Structural racism, nativity and risk of adverse perinatal outcomes among Black women.

BACKGROUND: Black women in the United States (US) have the highest risk of preterm birth (PTB) and small for gestational age (SGA) births, compared to women of other racial groups. Among Black women, there are disparities by nativity whereby foreign-born women have a lower risk of PTB and SGA compared to US-born women. Differential exposure to racism may confer nativity-based differences in adverse perinatal outcomes between US- and foreign-born Black women. This remains unexplored among US- and African-born women in California. OBJECTIVES: Evaluate the relationship between structural racism, nativity, PTB and SGA among US- and African-born Black women in California. METHODS: We conducted a population-based study of singleton births to US- and African-born Black women in California from 2011 to 2017 (n = 131,424). We examined the risk of PTB and SGA by nativity and neighbourhoods with differing levels of structural racism, as measured by the Index of Concentration at the Extremes. We fit crude and age-adjusted Poisson regression models, estimated using generalized estimating equations, with risk ratios (RR) and 95% confidence intervals (CI) as the effect measure. RESULTS: The proportions of PTB and SGA were 9.7% and 14.5%, respectively, for US-born women, while 5.6% and 8.3% for African-born women. US-born women (n = 24,782; 20.8%) were more likely to live in neighbourhoods with high structural racism compared to African-born women (n = 1474; 11.6%). Structural racism was associated with an elevated risk of PTB (RR 1.19, 95% CI 1.12, 1.26) and SGA (RR 1.19, 95% CI 1.13, 1.25) for all Black women, however, there was heterogeneity by nativity, with US-born women experiencing a higher magnitude of effect than African-born women. CONCLUSIONS: Among Black women in California, exposure to structural racism and the impacts of structural racism on the risk of PTB and SGA varied by nativity.

Implementation of cross-sector partnerships: a description of implementation factors related to addressing social determinants to reduce racial disparities in adverse birth outcomes.

Introduction: Traditional perinatal care alone cannot address the social and structural determinants that drive disparities in adverse birth outcomes. Despite the wide acceptance of partnerships between healthcare systems and social service agencies to address this challenge, there needs to be more research on the implementation factors that facilitate (or hinder) cross-sector partnerships, particularly from the perspective of community-based organizations. This study aimed to integrate the views of healthcare staff and community-based partner organizations to describe the implementation of a cross-sector partnership designed to address social and structural determinants in pregnancy. Methods: We used a mixed methods design (in-depth interviews and social network analysis) to integrate the perspectives of healthcare clinicians and staff with those of community-based partner organizations to identify implementation factors related to cross-sector partnerships. Results: We identified seven implementation factors related to three overarching themes: relationship-centered care, barriers and facilitators of cross-sector partnerships, and strengths of a network approach to cross-sector collaboration. Findings emphasized establishing relationships between healthcare staff, patients, and community-based partner organizations. Conclusion: This study provides practical insights for healthcare organizations, policymakers, and community organizations that aim to improve access to social services among historically marginalized perinatal populations.

"It was just one moment that I felt like I was being judged": Pregnant and postpartum black Women's experiences of personal and group-based racism during the COVID-19 pandemic.

BACKGROUND: Racial inequities in maternal and child health outcomes persist: Black women and birthing people experience higher rates of adverse outcomes than their white counterparts. Similar inequities are seen in coronavirus disease (COVID-19) mortality rates. In response, we sought to explore the intersections of racism and the COVID-19 pandemic impact on the daily lives and perinatal care experiences of Black birthing people. METHODS: We used an intrinsic case study approach grounded in an intersectional lens to collect stories from Black pregnant and postpartum people residing in Fresno County (July-September 2020). All interviews were conducted on Zoom without video and were audio recorded and transcribed. Thematic analysis was used to group codes into larger themes. RESULTS: Of the 34 participants included in this analysis, 76.5% identified as Black only, and 23.5% identified as multiracial including Black. Their mean age was 27.2 years [SD, 5.8]. Nearly half (47%) reported being married or living with their partner; all were eligible for Medi-Cal insurance. Interview times ranged from 23 to 96 min. Five themes emerged: (1) Tensions about Heightened Exposure of Black Lives Matter Movement during the pandemic; (2) Fear for Black Son's Safety; (3) Lack of Communication from Health Care Professionals; (4) Disrespect from Health Care Professionals; and (5) Misunderstood or Judged by Health Care Professionals. Participants stressed that the Black Lives Matter Movement is necessary and highlighted that society views their Black sons as a threat. They also reported experiencing unfair treatment and harassment while seeking perinatal care. CONCLUSIONS: Black women and birthing people shared that exposure to racism has heightened during the COVID-19 pandemic, increasing their levels of stress and anxiety. Understanding how racism impacts Black birthing people's lives and care experiences is critical to reforming the police force and revising enhanced prenatal care models to better address their needs.

