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.

Preconception stress, birth weight, and birth weight disparities among US women.

OBJECTIVES: We examined the impact of preconception acute and chronic stressors on offspring birth weight and racial/ethnic birth weight disparities. METHODS: We included birth weights for singleton live first (n = 3512) and second (n = 1901) births to White, Mexican-origin Latina, other-origin Latina, and Black women reported at wave IV of the National Longitudinal Study of Adolescent Health (2007-2008; ages 24-32 years). We generated factor scores for preconception acute and chronic stressors from wave I (1994-1995; ages 11-19 years) or wave III (2001-2002; ages 18-26 years) for the same cohort of women. RESULTS: Linear regression models indicated that chronic stressors, but not acute stressors, were inversely associated with birth weight for both first and second births (b = -192; 95% confidence interval = -270, -113; and b = -180; 95% confidence interval = -315, -45, respectively), and partially explained the disparities in birth weight between the minority racial/ethnic groups and Whites. CONCLUSIONS: Preconception chronic stressors contribute to restricted birth weight and to racial/ethnic birth weight disparities.

Institutional racism, neighborhood factors, stress, and preterm birth.

OBJECTIVE: Racial/ethnic disparities in the risk of preterm birth may be explained by various factors, and previous studies are limited in examining the role of institutional racism. This study focused on the following questions: what is the association between preterm birth and institutional racism as measured by residential racial segregation (geographic separation by race) and redlining (black-white disparity in mortgage loan denial); and what is the association between preterm birth and reported stress, discrimination, and neighborhood quality. DESIGN: We used data from a clinic-based sample of pregnant women (n = 3462) participating in a stress and pregnancy study conducted from 1999 to 2004 in Philadelphia, PA (USA). We linked data from the 2000 US Census and Home Mortgage Disclosure Act (HMDA) data from 1999 to 2004 and developed measures of residential redlining and segregation. RESULTS: Among the entire population, there was an increased risk for preterm birth among women who were older, unmarried, tobacco users, higher number of previous births, high levels of experiences of everyday discrimination, owned their homes, lived in nonredlined areas, and areas with high levels of segregation measured by the isolation index. Among black women, living in a redlined area (where blacks were more likely to be denied mortgage loans compared to whites) was moderately associated with a decreased risk of preterm birth (aRR = 0.8, 95% CI: 0.6, 0.99). CONCLUSION: Residential redlining as a form institutional racism and neighborhood characteristic may be important for understanding racial/ethnic disparities in pregnancy and preterm birth.

Barriers to women's participation in inter-conceptional care: a cross-sectional analysis.

BACKGROUND: We describe participation rates in a special interconceptional care program that addressed all commonly known barriers to care, and identify predictors of the observed levels of participation in this preventive care service. METHODS: A secondary analysis of data from women in the intervention arm of an interconceptional care clinical trial in Philadelphia (n = 442). Gelberg-Andersen Behavioral Model for Vulnerable Populations to Health Services (herein called Andersen model) was used as a theoretical base. We used a multinomial logit model to analyze the factors influencing women's level of participation in this enhanced interconceptional care program. RESULTS: Although common barriers were addressed, there was variable participation in the interconceptional interventions. The Andersen model did not explain the variation in interconceptional care participation (Wald ch sq = 49, p = 0.45). Enabling factors (p = 0.058), older maternal age (p = 0.03) and smoking (p = < 0.0001) were independently associated with participation. CONCLUSIONS: Actively removing common barriers to care does not guarantee the long-term and consistent participation of vulnerable women in preventive care. There are unknown factors beyond known barriers that affect participation in interconceptional care. New paradigms are needed to identify the additional factors that serve as barriers to participation in preventive care for vulnerable women.

Institutional racism and pregnancy health: using Home Mortgage Disclosure act data to develop an index for Mortgage discrimination at the community level.

