were no longer significant predictors of neonatal outcomes. Smoking was independently associated with a reduction in length, head circumference and fat free mass. Frequent fast food intake remained independently associated with SSF (ß-coefficient 1.08 mm, p = 0.02). CONCLUSION: In women with hyperglycaemia in pregnancy, social factors were associated with neonatal adiposity, particularly skinfold measures. Promoting smoking cessation and limited intake of energy-dense, nutrient-poor foods in pregnancy are important to improve neonatal adiposity and lean mass outcomes. Addressing inequities in social and economic factors are likely to be important, particularly for Indigenous women or women experiencing social disadvantage.

Ethnic Enclaves and Pregnancy and Behavior Outcomes Among Asian/Pacific Islanders in the USA.

OBJECTIVES: Ethnic enclaves are ethnically, spatially, and socially distinct communities that may promote health through access to culturally appropriate resources and reduced exposure to discrimination. This study examined ethnic enclave residence and pregnancy outcomes among Asian/Pacific Islander (API) women in the USA. DESIGN: We examined 9206 API births in the Consortium on Safe Labor (2002-2008). Ethnic enclaves were defined as hospital regions with high percentage of API residents (> 4%), high dissimilarity index (> 0.41; distribution of API and white residents within a geographic area), and high isolation index (> 0.03; interaction between API and white residents in an area). Gestational diabetes mellitus (GDM), preterm birth (PTB), small for gestational age (SGA), and smoking and alcohol use during pregnancy were reported in medical records supplemented with ICD-9 codes. Hierarchical logistic regression models estimated associations between ethnic enclaves and pregnancy outcomes, adjusted for maternal factors, area-level poverty, and air pollution. RESULTS: Women in enclaves had lower odds of GDM (OR 0.61; 95%CI 0.45, 0.82), PTB (OR 0.74; 95%CI 0.56, 0.99), and SGA (OR 0.68; 95%CI 0.52, 0.89) compared with women in non-enclaves. Prenatal smoking and alcohol use appeared less likely in enclaves, but estimates were imprecise. Within enclaves, about 10.5% of homes speak an API language, compared with 6.0% in non-enclaves. The mean percent of foreign-born API populations was 67.4% in enclaves and 68.8% in non-enclaves. CONCLUSIONS: API women residing in ethnic enclaves had better pregnancy outcomes than API women residing in non-enclave areas. Access to culturally appropriate social supports and resources may be important for health promotion among API populations.

Birth Mode after Primary Cesarean among Hispanic and non-Hispanic Women at One U.S. Institution.

BACKGROUND: Despite a lower percentage of primary cesareans than non-Hispanic White and Black women, Hispanic women in the United States had the highest rate of repeat cesarean deliveries (RCD) in 2016; it is unclear if reasons for differences are due to known risk factors. Our study examined the association between ethnicity/race and RCD among women with one previous cesarean and whether demographic (age, marital status, education, language, and delivery year), anthropomorphic (height, prepregnancy body mass index), obstetrical/medical (parity, gestational age, infant birth weight, gestational diabetes, labor induction or augmentation, vaginal birth after cesarean delivery history), or health system (delivery day/time, payer source, provider gender) factors accounted for any observed differences by ethnicity/race. METHODS: Our retrospective cohort study used logistic regression to evaluate the relationship between ethnicity/race and RCD based on data from electronic delivery and prenatal records from 2010 to 2016, including 1800 births to Hispanic and non-Hispanic women with one previous cesarean at a District of Columbia hospital. RESULTS: Statistically significant differences by ethnicity/race were noted after adjustment for obstetric/medical factors, particularly parity and use of induction or augmentation methods. Hispanic (adjusted odds ratio, 2.48; 95% confidence interval, 1.03-6.01) and Black women (adjusted odds ratio, 2.83; 95% confidence interval, 1.67-4.81) had higher odds of RCD than White women. CONCLUSIONS: Adjustment for parity and use of induction or augmentation methods revealed higher odds of RCD for Hispanic and Black women than White women. Demographic and anthropometric factors did not alter these results. Our work is a first step in creating effective public health policy and programs that target potentially preventable RCD by highlighting the need to evaluate risk factors beyond those included in the literature to date.

Variation in relationships between maternal age at first birth and pregnancy outcomes by maternal race: a population-based cohort study in the United States.