A qualitative exploration of experiences accessing community and social services among pregnant low-income people of color during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has been associated with increased social and economic stressors among pregnant individuals. While community and social services have been available to mitigate stressors in pregnancy (e.g. food insecurity and financial hardship) and reduce the risk of adverse maternal outcomes, it is unclear how the pandemic impacted access to these resources, particularly in communities of color with lower incomes. OBJECTIVE: To examine the experiences accessing community and social service resources during the COVID-19 pandemic among pregnant people of color with low incomes. DESIGN: Participants for this COVID-related qualitative study were recruited from two sources-a prospective comparative effectiveness study of two models of enhanced prenatal care and the California Black Infant Health Program between August and November of 2020. METHODS: We conducted 62 interviews with Medicaid-eligible participants in California's Central Valley. During their interviews, study participants were asked to share their pregnancy-related experiences, including how they felt the pandemic had affected those experiences. RESULTS: We identified two broad themes: challenges with accessing community and social service resources during the pandemic and opportunities for improving access to these resources. Sub-themes related to challenges experienced included difficulty with remote access, convoluted enrollment processes for community and social services, and problems specific to accessing COVID-19 resources (e.g. testing). Sub-themes related to opportunities to improve access included leveraging instrumental support from perinatal staff and informational (e.g. practical) support from other community programs and pregnant peers. Participant recommendations included leveraging opportunities to improve client experiences through increased transparency and better patient-provider communication. CONCLUSION: This study highlights some important trends that emerged with the rollout of remote service delivery for social services among a vulnerable population. Many participants were able to leverage support through other programs and perinatal staff. These individuals identified additional opportunities to improve client experiences that can inform the future implementation of support services for pregnant people.

Perceived stress and COVID-19-related stressors: the moderating role of social support during pregnancy.

Recent evidence on perceived stress during the COVID-19 pandemic shows that birthing people experienced stress from pandemic-related stressors. While psychosocial stress is a significant predictor of adverse birth outcomes, social support can reduce stress levels during pregnancy. This study examined social support moderation of relationships between COVID-19-related stressors and perceived stress during pregnancy. The analysis included data from publicly insured pregnant participants who were enrolled in a randomized control trial of two enhanced prenatal care models in Fresno, California, and completed a third-trimester questionnaire between April and August 2020 (n = 77). Multivariate linear regression was used to estimate the associations between perceived stress and COVID-19-related stressors and social support moderation. COVID-19-related stressors related to childcare and tension at home remained significantly associated with perceived stress adjusting for sociodemographic characteristics and other COVID-19-related stressors. Social support moderated the relationship between perceived stress and loss of childcare (ß = 2.4, 95 percent CI = 0.5-4.3, p = .014). Overall, social support moderated the association between COVID-19 stressors and perceived stress. While social support is commonly conceptualized as protective, the finding of greater stress around childcare among individuals reporting greater social support suggests complexity for leveraging these support networks during the pandemic.

Variations in Maternal Factors and Preterm Birth Risk among Non-Hispanic Black, White, and Mixed-Race Black/White Women in the United States, 2017.

OBJECTIVE: This study aims to compare preterm birth (PTB) risk and maternal factors associated with PTB among non-Hispanic White, Black, and mixed-race Black/White women in the United States. METHODS: In this study, we used U.S. birth certificate data from the 2017 National Vital Statistics System. We included live singleton births to women who self-identified as non-Hispanic White, Black, or mixed-race Black/White. PTB was defined as less than 37 weeks of gestation. We used logistic regression models to estimate the PTB odds ratios for Black and Black/White relative to White women, adjusted for maternal factors. We used logistic regression to estimate associations between PTB and maternal factors in race-stratified models. RESULTS: The sample included a total of 2,297,076 births in 2017 to White (n = 1,792,257), Black (n = 476,969), and Black/White (n = 27,850) women. The prevalence of PTB varied for Black (11.2%), Black/White (8.2%), and White (6.8%) women. The odds of PTB compared with White differed for Black (odds ratio, 1.51; 95% confidence interval, 1.49-1.53) and Black/White (odds ratio, 1.13; 95% confidence interval, 1.08-1.18) women after adjusting for maternal factors. The odds of PTB associated with maternal sociodemographic, prepregnancy, and gestational factors differed by maternal race. CONCLUSIONS: Evaluation of PTB risk among White, Black, and Black/White women revealed distinct associations between PTB and maternal factors for Black/White women. This study highlights the need for research assessing the relationships between social risk factors such as colorism and racism and the outcome of PTB, and it provides evidence that may inform more targeted PTB prevention among Black/White and Black women.

The association of COVID-19 infection in pregnancy with preterm birth: A retrospective cohort study in California.