OBJECTIVES: We used Home Mortgage Disclosure Act (HMDA) data to demonstrate a method for constructing a residential redlining index to measure institutional racism at the community level. We examined the application of the index to understand the social context of health inequities by applying the residential redlining index among a cohort of pregnant women in Philadelphia. METHODS: We used HMDA data from 1999-2004 to create residential redlining indices for each census tract in Philadelphia County, Pennsylvania. We linked the redlining indices to data from a pregnancy cohort study and the 2000 Census. We spatially mapped the levels of redlining for each census tract for this pregnancy cohort and tested the association between residential redlining and other community-level measures of segregation and individual health. RESULTS: From 1999-2004, loan applicants in Philadelphia County, Pennsylvania, of black race/ethnicity were almost two times as likely to be denied a mortgage loan compared with applicants who were white (e.g., 1999 odds ratio [OR] = 2.00, 95% confidence interval [CI] 1.63, 2.28; and 2004 OR=2.26, 95% CI 1.98, 2.58). The majority (77.5%) of the pregnancy cohort resided in redlined neighborhoods, and there were significant differences in residence in redlined areas by race/ethnicity (p<0.001). Among the pregnancy cohort, redlining was associated with residential segregation as measured by the percentage of black population (r=0.155), dissimilarity (r=0.250), exposure (r=-0.115), and isolation (r=0.174) indices. CONCLUSIONS: The evidence of institutional racism may contribute to our understanding of health disparities. Residential redlining and mortgage discrimination against communities may be a major factor influencing neighborhood structure, composition, development, and wealth attainment. This residential redlining index as a measure for institutional racism can be applied in health research to understand the unique social and neighborhood contexts that contribute to health inequities.

Ethnic density and preterm birth in African-, Caribbean-, and US-born non-Hispanic black populations in New York City.

Segregation studies suggest that the health of blacks in the United States is poorer in majority-black compared with mixed-race neighborhoods. However, segregation studies have not examined black immigrants, who may benefit from social support and country-of-origin foods in black immigrant areas. The authors used 1995-2003 New York City birth records and a spatial measure of ethnic density to conduct a cross-sectional investigation of the risks of preterm birth for African-, Caribbean-, and US-born non-Hispanic black women associated with neighborhood-level African-, Caribbean-, and US-born non-Hispanic black density, respectively. Preterm birth risk differences were computed from logistic model coefficients, comparing neighborhoods in the 90th percentile of ethnic density with those in the 10th percentile. African black preterm birth risks increased with African density, especially in more deprived neighborhoods, where the risk difference was 6.1 per 1,000 (95% confidence interval: 1.9, 10.2). There was little evidence of an ethnic density effect among non-Hispanic black Caribbeans. Among US-born non-Hispanic blacks, an increase in preterm birth risk associated with US-born black density was observed in more deprived neighborhoods only (risk difference = 12.5, 95% confidence interval: 6.6, 18.4). Ethnic density seems to be more strongly associated with preterm birth for US-born non-Hispanic blacks than for non-Hispanic black immigrants.

Recruitment and retention of women in a large randomized control trial to reduce repeat preterm births: the Philadelphia Collaborative Preterm Prevention Project.

BACKGROUND: Recruitment and retention of patients for randomized control trial (RCT) studies can provide formidable challenges, particularly with minority and underserved populations. Data are reported for the Philadelphia Collaborative Preterm Prevention Project (PCPPP), a large RCT targeting risk factors for repeat preterm births among women who previously delivered premature (< 35 weeks gestation) infants. METHODS: Design of the PCPPP incorporated strategies to maximize recruitment and retention. These included an advanced database system tracking follow-up status and assessment completion rates; cultural sensitivity training for staff; communication to the community and eligible women of the benefits of participation; financial incentives; assistance with transportation and supervised childcare services; and reminder calls for convenient, flexibly scheduled appointments. Analyses reported here: 1) compare recruitment projections to actual enrollment 2) explore recruitment bias; 3) validate the randomization process 4) document the extent to which contact was maintained and complete assessments achieved 5) determine if follow-up was conditioned upon socio-economic status, race/ethnicity, or other factors. RESULTS: Of eligible women approached, 1,126 (77.7%) agreed to participate fully. Of the 324 not agreeing, 118 (36.4%) completed a short survey. Consenting women were disproportionately from minority and low SES backgrounds: 71.5% consenting were African American, versus 38.8% not consenting. Consenting women were also more likely to report homelessness during their lifetime (14.6% vs. 0.87%) and to be unmarried at the time of delivery (81.6% versus 47.9%). First one-month postpartum assessment was completed for 83.5% (n = 472) of the intervention group (n = 565) and 76% (426) of the control group. Higher assessment completion rates were observed for the intervention group throughout the follow-up. Second, third, fourth and fifth postpartum assessments were 67.6% vs. 57.5%, 60.0% vs. 48.9%, 54.2% vs. 46.3% and 47.3% vs. 40.8%, for the intervention and control group women, respectively. There were no differences in follow-up rates according to race/ethnicity, SES or other factors. Greater retention of the intervention group may reflect the highly-valued nature of the medical and behavior services constituting the intervention arms of the Project. CONCLUSION: Findings challenge beliefs that low income and minority women are averse to enrolling and continuing in clinical trials or community studies.

