Neighborhood Diversity Is Good for Your Health: An Example of Racial/Ethnic Integration and Preterm Birth in Texas.

Racial concentration of neighborhoods is often associated with the risk of preterm birth (PTB) for women. This study examined differences between racially diverse and racially concentrated neighborhoods when examining preterm birth. Individual-level data were obtained from Texas natality files for 2009-2011, and neighborhood-level (i.e., census tract) data were obtained from the decennial census in 2010 and the American Community Survey 2005-2009. We used multilevel modeling to assess the association between neighborhood racial diversity and odds of PTB, after controlling for individual characteristics, neighborhood poverty, and population density. We found that neighborhood racial diversity and concentration matter for PTB. Results suggest that systemic racism is still key to understanding PTB. Furthermore, findings support policies that prevent displacement from gentrification of diverse neighborhoods and promote equal access to health-related resources for women in predominantly Black, Hispanic, and/or immigrant neighborhoods.

Neighborhood-level variability in asthma-related emergency department visits in Central Texas.

BACKGROUND: The extent to which incidence rates of asthma-related emergency department (ED) visits vary from neighborhood to neighborhood and predictors of neighborhood-level asthma ED visit burden are not well understood. OBJECTIVE: We aimed to describe the census tract-level spatial distribution of asthma-related ED visits in Central Texas and identify neighborhood-level characteristics that explain variability in neighborhood-level asthma ED visit rates. METHODS: Conditional autoregressive models were used to examine the spatial distribution of asthma-related ED visit incidence rates across census tracts in Travis County, Texas, and assess the contribution of census tract characteristics to their distribution. RESULTS: There were distinct patterns in ED visit incidence rates at the census tract scale. These patterns were largely unexplained by socioeconomic or selected built environment neighborhood characteristics. However, racial and ethnic composition explained 33% of the variability of ED visit incidence rates across census tracts. The census tract predictors of ED visit incidence rates differed by racial and ethnic group. CONCLUSIONS: Variability in asthma ED visit incidence rates are apparent at smaller spatial scales. Most of the variability in census tract-level asthma ED visit rates in Central Texas is not explained by racial and ethnic composition or other neighborhood characteristics.

Engaging Community-Academic Partnerships: A Case Study of the Influence of Social Drivers of Health on Equitable Transitions of Cancer Care in the United States.

Enduring community-academic partnerships are essential for expediting the successful dissemination and implementation of promising interventions and programs, particularly for complex public health issues such as cancer prevention and control. The purpose of this case study was to understand the combined voices of a diverse group of stakeholders to outline the essential factors needed to translate research into sustainable cancer care within communities. System dynamics group model building was used to develop system maps of the factors impacting equitable access to cancer care services among three stakeholder groups (Group A: survivors and family members, n = 20; Group B: providers and administrators in community agencies/organizations, n = 40; Group C: administrators from a cancer institute, academic universities, foundations, and healthcare facilities that coordinate care, n = 25) in central Texas, USA. The lead researcher identified factors involved in transitions of care and their linkages with each other. The analysis of this work displays these connections visually. These models represent the ripple effect of factors influencing the transition of care for stakeholders who are invested in cancer care outcomes. All three groups identified medical mistrust, a culturally sensitive and diverse provider workforce, and care coordination as three essential factors (i.e., themes). Group A also identified caregiver navigation. The groups varied in their emphasis on upstream vs. downstream social drivers of health, with Group B emphasizing the former and Group C emphasizing the latter. To achieve cancer care equity, all stakeholder groups agreed on the importance of addressing the impact of social drivers as critical gaps. Eliminating or reducing these impacts allows each stakeholder group to work more efficiently and effectively to improve cancer care for patients.

Impact of Geography and Rurality on Preconception Health Status in the United States.

