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OBJECTIVES: As part of a larger mixed-methods study to better define equity in access to sexual and reproductive health (SRH) care in Georgia, this analysis sought to understand: (1) how individuals define quality care for their SRH services; and (2) how quality of care is salient in their SRH care-seeking. STUDY DESIGN: From January 2019 to February 2020, we conducted life history interviews with individuals with the capacity to become pregnant in suburban areas in Georgia. We analyzed interviews using thematic analysis. RESULTS: SRH care quality was shaped by experiences with health center environment, with providers, and with staff. Study participants emphasized elements associated with trusted SRH care such as showing compassion, respecting and non-judging, taking time, providing information, and assuring agency. Participants also voiced a desire for holistic care that addressed the lived experiences of the individual. Participants took quality of care into account when care-seeking but sometimes had to weigh out preferences for quality with issues of affordability. CONCLUSIONS: Access to quality person-centered care is an essential component of realized access to SRH services. Measures of equitable access and quality should account for experiences of quality care that include both provider and staff interactions as well as the larger healthcare environment and ability to use quality care despite financial constraints. IMPLICATIONS: Quality family planning care should involve both clinicians and staff to incorporate showing compassion, providing respectful and non-judgmental care, taking time with patients, providing information, assuring agency in decision-making, as well as addressing the lived experiences of individuals.
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OBJECTIVES: To examine US in-hospital exclusive breastfeeding (EBF) and the associations with Baby-Friendly designation and neighborhood sociodemographic factors. METHODS: Hospital data from the 2018 Maternity Practices in Infant Nutrition and Care survey were linked to hospital zip code tabulation area (ZCTA) sociodemographic data from the 2014-2018 American Community Survey (n = 2,024). The percentages of residents in the hospital ZCTA were dichotomized based on the relative mean percentage of the hospital's metropolitan area, which were exposure variables (high/low Black hospitals, high/low poverty hospitals, high/low educational attainment hospitals) along with Baby-Friendly designation. Using linear regression, we examined the associations and effect measure modification between Baby-Friendly designation and hospital sociodemographic factors with in-hospital EBF prevalence. RESULTS: US mean in-hospital EBF prevalence was 55.1%. Baby-Friendly designation was associated with 9.1% points higher in-hospital EBF prevalence compared to non-designated hospitals [95% confidence interval (CI): 7.0, 11.2]. High Black hospitals and high poverty hospitals were associated with lower EBF prevalence (difference= -3.3; 95% CI: -5.1, -1.4 and - 3.8; 95% CI: -5.7, -1.8). High educational attainment hospitals were associated with higher EBF prevalence (difference = 6.7; 95% CI: 4.1, 9.4). Baby-Friendly designation was associated with significant effect measure modification of the in-hospital EBF disparity attributed to neighborhood level poverty (4.0% points higher in high poverty/Baby-Friendly designated hospitals than high poverty/non-Baby-Friendly designated hospitals).
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Aleitamento Materno , Hospitais , Pobreza , Características de Residência , Humanos , Aleitamento Materno/estatística & dados numéricos , Feminino , Pobreza/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Recém-Nascido , Estados Unidos , Lactente , Adulto , Disparidades em Assistência à Saúde/estatística & dados numéricos , Características da Vizinhança/estatística & dados numéricos , Promoção da Saúde/métodos , Fatores SocioeconômicosRESUMO
OBJECTIVE: To estimate the effect of geographic variation in historic slavery on perinatal outcomes [chronic hypertension, hypertensive disorders of pregnancy (HDP), very preterm birth (VPTB), or very low birth weight birth (VLBW)] among Black people living in states where slavery was legal in 1860 and test mediation by Black homeownership. METHODS: We linked data from the 1860 census (the proportion of enslaved residents) to natality data on outcomes (2013-2021) using resident county. The percent of Black residents in a county who owned their home was a potential mediator. We fit log binomial models to estimate risk ratios (RRs) representing total and controlled direct effects (accounting for Black homeownership) of proportion enslaved on outcomes, accounting for potential confounding using marginal structural models. RESULTS: Among 2,443,198 included births, 8.8% (213,829) experienced HDP, 4.1% (100,549) chronic hypertension, 3.3% (81,072) VPTB, and 2.6% (62,538) VLBW. There was an increase in chronic hypertension and VPTB risk, but not HDP or VLBW, in counties with a 10% greater proportion enslaved in 1860 [adjusted RR: 1.06, 95% CI: (1.02, 1.1); 1.02 (1.00, 1.05); 1.00 (0.98, 1.02); 1.01 (1.00, 1.03)]. There was not evidence of mediation by Black homeownership. CONCLUSIONS: Historic slavery remains relevant for perinatal health.