What's the 411? Assessing the feasibility of providing African American adolescents with HIV/AIDS prevention education in a faith-based setting.

This study examines African American faith based leaders' attitudes and beliefs about providing HIV prevention education and services to adolescents. Using a convenience sample, we identified priority adolescent health issues, attitudes about abstinence messages, and willingness to provide and participate in HIV prevention. Leaders identified drugs, gangs, alcohol, sex, and pregnancy as priority health issues affecting youth in their institutions. Leaders' strongly preferred to emphasize abstinence messages. Although leaders were willing to provide youth with health education, they were not willing to discuss specific behaviors associated with HIV transmission. African American churches provide a venue to reach African American youth; however, there are limitations to relying on faith-based HIV prevention services. HIV prevention education should continue to be supplemented via parents, schools, and public health agencies.

The clinical content of preconception care: infectious diseases in preconception care.

A number of infectious diseases should be considered for inclusion as part of clinical preconception care. Those infections strongly recommended for health promotion messages and risk assessment or for the initiation of interventions include Chlamydia infection, syphilis, and HIV. For selected populations, the inclusion of interventions for tuberculosis, gonorrheal infection, and herpes simplex virus are recommended. No clear evidence exists for the specific inclusion in preconception care of hepatitis C, toxoplasmosis, cytomegalovirus, listeriosis, malaria, periodontal disease, and bacterial vaginosis (in those with a previous preterm birth). Some infections that have important consequences during pregnancy, such as bacterial vaginosis (in those with no history of preterm birth), asymptomatic bacteriuria, parvovirus, and group B streptococcus infection, most likely would not be improved through intervention in the preconception time frame.

Concept mapping as a tool to engage a community in health disparity identification.

OBJECTIVES: To engage a community to critically examine local health disparities. DESIGN: Concept mapping is a tool used to rapidly assess the variations in thinking of large stakeholder groups' about a particular topic. SETTING: Jackson, Mississippi. PARTICIPANTS: Community members. METHODS: Dialog groups and community meetings were held, and participants were asked to respond to the statement, "A specific thing that causes African Americans to get sicker and die sooner is..." Aggregate responses were rated for importance and feasibility and then sorted into related groups. Aggregate sorts and ratings were then processed by using multidimensional scaling and hierarchical cluster analysis. RESULTS: There were 132 (unduplicated) reported contributors to health disparities. These responses fell into eight general clusters: economic issues, government, contextual factors, cultural factors, HIV, stress, environment, and motivation. Factors respondents felt were the most important contributors to disparities (economic factors, contextual factors, stress) did not correlate with those that they thought were most likely to be changed in society (contextual factors, government, motivation). CONCLUSIONS: Concept mapping provided a mechanism for rapidly documenting community thinking about health disparities. This mechanism stimulated community dialog and was used as a first step toward the long-term goal of creating equal community, academic, and medical partnerships for addressing disparities. The concept mapping process stimulated critical thinking about contributors to health inequities and uncovered contextual factors previously unknown to researchers and public health planners. The process allowed for active engagement and exchange of knowledge between the community and researchers and allowed a mechanism for identifying and rectifying disconnects in knowledge within and between stakeholder groups.

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.

"We black women have to kill a lion everyday": An intersectional analysis of racism and social determinants of health in Brazil.

The concept of intersectionality has been used to analyze and understand how multiple forms of identity and oppression interact to shape life experiences of marginalized groups. We conducted a qualitative study to explore how Black Brazilian women experience the intersections of race, class, and gender and the ways in which these intersecting experiences act as social determinants of health. Nine focus groups were conducted with Black, White, and mixed-race women of childbearing age (n = 37), social and health activists (n = 11), and health professionals (n = 20). The focus groups took place in two cities in the Brazilian state of Bahia during October and November 2012. Using a comparative approach, we describe participants' responses regarding the life experiences of women of differing racial and class backgrounds. Our findings highlight how the intersectional relationship between race, class, and gender alters women's social context and life course opportunities, as well as their stressors and protective buffers. We argue that the differing intersectional experiences of women due to race and class create unique social contexts that define the parameters of health and wellness. In addition, we argue that the experiences at each intersection (i.e., raceXclass, raceXgender, classXgender, raceXclassXgender) have a unique character that can be qualitatively described. Improved specification of exposures experienced by marginalized populations who experience intersecting forms of oppression can help explain intra- and inter-group differences in health outcomes, and may also lead to improved intervention models.

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.

Racial and ethnic disparities in influenza vaccination among elderly adults.