OBJECTIVE: To estimate absolute risks of obstetric outcomes in the USA according to maternal age at first birth from age 15 to 45 separately by maternal race. DESIGN AND SETTING: Population-based cohort study. SETTING: Vital statistics Birth Cohort-Linked Birth- Infant Death Data Files and Fetal Death Data Files in the USA. PARTICIPANTS: 16 514 849 births to nulliparous women from 2004 to 2013. OUTCOME MEASURES: We estimated absolute risks of obstetric outcomes (multiple gestations, caesarean delivery, early and late preterm birth, small for gestational age birth, stillbirth, neonatal mortality, postneonatal infant mortality) at each year of maternal age from 15 to 45 years using logistic regression in the overall population and stratified by maternal race. We modelled maternal age flexibly to allow curvilinear shapes and plotted risk curves for each outcome. RESULTS: In the overall population, multiple gestations, caesarean delivery and stillbirth risks were lowest at young maternal ages with linear or quadratic increases with age. Curves for preterm birth, small for gestational age, neonatal mortality and postneonatal mortality were u or j shaped, with nadirs between 20 and 29 years, and elevated risks at both younger and older maternal ages. In race-stratified analyses, the shapes of the curves were generally similar across races. Risks increased for all women for all outcomes after age 30. However, increased risks at young maternal ages were most pronounced for white and Asian/Pacific Islander women, for whom young childbearing was least common. Conversely, risks at older ages were more pronounced for Black and American Indian/Alaska Native women, for whom delayed childbearing was least common. CONCLUSION: Our findings confirm risks associated with first births to women younger than 20 and older than 30 years, provide easily interpretable risk curves and illuminate variability in these relationships across categories of maternal race in the USA.

Ethnic differences in the risk of caesarean section: a Danish population-based register study 2004-2015.

BACKGROUND: Studies have shown differences in the risk of caesarean section (CS) between ethnic minority groups. This could be a marker of unequal health care. The aim of this study was to investigate differences in the risk of CS between immigrants of various origins in Denmark, where all health care is free and easy to access, and Danish-born women. A further aim was to determine the possible influence of known risk factors for CS. METHODS: The design was a population-based register study using national Danish registers and included all live- and stillborn singleton deliveries by primiparous women in Denmark from 2004 to 2015. The total study population consisted of 298,086 births, including 25,198 births to women from the 19 largest immigrant groups in Denmark. Multinomial logistic regression analysis was used to estimate relative risk ratios (RRR) of emergency and planned CS, using vaginal delivery (VD) as reference, in immigrant women compared to Danish-born women. A number of known risk factors were included separately. RESULTS: Women from Turkey, the Philippines, Thailand, Somalia, Vietnam, Iran and Afghanistan had a statistically significant elevated risk ratio of emergency CS vs. VD compared to Danish-born women; adjusted RRR's ranging 1.15-2.19. The risk ratio of planned CS vs. VD was lower among the majority of immigrant groups, however higher among women from Poland, Thailand and Iran, when compared to Danish-born women. None of the studied explanatory variables affected the risk ratio of planned CS vs. VD, whereas maternal height contributed with varying strength to the risk ratio of emergency CS vs. VD for all immigrant groups. CONCLUSION: Substantial variations in CS risks by maternal country of birth were documented. Some of the disparities in emergency CS seem to be explained by maternal height.

The effect of a preconception care outreach strategy: the Healthy Pregnancy 4 All study.

BACKGROUND: Preconception care has been acknowledged as an intervention to reduce perinatal mortality and morbidity. However, utilization of preconception care is low because of low awareness of availability and benefits of the service. An outreach strategy was employed to promote uptake of preconception care consultations. Its effect on the uptake of preconception care consultations was evaluated within the Healthy Pregnancy 4 All study. METHODS: We conducted a community-based intervention study. The outreach strategy for preconception care consultations included four approaches: (1) letters from municipal health services; (2) letters from general practitioners; (3) information leaflets by preventive child healthcare services and (4) encouragement by peer health educators. The target population was set as women aged 18 to 41 years in 14 Dutch municipalities with relatively high perinatal morbidity and mortality rates. We evaluated the effect of the outreach strategy by analyzing uptake of preconception care consultations between February 2013 and December 2014. Registration data of applications for preconception care as well as participant questionnaires were obtained for analysis. RESULTS: The outreach strategy led to 587 applications for preconception care consultations. The majority of applications (n = 424; 72%) were prompted by the invitation letters (132,129) from the municipalities and general practitioners. The effect of the municipal letter seemed to fade out after 3 months. CONCLUSIONS: Outreach strategies amongst the general population promote uptake of preconception care consultations, although on a small scale and with a temporary effect.

Racial disparities in the transgenerational transmission of low birthweight risk.