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OBJECTIVES: As crises of drug-related maternal harms escalate, US public health surveillance capacity remains suboptimal for drug-related maternal morbidities. Most state hospital discharge databases (HDDs) are encounter-based, and thus limit ascertainment of morbidities to delivery visits and ignoring those occurring during the 21 months spanning pregnancy and postpartum year. This study analyzes data from a state that curates person-centered HDD to compare patterns of substance use disorder (SUD) diagnoses at delivery vs. the full 21 pregnancy/postpartum months, overall and by maternal social position. METHODS: Among people who experienced an in-hospital birth in New York State between 9/1/2016 and 1/1/2018 (N = 330,872), we estimated SUD diagnosis (e.g., opioids, stimulants, benzodiazepines, cannabis) prevalence at delivery; across the full 9 months of pregnancy and 12 postpartum months; and by trimester and postpartum quarter. Risk ratio and risk difference estimated disparities by race/ethnicity, age, rurality, and payor. RESULTS: The 21-month SUD prevalence rate per 100,000 was 2671 (95% CI 2616-2726), with 31% (29.5%-31.5%) missing SUD indication when ascertained at delivery only (1866; 95% CI 1820-1912). Quarterly rates followed a roughly J-shaped trajectory. Structurally marginalized individuals suffered the highest 21-month SUD prevalence (e.g., Black:White risk ratio=1.80 [CI:1.73-1.88]). CONCLUSION: By spanning the full 21 months of pregnancy/postpartum, person-centered HDD reveal than the maternal SUD crisis is far greater than encounter-based delivery estimates had revealed. Generating person-centered HDD will improve efforts to tailor interventions to help people who use drugs survive while pregnant and postpartum, and eliminate inequities.
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Overdose de Drogas , Alta do Paciente , Complicações na Gravidez , Transtornos Relacionados ao Uso de Substâncias , Humanos , Feminino , Gravidez , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto , Overdose de Drogas/epidemiologia , Alta do Paciente/estatística & dados numéricos , Complicações na Gravidez/epidemiologia , New York/epidemiologia , Adulto Jovem , Vigilância em Saúde Pública/métodos , Prevalência , Adolescente , Período Pós-PartoRESUMO
BACKGROUND: Historical redlining, a discriminatory lending practice, is an understudied component of the patient risk environment following hospital discharge. We investigated associations between redlining, patient race, and outcomes following heart failure hospitalization. METHODS AND RESULTS: We followed a hospital-based cohort of Black and White patients using electronic medical records for acute heart failure hospitalizations between 2010 and 2018 (n=6800). Patient residential census tracts were geocoded according to the 1930s Home Owners' Loan Corporation map grades (A/B: best/still desirable, C: declining, D: redlined). We used Poisson regression to analyze associations between Home Owners' Loan Corporation grade and 30-day outcomes (readmissions, mortality, and their composite). One-third of patients resided in historically redlined tracts (n=2034). In race-stratified analyses, there was a positive association between historically declining neighborhoods and composite readmissions and mortality for Black patients (risk ratio [RR], 1.24 [95% CI, 1.003-1.54]) and an inverse association between redlined neighborhoods and 30-day readmissions among White patients (RR, 0.58 [95% CI, 0.39-0.86]). Examining racial disparities across Home Owners' Loan Corporation grades, Black patients had higher 30-day readmissions (RR, 1.86 [95% CI, 1.31-2.65]) and composite readmissions and mortality (RR, 1.32 [95% CI, 1.04-1.65]) only in historically redlined neighborhoods. CONCLUSIONS: Historical redlining had potentially mixed impacts on outcomes by race, such that residing in less desirable neighborhoods was associated with an elevated risk of an adverse outcome following heart failure hospitalization in Black patients and a reduced risk in White patients. Moreover, racial disparities in patient outcomes were present only in historically redlined neighborhoods. Additional research is needed to explore observed heterogeneity in outcomes.