Introduction: Maternal illness and death are largely preventable; however, the field of preconception health needs further study. Geographic region and rurality play a large role in maternal health, and an understanding of the effect of these 2 factors at the individual level could prevent future adverse maternal health outcomes. Methods: We developed an abbreviated index of preconception health risk (diabetes, hypertension, body weight, mental health, unintended pregnancy, HIV, alcohol and nicotine use, nutrition, physical activity, receipt of the influenza vaccine) by using data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS). A score of 1 was assigned for each behavior factor classified as unhealthy and a score of 0 for each factor classified as healthy, for a total potential score of 11. Respondent women from the 37 states that included the BRFSS family planning supplemental module who were aged 18 to 44 years who could become pregnant (N = 25,999) were included. We used univariate and multivariate regression models to assess the relationship between sociodemographic factors (age, race or ethnicity, relationship status, insurance status, education, income, and rurality and region) and preconception health, with a primary focus on rurality and region. Results: The average preconception health risk index score among participants was 3.5, with higher average scores in rural areas than in urban areas. All factors were independently associated with preconception health. Compared with women living in the urban Northeast, women living in all rural and region groups, except the rural West, had increased preconception health risk. Conclusion: Preconception health scores from our study showed that, on average, a person had more than 3 risk factors or behaviors. Given the current state of reproductive health policy in the United States, increased efforts are needed to address preconception health.

The Price of Growing Up in a Low-Income Neighborhood: A Scoping Review of Associated Depressive Symptoms and Other Mood Disorders among Children and Adolescents.

Neighborhoods, as built and social environments, have significant implications for mental health. Children raised in high-poverty neighborhoods, who are disproportionately Black, Indigenous, and people of color, have a greater risk of adverse life outcomes. Neighborhood gentrification is also salient when examining mental health outcomes as neighborhood economic contexts shift around a child. This review scopes, describes, synthesizes, and critiques the existing literature on the relationship between neighborhood poverty/gentrification and mood disorder symptoms among children ages 3-17 in the United States (U.S.). Given the history of structural racism in the creation of U.S. neighborhoods, inclusion criteria required that study samples be racially diverse. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, seven databases and grey literature were searched; 17 studies were included (total n = 122,089). Fourteen studies found significant associations between neighborhood poverty/gentrification and child depression. Three longitudinal studies found significant results suggesting that childhood neighborhood poverty/gentrification may have a lagged effect, with depression emerging later in life. Neighborhood poverty and gentrification require further examination as social determinants of mental health. Researchers should examine neighborhood poverty and gentrification as social determinants of mental health. Policies that reduce neighborhood economic disparities are needed across the U.S.

The impacts of adverse childhood experiences on socioeconomic disadvantage by sexual and gender identity in the U.S.

BACKGROUND: Adverse childhood experiences (ACEs) predict low education and low income, but this has scarcely been examined by sexual orientation and gender identity. OBJECTIVE: We investigated prevalence and associations between ACEs, low income, and low education in sexual and gender diverse (SGD) and cisgender heterosexual (CGH) sub-groups. PARTICIPANTS AND SETTING: Data came from 14 states in the 2019 Behavioral Risk Factor Surveillance System survey (n = 79,303). METHODS: Chi-square, logistic regression, and moderation analyses were implemented to examine the prevalence and associations between ACEs, low income, and low education. Sample stratification was used to examine differences between SGD and CGH sub-groups. RESULTS: SGD participants reported higher prevalence of ACEs, low income, and low education compared to CGH participants (p < 0.0001) with the highest proportions in transgender and queer/something else groups. ACEs were associated with low income (AOR 1.084, CI 1.067-1.102) and low education (AOR 1.056, CI 1.041-1.071) in the entire sample. Transgender and queer/something else groups had higher odds of low income (AOR 3.345, CI 1.975-5.665; AOR 1.702, CI 1.096-2.643) and low education (AOR 1.702, CI 1.096-2.643; AOR 3.552, CI 2.842-4.440) and gay/lesbian identity had reduced odds of low education (AOR 0.586, CI 0.457-0.751) compared to CGH males. The strength of associations between ACEs and low income and low education were weaker among SGD compared to CGH sub-groups. CONCLUSION: These findings highlight the importance of including categories of sexual identity cross-classified by gender identity in population-based analyses in order to facilitate a comprehensive characterization of the life course outcomes of SGD populations.

Correction: Perceived neighborhood social cohesion and cervical and breast cancer screening utilization among U.S.-born and immigrant women.

[This corrects the article DOI: 10.3934/publichealth.2022039.].

Socioeconomic disparities in health outcomes in the United States in the late 2010s: results from four national population-based studies.