Objective: To examine the association of maternal low birthweight (LBW) with infant LBW and infant LBW subgroups (i.e. moderate and very LBW), overall and among non-Hispanic (NH) white and NH black mothers. Design: We conducted a population-based cohort study in Allegheny County, Pennsylvania, using linked birth record data of NH white and NH black mother-infant pairs (N = 6,633) born in 1979-1998 and 2009-2011, respectively. The exposure of interest was maternal LBW (birthweight <2500 grams) while the outcomes were infant LBW and LBW subgroups - moderate LBW (1,500-2,499 grams) or very LBW (<1,500 grams). Logistic regression (binomial and multinomial) models were used to estimate adjusted Odds Ratios (ORs), Relative Risk Ratios (RRRs), and related 95% confidence intervals (CI). Stratified analyses were conducted to assess effect modification by mothers' race. Results: Maternal LBW was associated with 1.53 (95%CI: 1.15-2.02) and 1.75 (95%CI: 1.29-2.37) -fold increases in risk of infant LBW and MLBW, respectively, but not VLBW (RRR = 0.86; 95%CI: 0.44-1.70). In race-stratified models, maternal LBW-infant LBW associations were observed among NH blacks (OR = 1.88; 95%CI: 1.32-2.66) and not among NH whites (OR = 1.03; 95%CI: 0.62-1.73) (P for interaction = 0.07). Among NH blacks, maternal LBW was associated with a 2.18 (95%CI: 1.49, 3.20) -fold increase in risk of infant MLBW, but not VLBW (RRR = 1.12; 95%CI: 0.54, 2.35). Among NH whites, LBW subgroup analyses could not be performed due to small numbers of VLBW infants among LBW mothers. Conclusion: Mothers who were LBW at their own birth were more likely to have MLBW infants. Maternal race modified associations of maternal LBW with infant LBW, particularly infant MLBW. Further research is needed in this area to understand the potential mechanisms involved in the transgenerational transmission of LBW risk and race-specific differences in the transmission.

Cervical pathways for racial disparities in preterm births: the Preterm Prediction Study.

Purpose: Racial disparities in preterm birth have been long recognized, but the social and biological mechanisms for these differences are unclear. Our analysis had three goals: (1) to determine the relation between race and other social risk factors and cervical structure; (2) to determine whether social factors mediate the relation between race and cervical structure; and (3) to determine whether racial disparities in preterm birth (PTB) are mediated through changes in cervical structure observed earlier in pregnancy. Materials and methods: Data from the Maternal Fetal Medicine Unit network Preterm Prediction Study were used to examine the relation between race and other social factors and cervical properties throughout pregnancy in 2920 black and white women. Outcomes included cervical length and dilation; cervical score (cervical length-internal dilation); and whether membranes protruded at 22-24 and 26-29 weeks. Race, education, income, insurance type, and marital status were examined as predictors of the outcomes using linear and logistic regression, adjusting for age, BMI, parity, and smoking. Mediation analysis was used to examine whether (a) any social factors explained racial differences in cervical properties, and (b) whether cervical properties mediated racial differences in risk for preterm birth. Results: Shorter cervical length, especially at a subject's first visit, was associated with black race (adjusted beta -1.56 mm, p < .01) and lower income (adjusted beta -1.48, p =.05). External dilation was not associated with social factors, while internal dilation was associated with black race and lower education. Black race and marital status were associated with lower cervical score. There was no evidence of mediation of the racial effect on cervical properties by any social factor. Shorter cervical length, dilation, and score were all associated with preterm birth (p < .01). Mediation analysis indicated that each of these mediated the effect of race, but explained a small proportion of the total effect (15-25%). Conclusions: Race, and, to a lesser extent, other social factors are correlated with adverse cervical properties. This pathway could explain a proportion of the racial disparity in preterm birth.

A test of the epidemiological paradox in a context of forced migration: low birthweight among Syrian newborns in Lebanon.

BACKGROUND: Studies on immigrants revealed an epidemiological paradox whereby low-socioeconomic status (SES) immigrant mothers exhibit favourable birth outcomes compared with native-born mothers. We tested the epidemiological paradox in a context of forced migration, comparing associations of low birthweight (LBW) and maternal SES between Syrian and Lebanese newborns in Lebanon. METHODS: We used data from the National Collaborative Perinatal Neonatal Network (NCPNN) of 31 Lebanese hospitals, including 45 442 Lebanese and 4910 Syrian neonates born 2011-13. We assessed associations between LBW and maternal SES for both groups. Logistic regression models examined interactions between maternal origin and SES. RESULTS: Syrian births increased exponentially between 2011 and 2013, along with the group's forced migration into Lebanon. Although Syrian mothers are more socioeconomically disadvantaged compared with Lebanese mothers, Syrian LBW (6.2%) was only marginally higher than Lebanese LBW (5.6%; P = 0.059). Only 20-24-years-old Syrian women [odds ratio (OR) = 1.70 (1.22-2.36)] and those with ≥ university education [OR = 2.02 (0.98-4.16)] exhibited higher odds of delivering an LBW baby compared with Lebanese women of the same age and education. CONCLUSIONS: The findings do not provide strong evidence for the epidemiological paradox in a forced migration context. However, the relatively advantageous LBW profile among Syrian neonates, despite their mothers' low SES and exposure to acute and chronic psychological stress, points to protective mechanisms. One of these mechanisms may be a collective response by the displaced population to improve neonatal outcomes as a way of recovering from loss and death.