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Insuficiência Cardíaca , Características de Residência , Humanos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Hospitalização , Sudeste dos Estados Unidos , Negro ou Afro-Americano , BrancosRESUMO
OBJECTIVE: To study the relationship between neighborhood deprivation index (NDI) and markers of ovarian reserve and outcomes of controlled ovarian stimulation among young, healthy oocyte donors. DESIGN: Retrospective cohort study. PATIENTS: A total of 547 oocyte donors who underwent 905 oocyte retrieval cycles (2008-2020) at a private fertility center in Sandy Springs, Georgia, United States. INTERVENTIONS: Neighborhood deprivation index was calculated using principal component analysis applied to census-level measures of poverty, employment, household composition, and public assistance, which was then standardized and linked to donor information on the basis of donor residence. MAIN OUTCOME MEASURES: Markers of ovarian reserve, including antral follicle count (AFC) and antimüllerian hormone (AMH) levels, and outcomes of controlled ovarian stimulation including number of total and mature oocytes retrieved and ovarian sensitivity index (OSI) (defined as the number of oocytes retrieved/total gonadotropin dose × 1,000). Multivariable generalized estimating equations with Poisson and normal distribution were used to model the relationship between NDI and outcome measures adjusting for age, body mass index, and year of retrieval. RESULTS: The mean (SD) age of donors was 25.0 (2.8) years and 29% of the donors were racial or ethnic minorities. There were no associations between donor NDI and ovarian reserve markers. For every interquartile range increase in NDI, there was a reduction of -1.5% (95% confidence interval: -5.3% to 2.4%) in total oocytes retrieved although the effect estimate was imprecise. Associations of NDI with a number of mature oocytes retrieved and OSI were in a similar direction. We observed evidence for effect modification of the NDI and OSI association by donor race. There was a suggestive positive association between NDI and OSI in Black donors but no association in White donors. CONCLUSION: In this cohort of young, healthy, racially diverse oocyte donors, we found little evidence of associations between NDI and markers of ovarian reserve or outcomes of ovarian stimulation.
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Doação de Oócitos , Reserva Ovariana , Indução da Ovulação , Humanos , Feminino , Adulto , Reserva Ovariana/fisiologia , Estudos Retrospectivos , Indução da Ovulação/métodos , Adulto Jovem , Características de Residência , Recuperação de Oócitos/estatística & dados numéricos , Resultado do Tratamento , Georgia/epidemiologia , PobrezaRESUMO
BACKGROUND: Studies find that delivery hospital explains a significant portion of the Black-White gap in severe maternal morbidity. No such studies have focused on the US Southeast, where racial disparities are widest, and few have examined the relative contribution of hospital, residential, and maternal factors. OBJECTIVE: This study aimed to estimate the portion of Georgia's Black-White gap in severe maternal morbidity during delivery through 42 days postpartum explained by hospital, residential, and maternal factors. STUDY DESIGN: Using linked Georgia hospital discharge, birth, and fetal death records for 2016 through 2020, we identified 413,124 deliveries to non-Hispanic White (229,357; 56%) or Black (183,767; 44%) individuals. We linked hospital data from the American Hospital Association and Center for Medicare and Medicaid Services, and area data from the Area Resource File and American Community Survey. We identified severe maternal morbidity indicator conditions during delivery or subsequent hospitalizations through 42 days postpartum. Using race-specific logistic models followed by a decomposition technique, we estimated the portion of the Black-White severe maternal morbidity gap explained by the following: (1) sociodemographic factors (age, education, marital status, and nativity), (2) medical conditions (diabetes mellitus, gestational diabetes, chronic hypertension, gestational hypertension or preeclampsia, and smoking), (3) obstetrical factors (singleton or multiple, and birth order); (4) access to care (no or third trimester care, and payer), (5) hospital factors that are time-varying (delivery volume, deliveries per full-time equivalent nurse, doctor communication, patient safety, and adverse event composite score) or measured time-invariant characteristics (ownership, profit status, religious affiliation, teaching status, and perinatal level), and (6) residential factors (county urban/rural classification, percent uninsured women of reproductive age, obstetrician-gynecologists per women of reproductive age, number of federally-qualified and community health centers, medically-underserved area [yes/no], and census tract neighborhood deprivation index). We estimated models with and without hospital fixed-effects, which account for unobserved time-invariant hospital characteristics such as within-hospital