BACKGROUND: Despite the importance of monitoring health disparities by multiple socioeconomic categories, there have been no recent updates on the prevalence of general health indicators by socioeconomic categories. The present study aims to update the prevalence estimates of health indicators by education and income categories across three age groups (children, young and middle-aged adults, and older adults) in the late 2010s by using four nationally representative data sources. We also examine socioeconomic differences in health by race/ethnicity subgroups. METHODS: Data were obtained from four nationally representative data sources from the U.S.: The National Health Interview Survey (2015-2018); the National Health and Nutrition Examination Survey, NHANES (2017-2020); the Behavioral Risk Factor Surveillance System (2016-2020); and the Health & Retirement Study (2016). Respondent-rated health and obesity were selected as the health indicators of interest. Socioeconomic factors included percentages of the federal poverty level and years of educational attainment. We conducted logistic regression analyses to calculate adjusted prevalence rates of respondent-rated (or measured, in the case of obesity in NHANES) poor health and obesity by income and education categories after controlling for sociodemographic characteristics. The complex sampling designs were accounted for in all analyses. RESULTS: Prevalence rates across racial/ethnic groups and age groups demonstrated clear and consistent socioeconomic gradients in respondent-rated poor health, with the highest rates among those in the lowest income and education categories, and decreased rates as income and education levels increased. On the other hand, there were less evident socioeconomic differences in obesity rates across all data sources, racial/ethnic groups, and age groups. CONCLUSIONS: Our results confirmed earlier, persistent evidence indicating socioeconomic disparities in respondent-rated poor health across all age and race/ethnicity groups by using four nationally representative datasets. In comparison to a decade earlier, socioeconomic disparities in poor health appeared to shrink while they emerged or increased for obesity. The results suggest an urgent need for action to alleviate pervasive health disparities by socioeconomic status. Further research is needed to investigate potentially modifiable factors underlying socioeconomic disparities in health, which may help design targeted health promotion programs.

Racial and ethnic disparities in cervical and breast cancer screenings by nativity and length of U.S. residence.

OBJECTIVE: Previous studies of disparities in breast and cervical cancer screenings have focused on broad racial/ethnic groups or nativity status without accounting for immigration histories. Recent theoretical work argues for using intersectional approaches and examining within-group inequalities. Utilizing multiple years of National Health Interview Survey (NHIS) data, we examined between- and within-group Papanicolaou (Pap) test and mammogram screening based on nativity and length of U.S. residence for Asian and Hispanic women, along with non-Hispanic Black and White women. DESIGN: The study samples consist of 54,900 women ages 21-64 without a hysterectomy who responded to questions about Pap test screening and 36,300 women ages 40-64 who responded to questions about mammogram screening. Asian and Hispanic women were further stratified by nativity and, for immigrants, length of time in the United States. Logistic regression analysis was used to identify significant associations with Pap test and mammogram screenings. RESULTS: Recent Asian and Hispanic immigrants had the lowest Pap test and mammogram rates among all other groups, while Black (and White women for mammograms) women had the highest rates. After accounting for age, marital status, health insurance, education, employment status, and income, both Asian groups had lower odds, and Black and all Hispanic groups had higher odds of Pap test screening compared with White women. Similar results were observed for mammogram screening, except that long-term immigrant/U.S.-born Asian and U.S.-born Hispanic women did not have significantly different odds compared with White women. In general, the strength and direction of most sociodemographic variables were similar across groups for Pap test screening but differed for mammogram screening. CONCLUSIONS: The between-group differences identified emphasize the disparities in screening between racial/ethnic groups while the within-group differences suggest the need to examine whether more targeted outreach efforts and prevention messages can increase screening for specific groups.

Breastfeeding, socioeconomic status, and long-term postpartum weight retention.