OBJECTIVES: To examine whether access to care factors account for racial/ethnic disparities in influenza vaccination among elderly adults in the United States. DESIGN: Indicators of access to care (predisposing, enabling, environmental/system, and health need) derived from Andersen's behavioral model were identified in the National Health Interview Survey questionnaire. The relationship of these indicators to influenza vaccination and race/ethnicity was assessed with multiple logistic regression models. MAIN RESULTS: Significant differences in vaccination were observed between non-Hispanic (NH) whites (66%) and Hispanics (50%, P<.001) and between NH whites (66%) and NH blacks (46%, P<.001). Controlling for predisposing and enabling access to care indicators, education, marital status, regular source of care, and number of doctor visits, reduced the prevalence odds ratios (POR) comparing Hispanics to non-Hispanic whites from 1.89 to 1.27. For NH blacks, controlling for access to care indicators changed the POR only from 2.24 (95% CI, 1.9 to 2.7) to 1.93 (95% CI, 1.6 to 2.4). CONCLUSIONS: This study confirmed the existence of sizable racial/ethnic differences in influenza vaccination among elderly adults. These disparities were only partially explained by differences in indicators of access to care, especially among non-Hispanic blacks for whom large disparities remained. Factors not available in the National Health Interview Survey, such as patient attitudes and provider performance, should be investigated as possible explanations for the racial/ethnic disparity in influenza vaccination among non-Hispanic blacks.

Stress during pregnancy: the role of institutional racism.

Institutional racism, also known as structural racism, can be defined as differential access to resources and opportunities by race as well as policies, laws, and practices that reinforce racial inequity. This study examines how institutional racism in the form of residential redlining (neighbourhood-level racial inequities in mortgage lending) and segregation (geographic separation of groups by race) is associated with self-reported stress among a diverse cohort of pregnant women. Institutional racism was measured by a residential redlining index using Home Mortgage Disclosure Act data and residential segregation using 2000 US Census data. These redlining and segregation indices were linked with data from a pregnancy cohort study (n = 4652), which included individual measures of reported stress. We ran multilevel linear regression models to examine the association between redlining, segregation and reported stress. Hispanic women compared with all other women were slightly more likely to report stress. There was no significant relationship between redlining and stress among this population. However, higher neighbourhood percentage black was inversely associated with stress. This study suggests that some forms of segregation may be associated with reported stress. Future studies should consider how redlining and segregation may provide an understanding of how institutional racism and the neighbourhood context may influence stress and health of populations.

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.

Black preterm birth risk in nonblack neighborhoods: effects of Hispanic, Asian, and non-Hispanic white ethnic densities.

PURPOSE: Studies of ethnic density and health in the United States have documented poorer health outcomes among black individuals living in black compared with nonblack neighborhoods, but few studies have considered the identities of the populations in nonblack neighborhoods. METHODS: New York City birth records from 1995 through 2003 and a spatial measure of ethnic density were used to examine preterm birth risks among non-Hispanic black women associated with non-Hispanic white, Hispanic, Asian, and non-Hispanic black neighborhood densities. Logistic regression models were used to estimate the effect on black preterm birth risks of replacing white neighbors with Hispanic, Asian, and black neighbors. Risk differences were computed for changes from the 10th to the 90th percentiles of ethnic density. RESULTS: Increasing Hispanic density was associated with reduced preterm birth risks among non-Hispanic black women, especially if the black women were foreign-born (RD = -19.1 per 1,000 births; 95% confidence interval. -28.6 to -9.5). Estimates for increasing Asian density were null. Increasing black density was associated with increasing black preterm birth risk, with a threshold at greater levels of black density. CONCLUSIONS: The low risks of preterm birth among foreign-born non-Hispanic black women in majority-Hispanic neighborhoods may be related to protective psychosocial or lifestyle and warrant further investigation.

Neighborhood ethnic density and preterm birth across seven ethnic groups in New York City.

Residential segregation limits non-white ethnic groups' access to white neighborhood resources, but may also reduce their exposure to discrimination and facilitate social support. We computed adjusted preterm birth risk differences (RDs) for seven ethnic groups comparing >25% to ≤ 25% ethnic density neighborhoods using 1995-2003 New York City birth records and a spatial ethnic density measure. RDs ranged from -15.0 per 1000 (95% CI: -18.5, -11.4) for whites to 6.4 per 1000 (95% CI: 2.8, 9.9) for blacks, with Hispanic and Asian estimates falling in between but tending to be protective. Results suggest that ethnic density is uniquely harmful for non-Hispanic blacks.