care processes or unmeasured hospital-specific factors. RESULTS: There was 1.8 times the rate of severe maternal morbidity per 100 discharges among non-Hispanic Black (3.15) than among White (1.73) individuals, with an explained proportion of 30.4% in models without and 49.8% in models with hospital fixed-effects. In the latter, hospital fixed-effects explained the largest portion of the Black-White severe maternal morbidity gap (15.1%) followed by access to care (14.9%) and sociodemographic factors (14.4%), with residential factors being protective for Black individuals (-7.5%). Smaller proportions were explained by medical (5.6%), obstetrical (4.0%), and time-varying hospital factors (3.2%). Within each category, the largest explanatory portion was payer type (13.3%) for access to care, marital status (10.3%) for sociodemographic, gestational hypertension (3.3%) for medical, birth order (3.6%) for obstetrical, and patient safety indicator (3.1%) for time-varying hospital factors. CONCLUSION: Models with hospital fixed-effects explain a greater proportion of Georgia's Black-White severe maternal morbidity gap than models without them, thereby supporting the point that differences in care processes or other unmeasured factors within the same hospital translate into racial differences in severe maternal morbidity during delivery through 42 days postpartum. Research is needed to discern and ameliorate sources of within-hospital differences in care. The substantial proportion of the gap attributable to racial differences in access to care and sociodemographic factors points to other needed policy interventions.
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We develop county-level measures of structural and institutional barriers to care, and test associations between these barriers and birth outcomes for US-born Black and White mothers using national birth records for 2014-2017. Results indicate elevated odds of greater preterm birth severity for Black mothers in counties with higher uninsurance rates among Black adults, fewer Black physicians per Black residents, and fewer publicly-funded contraceptive services. Most structural barriers were not associated with small-for-gestational-age birth, and barriers defined for Black residents were not associated with birth outcomes for White mothers, with the exception of Black uninsurance rate. Structural determinants of care may influence preterm birth risk for Black Americans.
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Recém-Nascido Pequeno para a Idade Gestacional , Nascimento Prematuro , Adulto , Feminino , Humanos , Recém-Nascido , Atenção à Saúde , Nascimento Prematuro/epidemiologia , Fatores de Risco , Brancos , Negro ou Afro-Americano , Pessoas sem Cobertura de Seguro de SaúdeRESUMO
BACKGROUND: There are significant racial disparities in in vitro fertilization outcomes, which are poorly explained by individual-level characteristics. Environmental factors such as neighborhood-level socioeconomic factors may contribute to these disparities. However, few studies have directly addressed this research question in a large, racially diverse cohort. OBJECTIVE: This study aimed to investigate whether neighborhood deprivation is associated with differences in in vitro fertilization outcomes. STUDY DESIGN: Our retrospective cohort study included 1110 patients who underwent 2254 autologous in vitro fertilization cycles between 2014 and 2019 at an academic fertility center in the Southeastern United States. Neighborhood deprivation was estimated using the Neighborhood Deprivation Index, a composite variable measuring community levels of material capital based on poverty, occupation, housing, and education domains. Using multivariable log-binomial generalized estimating equations with cluster weighting, risk ratios and 95% confidence intervals were estimated for cycle cancellation, miscarriage (defined as spontaneous pregnancy loss before 20 weeks after a confirmed intrauterine gestation), and live birth according to patient Neighborhood Deprivation Index. RESULTS: There were positive associations between increasing Neighborhood Deprivation Index (indicating worsening neighborhood deprivation) and body mass index, as well as increasing prevalence of tubal and uterine factor infertility diagnoses. The crude probability of live birth per cycle was lower among Black (24%) than among White patients (32%), and the crude probability of miscarriage per clinical pregnancy was higher among Black (22%) than among White patients (12%). After adjustment, the Neighborhood Deprivation Index was not significantly associated with risk of cycle cancellation or live birth. Results were consistent when analyses were stratified by race. CONCLUSION: Our research demonstrates racial disparities between Black and White women in the incidence of miscarriage and live birth following in vitro fertilization. Although the level of neighborhood deprivation was closely related to race, it did not have strong associations with in vitro fertilization outcomes in our population as a whole or within strata of race.