BACKGROUND: Almost half of all pregnant women in the United States gain weight above Institute of Medicine gestational weight gain guidelines. Breastfeeding has been shown to reduce weight retention in the first year postpartum; however, women with lower socioeconomic status (SES) tend to initiate breastfeeding less often than women with higher SES. We investigated associations between duration of breastfeeding with mother's long-term postpartum weight status at 4-10 years and evaluated whether the associations varied by SES. METHODS: Maternal and infant dyads (N = 2144 dyads) are from the Geographic Research on Wellbeing survey (GROW), 2012-2013, a long-term, cross-sectional follow-up of the Maternal and Infant Health Assessment (MIHA) based in California, USA. Pre-pregnancy body mass index (BMI) was obtained from self-report of height and weight during MIHA, while breastfeeding history and self-report of current body weight was collected at the 4-10 year GROW postpartum visit. SES score was derived from a composite score of percent federal poverty level and education and was dichotomized into High and Low SES groups at a score of three. Multivariable linear regression was used to examine association between breastfeeding and maternal weight status, and to examine for effect modification by SES. RESULTS: Average long-term weight retention 4-10 years postpartum was 4.0 kg. Fewer lower SES vs. higher SES women breast fed at least six months (51% versus 70%, p < .001) or ever breastfed (74% versus 89%, P < .001). Women who breastfed at least six months had lower long-term postpartum weight retention compared to those who did not (b = -1.06 kg, (-1.93, 0.25); p = 0.01); however, these association did not vary by SES. CONCLUSION: Six months of breastfeeding is associated with lower BMI at 4-10 years and lower body weight, and effects do not vary by SES. Future policies and guidelines should consider building an infrastructure that is supportive of longer breastfeeding duration. Moreover, further research is needed to identify the impact of additional behavioral and environmental factors on long-term maternal weight status. Understanding the drivers of excessive weight retention pospartum can help us not only improve the pregnant person's health but the health of their children.

Navigating Financial Barriers to Papanicolaou Tests and Mammograms for Young Adult Women Residing in Rural and Border Areas of Texas.

Purpose: Costs of Papanicolaou (Pap) tests and mammograms are a primary barrier for women aged 18-39 seeking screening and diagnostic services. Race/ethnicity and rural/border resident status compound their risks for delayed diagnosis, possibly resulting in higher mortality. Methods: We analyzed cross-sectional data from young adult (YA) women (aged 18-39) from a cancer education and patient navigation (PN) program in rural and border Texas from 2012 to 2016. Descriptive statistics, Chi-square tests, and logistic regressions summarized sociodemographic variables and receipt of PN, Pap tests, and mammograms. Results: The sample consisted of 1181 women aged 31.8 years (standard deviation 5.5) on average. A total of 795 (67.3%) received PN, 494 (41.8%) received a Pap test, and 121 (10.3%) received a mammogram. The YA women attending the program due to cost (odds ratio [OR]: 7.24; confidence interval [CI]: 4.74-11.05) and reporting 1 (OR: 3.84; CI: 2.40-6.14) or 2+ barriers (OR: 6.00; CI: 3.61-9.99) had higher odds of being navigated than those not concerned about cost and not identifying a barrier. The YA women attending due to cost (OR: 2.22, CI: 1.61-3.05) and receiving navigation (OR: 1.92; CI: 1.29-2.84) had higher odds of receiving a Pap test than their counterparts. The majority receiving a mammogram were worried about cost (85.1%); 40.5% had a family history of breast cancer, and a doctor or nurse recommended a mammogram for 15.7%. Conclusion: Detection of cervical and breast cancer in YA women residing in rural and border Texas may be improved with PN to assist with financial barriers to care and service coordination.

An Intersectional Approach to Understanding Barriers to Healthcare for Women.

Access to health care depends on multiple sociodemographic factors such as race/ethnicity, marital status, education, income, and insurance status. However, a paucity of research has examined access to healthcare disparities as they uniquely affect women, specifically women of color. National data were analyzed from the Medical Expenditure Panel Survey (MEPS) utilizing an 11-year sample (2005-2015) of women ages 18-74 (N = 128,355). More recent data were not included due to changes in how sampling was conducted after 2015. Predictor variables included race/ethnicity cross-classified with marital status, education, income, or insurance status, controlling for age. A dichotomous outcome variable called "any barriers to healthcare" was created based on usual source of care, delayed medical care, delayed dental care and delayed prescription care. Multivariate logistic regression models were used to identify associations with barriers to care. The foundation of this methodology is intersectionality and how it impacts access to care for women across social identities. Hispanic women (OR 1.08, 95% CI 1.02-1.14) had higher odds of having a barrier to care compared to White women. However, Black women (OR 0.92, 95% CI 0.87-0.97) had lower odds of having a barrier to care compared to White women. Race/ethnicity also significantly moderated the relationship between socioeconomic variables (marital status, income, education and insurance status) and having a barrier to care. To achieve a healthy community, addressing these racial/ethnic and socioeconomic inequalities helps to support the people who live and work within these communities.