INTRODUCTION: Our understanding of the association between coronavirus disease 19 (COVID-19) and preterm or early term birth among racially and ethnically diverse populations and people with chronic medical conditions is limited. METHODS: We determined the association between COVID-19 and preterm (PTB) birth among live births documented by California Vital Statistics birth certificates between July 2020 and January 2021 (n=240,147). We used best obstetric estimate of gestational age to classify births as very preterm (VPTB, <32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks), as each confer independent risks to infant health and development. Separately, we calculated the joint effects of COVID-19 diagnosis, hypertension, diabetes, and obesity on PTB and VPTB. FINDINGS: COVID-19 diagnoses on birth certificates increased for all racial/ethnic groups between July 2020 and January 2021 and were highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). There was no effect modification of the overall association by race/ethnicity or insurance status. COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity. INTERPRETATION: In a large population-based study, COVID-19 diagnosis increased the risk of VPTB, PTB, and early term birth, particularly among people with medical comorbidities. Considering increased circulation of COVID-19 variants, preventative measures, including vaccination, should be prioritized for birthing persons. FUNDING: UCSF-Kaiser Department of Research Building Interdisciplinary Research Careers in Women's Health Program (BIRCWH) National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH) [K12 HD052163] and the California Preterm Birth Initiative, funded by Marc and Lynn Benioff.

Neighborhood Context and the Nativity Advantage in Preterm Birth among Black Women in California, USA.

Non-Hispanic Black women remain at increased risk for adverse birth outcomes, yet Black immigrant women are at lower risk than their US-born counterparts. This study examines whether neighborhood context contributes to the nativity advantage in preterm birth (PTB, < 37 weeks) among Black women in California. A sample of live singleton births to non-Hispanic US-born (n = 83,169), African-born (n = 7151), and Caribbean-born (n = 943) Black women was drawn from 2007 to 2010 California birth records and geocoded to urban census tracts. We used 2010 American Community Survey data to measure tract-level Black immigrant density, Black racial concentration, and a neighborhood deprivation index. Risk ratios (RR) and 95% confidence intervals (95%CI) were estimated using log-binomial regression to assess whether neighborhood context partially explained nativity differences in PTB risk. Compared to US-born Black women, African-born Black women had lower PTB risk (RR = 0.65, 95%CI: 0.60-0.71). The difference in PTB risk between US- and Caribbean-born women did not reach statistical significance (RR = 0.87, 95%CI: 0.71-1.05). The nativity advantage in PTB risk was robust to neighborhood social conditions and maternal factors for African-born women (RR = 0.59, 95%CI: 0.51-0.67). This study is one of few that considers area-level explanations of the nativity advantage among Black immigrants and makes a significant contribution by showing that the neighborhood context does not explain the nativity advantage in PTB among Black women in California. This could be due to many factors that should be examined in future research.

Maternal nativity and risk of adverse perinatal outcomes among Black women residing in California, 2011-2017.

OBJECTIVE: Examine the risk of adverse perinatal outcomes among the United States (US)-born and foreign-born Black women in California. STUDY DESIGN: The study comprised all singleton live births to Black women in California between 2011 and 2017. We defined maternal nativity as US-born or foreign-born. Using Poisson regression, we computed risk ratios (RR) and 95% confidence intervals (CI) for three adverse perinatal outcomes: preterm birth, small for gestational age deliveries, and infant mortality. RESULTS: Rates of adverse perinatal outcomes were significantly higher among US-born Black women. In adjusted models, US-born Black women experienced an increased risk of preterm birth (RR 1.51, 95% CI 1.39, 1.65) and small for gestational age deliveries (RR 1.52, 95% CI 1.41, 1.64), compared to foreign-born Black women. CONCLUSIONS: Future studies should consider experiences of racism across the life course when exploring heterogeneity in the risk of adverse perinatal outcomes by nativity among Black women in the US.

An Examination of Preterm Birth and Residential Social Context among Black Immigrant Women in California, 2007-2010.

The foreign-born black population contributes a considerable amount of heterogeneity to the US black population. In 2005, black immigrants accounted for 20% of the US black population. Compared to native-born black women, black immigrant women are at lower risk for adverse birth outcomes, including preterm birth. Some scholars posit that differential exposures to socioeconomic disadvantage and structural racism in the residential context may account for this advantage. However, to date, few studies offer comprehensive examinations of the black immigrant residential social context, particularly in settlement regions beyond predominantly black and historically segregated regions. Further, studies examining the black immigrant residential context typically use a single indicator, which limits discussion of the intersecting domains that simultaneously increase or decrease risk among black immigrants. We addressed these gaps by examining black immigrant neighborhoods in the state of California, where racial residential segregation of the black population is low. We operationalized the residential context of black immigrant women using three distinct attributes: immigrant co-ethnic density, black racial concentration, and neighborhood deprivation. We linked 2007-2010 California birth records of black immigrant women and 2010 census data on tract-level social attributes (N = 6930). OLS regression analyses showed that immigrant co-ethnic density, black racial concentration and neighborhood deprivation were not associated with preterm birth among black immigrants. Our findings indicate that in California, residential social context has little relation to black immigrant preterm birth-a finding that is unique compared to residential settings of other settlement contexts.