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Aborto Espontâneo , Infertilidade , Gravidez , Humanos , Feminino , Aborto Espontâneo/epidemiologia , Estudos Retrospectivos , Fatores Raciais , Fertilização in vitroRESUMO
Disparities in maternal-child health outcomes by race and ethnicity highlight structural differences in the opportunity for optimal health in the United States. Examples of these differences include access to state-level social policies that promote maternal-child health. States vary in their racial and ethnic composition as a result of the complex history of policies and laws related to slavery, Indigenous genocide and relocation, segregation, immigration, and settlement in the United States. States also vary in the social policies they enact. As a result, correlations exist between the demographic makeup of a state's population and the presence or absence of social policies in that state. These correlations become a mechanism by which racial and ethnic disparities in maternal-child health outcomes can operate. In this commentary, we use the example of three labor-related policies actively under consideration at state and federal levels (paid parental leave, paid sick leave, and reasonable accommodations during pregnancy) to demonstrate how correlations between state demographics and presence of these state policies could cause or exacerbate racial and ethnic disparities in maternal-child health outcomes. We conclude with a call for researchers to consider how the geographic distribution of racialized populations and state policies could contribute to maternal-child health disparities.
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Objective: The aim of this study is to examine in-hospital exclusive breastfeeding (EBF) and its association with sociodemographic factors, medical factors, breastfeeding intentions, and health care system breastfeeding support. Materials and Methods: We conducted a retrospective cross-sectional study using medical records from 2015 to 2019 of healthy term infants without breastfeeding contraindications at a public teaching hospital serving a racially and ethnically diverse patient population. Using multivariable regression analysis, we examined the associations between in-hospital EBF and sociodemographic factors, medical factors, breastfeeding intentions, and health care system breastfeeding support (in-hospital breastfeeding education and lactation support). Results: The prevalence of in-hospital EBF was 29.0%. The statistically significant findings from our fully adjusted regression analysis include that there was a higher prevalence of in-hospital EBF among adult mothers (prevalence ratio [PR]: range 1.78-1.96), married mothers (PR: 1.35, 95% confidence interval [CI]: 1.23-1.44), and mothers who were White (PR: 1.41, 95% CI: 1.20-1.66, compared with Black). Factors associated with a lower prevalence of in-hospital EBF were maternal diabetes (PR: 0.82, 95% CI: 0.70-0.95), pre-eclampsia/eclampsia (PR: 0.82, 95% CI: 0.71-0.95), cesarean delivery (PR: 0.84, 95% CI: 0.77-0.92), neonatal hypoglycemia (PR: 0.46, 95% CI: 0.36-0.59), and intention in the prenatal period to formula feed only (PR: 0.15, 95% CI: 0.10-0.22). In-hospital lactation support was associated with higher prevalence of in-hospital EBF (PR: 1.24, 95% CI: 1.16-1.33). Conclusions: Prioritizing lactation support for Black mothers, adolescent mothers, those intending in the prenatal period to formula feed only, and mother-infant dyads with certain medical factors could improve in-hospital EBF.