Social Inequalities in Multiple Chronic Disease Risk Factors among a population-based Sample of Latinas in California.

Data from 1,248 Latina mothers who participated in the Geographic Research on Wellbeing (GROW) study were used to examine associations between SES, neighborhood-level Latinx concentration, neighborhood-level poverty and having two or more modifiable behavioral risk factors (e.g., smoking, drinking) for chronic disease. Logistic regression models were estimated stratified by nativity and adjusted for age and marital status. Among immigrants, low SES was associated with higher odds of multiple risk factors (Adjusted Odds Ratio [AOR] = 1.66, 95% Confidence Interval [CI] = 1.17-2.38). Among US-born women, low neighborhood-level Latinx concentration was associated with lower odds of multiple risk factors (AOR = 0.43, 95% CI = 0.22-0.84), and high neighborhood-level poverty (AOR = 2.83, 95% CI = 1.61-4.99) and low SES (AOR = 1.72, 95% CI = 1.02-2.92) were associated with higher odds, respectively. Heterogeneous effects between nativity and social factors may produce risk for chronic disease among Latinas.

Impact of COVID social distancing measures on eating and exercise behaviors among a sample of Hispanic parents of young children in the United States.

Background: In the United States, healthy behaviors, such as eating fruits/vegetables and exercise, are well below recommended levels, particularly for Hispanics. The COVID pandemic may have exacerbated existing health behavior disparities. The current study examines the impact of COVID social distancing measures on Hispanic parents' eating and exercise behaviors, and how the impact may differ by socioeconomic status (SES) and distress levels. Design and methods: This cross-sectional logistic regression study utilized data from a sample of Hispanic parents in Texas (n = 237). COVID-related questions were collected in Summer 2020. Dependent variables included self-reported changes in exercise and eating behaviors due to the pandemic (i.e. got better or got worse). Primary independent variables included family-SES, neighborhood-SES, and distress due to COVID. Results: More than half (60%) of parents reported that their eating and exercise behaviors worsened. Results showed a significant relationship between distress due to COVID and both dependent variables; changes in eating (OR = 1.38, 95% CI [1.20, 1.58]) and changes in exercise (OR = 1.28, 95% CI [1.11, 1.48]). There were no observed differences by SES. Conclusions: Results suggest distress due to COVID was associated with worsening of eating and exercise behaviors, regardless of SES. The direction of the relationship between distress and healthy eating and exercise behaviors requires further attention.

Perceived neighborhood social cohesion and cervical and breast cancer screening utilization among U.S.-born and immigrant women.

Research suggests that factors beyond the individual level, such as neighborhood-level factors, warrant further investigation in explaining preventive screening utilization disparities. In addition, research shows that immigrant women, especially recent immigrants, are less likely than U.S.-born women to utilize preventive screenings. Our study examined the relationship between perceived neighborhood social cohesion and breast and cervical cancer screening utilization among U.S.-born and immigrant women. Data came from the 2018 National Health Interview Survey (NHIS). The sample for this study included 7801 women ages 21-64 without a hysterectomy. Of them, 1477 (19%) reported being born outside the United States. Logistic regression was used to examine associations of perceived neighborhood social cohesion and sociodemographic factors with the odds of screening by nativity status. Though we found no link between neighborhood social cohesion and Papanicolaou (Pap) test or mammogram utilization, our findings contribute to understanding sociodemographic barriers to and facilitators of preventive screening utilization among immigrant and U.S.-born women. Most importantly, racial/ethnic and socioeconomic disparities in Pap tests and mammogram utilization were evident among immigrant women. The disparities we identified indicate the need to target prevention messages and tailor interventions to address each group's sociodemographic characteristics and needs. Our findings also support the need to expand health insurance so that all women are covered.

Effect of Social Environments on Cardiovascular Disease in the United States.

Background This study aims to examine the effect of time-variant perceived neighborhood social cohesion, perceived neighborhood physical disorder, and local crime on cardiovascular disease (CVD) incidence from 2006 through 2016. Methods and Results We obtained data from the Health & Retirement Study. Respondents aged ≥50 years and with no recorded history of CVD until 2006 (N=8826) were included and followed for 10 years. Cox proportional hazards models were estimated with CVD incidence as an outcome variable and time-variant social environment factors (perceived neighborhood social cohesion, perceived neighborhood physical disorder, and local crime) as exposures, after controlling for sociodemographic factors and CVD-related risk/protective factors. Our results showed that perceived neighborhood social cohesion was associated with CVD among Black respondents, but not Hispanic and White respondents. Perceived neighborhood physical disorder and local crime rates were not associated with CVD incidence across all racial and ethnic groups. Conclusions The results demonstrate that perceptions of favorable social environments need to be considered to reduce CVD risk among Black adults. Further research is needed to identify different pathways through which living in favorable social environments benefits cardiovascular health by racial and ethnic groups.

The Impact of Medicaid Expansion on Black-White Disparities in Cardiovascular Disease Mortality.

Cardiovascular disease (CVD) is a leading cause of mortality among U.S. adults, especially low-income and uninsured adults. Non-Hispanic Black adults, who are overrepresented among low-income and uninsured populations, are disproportionately burdened by CVD mortality compared with non-Hispanic White adults. Medicaid expansion is associated with improved insurance coverage and access to care among low-income adults as well as reduced CVD mortality. It is unclear whether Medicaid expansion has reduced the Black-White disparity in CVD mortality. This study estimated a difference-in-differences model to compare changes in county-level CVD mortality ratios between expansion and non-expansion states. Findings indicate that Medicaid expansion is not associated with a statistically significant reduction in Black-White disparities in CVD mortality (ß = -.039; p =.30). In conclusion, Medicaid expansion may be associated with improved health outcomes and access to care overall; however, it is insufficient to overcome other (i.e., social and economic) drivers of racial/ethnic disparities in CVD mortality.

Examining School and Neighborhood Effects of Socioeconomic Status on Childhood Obesity in the U.S.

Obesity amongst Kindergartners in Texas is above the national average, particularly among Hispanic students. Research on the impact of school and neighborhood-level SES on obesity in childhood using multilevel models is lacking. Survey data were collected from Hispanic caregivers of pre-kindergarten students in Fall 2019 (n = 237). Students were clustered in thirty-two neighborhoods and twelve schools. The dependent variable was the child's body mass index z-score (BMIz). Covariates included the child's sex, primary caregiver's marital status, education level, relationship to the child, and family income. Level-two variables included neighborhood poverty and school SES. CTableross-classified multilevel linear regression models were conducted to examine the unique associations of neighborhood poverty and school SES with individual student BMIz, and how they interact. Twenty-four percent of students were classified as overweight, and five percent were classified as obese. The models resulted in a significant association between school SES and BMIz (B = −0.13; SE = 0.06; p < 0.05) and between neighborhood poverty and BMIz (B = −1.41; SE = 0.49; p < 0.01). Individual students' BMIz decreased as school SES increased and decreased as neighborhood poverty increased. Neighborhood poverty and school SES appear to play a role in the development of obesity in childhood, although in differing directions.

Neighborhood Poverty in Combination with Older Housing Is Associated with Adverse Birth Outcomes: A Study on Ubiquitous Lead Risk among 1 Million Births in Texas.

The purpose of this study was to determine whether housing age in combination with neighborhood poverty, as a proxy for fetal exposure to heavy metal lead, is associated with adverse birth outcomes. We linked population-level birth certificate data for Black, Hispanic, White and Other women, stratified by nativity, from 2009-2011 in Texas (n = 1,040,642) to census the tract-level median housing age/poverty level from the American Community Survey, 2007-2011. Tracts with median housing age values before 1975 with a poverty level of 20% or more were considered to be neighborhoods with a high risk of exposure to deteriorating lead-based paint. We estimated multilevel models to examine the relationship between neighborhood housing age/poverty level and each dependent variable (preterm birth, low birth weight, small-for-gestational age). The odds of adverse birth outcomes were significantly higher for mothers living in high-poverty neighborhoods with median housing built before the lead-based paint ban. Increased awareness of-and improved methods of alleviating- ubiquitous lead-based paint exposure in Texas may be necessary interventions for positive developmental trajectories of children. Allocating federal funds for place-based interventions, including universal lead paint mitigation, in older, high-poverty neighborhoods may reduce the disproportionate risk of adverse birth outcomes.