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Aleitamento Materno , Mães , Feminino , Lactente , Adulto , Gravidez , Recém-Nascido , Adolescente , Humanos , Estudos Retrospectivos , Estudos Transversais , Hospitais PúblicosRESUMO
BACKGROUND: Research examining the effects of historical redlining on present-day health outcomes is often complicated by the misalignment of contemporary census boundaries with the neighborhood boundaries drawn by the US Home Owners' Loan Corporation (HOLC) in the 1930s. Previous studies have used different approaches to assign historical HOLC grades to contemporary geographies, but how well they capture redlining exposure is unknown. METHODS: Our analysis included 7711 residences identified in the Multiple Listing Service database in Atlanta, Georgia (2017-2022). We evaluated the classification of HOLC grade assignment (A, B, C, D, or ungraded) when assigning exposure under four area-level approaches (centroid, majority land area, weighted score, and highest HOLC) compared with using complete address data (gold standard). We additionally compared approaches across three 2020 census geographies (tract, block group, and block). RESULTS: When comparing the use of census tracts to complete address data, sensitivity was highest for the weighted score approach, which correctly identified 77% of residences in truly A-D graded neighborhoods as compared with the majority land area (44%), centroid (54%), and highest HOLC (59%) approaches. Regarding specificity, the majority land area approach best-classified residences in truly ungraded neighborhoods (93%) as compared with the weighted score (65%), centroid (81%), and highest HOLC (54%) approaches. Classification improved regardless of approach when using census block compared with the census tract. CONCLUSIONS: Misclassification of historical redlining exposure is inevitable when using contemporary census geographies rather than complete address data. This study provides a framework for assessing spatial misalignment and selecting an approach for classification.
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Setor Censitário , Censos , Humanos , Bases de Dados Factuais , Geografia , Avaliação de Resultados em Cuidados de SaúdeRESUMO
BACKGROUND: Individual measures of socioeconomic status (SES) have been associated with an increased risk of neural tube defects (NTDs); however, the association between neighborhood SES and NTD risk is unknown. Using data from the National Birth Defects Prevention Study (NBDPS) from 1997 to 2011, we investigated the association between measures of census tract SES and NTD risk. METHODS: The study population included 10,028 controls and 1829 NTD cases. We linked maternal addresses to census tract SES measures and used these measures to calculate the neighborhood deprivation index. We used generalized estimating equations to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) estimating the impact of quartiles of census tract deprivation on NTDs adjusting for maternal race-ethnicity, maternal education, and maternal age at delivery. RESULTS: Quartiles of higher neighborhood deprivation were associated with NTDs when compared with the least deprived quartile (Q2: aOR = 1.2; 95% CI = 1.0, 1.4; Q3: aOR = 1.3, 95% CI = 1.1, 1.5; Q4 (highest): aOR = 1.2; 95% CI = 1.0, 1.4). Results for spina bifida were similar; however, estimates for anencephaly and encephalocele were attenuated. Associations differed by maternal race-ethnicity. CONCLUSIONS: Our findings suggest that residing in a census tract with more socioeconomic deprivation is associated with an increased risk for NTDs, specifically spina bifida.
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Defeitos do Tubo Neural , Humanos , Escolaridade , Etnicidade , Idade Materna , Defeitos do Tubo Neural/epidemiologia , Defeitos do Tubo Neural/etiologia , Razão de Chances , FemininoRESUMO
BACKGROUND: It has been hypothesized that low access to healthy and nutritious food increases health disparities. Low-accessibility areas, called food deserts, are particularly commonplace in lower-income neighborhoods. The metrics for measuring the food environment's health, called food desert indices, are primarily based on decadal census data, limiting their frequency and geographical resolution to that of the census. We aimed to create a food desert index with finer geographic resolution than census data and better responsiveness to environmental changes. MATERIALS AND METHODS: We augmented decadal census data with real-time data from platforms such as Yelp and Google Maps and crowd-sourced answers to questionnaires by the Amazon Mechanical Turks to create a real-time, context-aware, and geographically refined food desert index. Finally, we used this refined index in a concept application that suggests alternative routes with similar ETAs between a source and destination in the Atlanta metropolitan area as an intervention to expose a traveler to better food environments. RESULTS: We made 139,000 pull requests to Yelp, analyzing 15,000 unique food retailers in the metro Atlanta area. In addition, we performed 248,000 walking and driving route analyses on these retailers using Google Maps' API. As a result, we discovered that the metro Atlanta food environment creates a strong bias towards eating out rather than preparing a meal at home when access to vehicles is limited. Contrary to the food desert index that we started with, which changed values only at neighborhood boundaries, the food desert index that we built on top of it captured the changing exposure of a subject as they walked or drove through the city. This model was also sensitive to the changes in the environment that occurred after the census data was collected. CONCLUSIONS: Research on the environmental components of health disparities is flourishing. New machine learning models have the potential to augment various information sources and create fine-tuned models of the environment. This opens the way to better understanding the environment and its effects on health and suggesting better interventions.
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Censos , Crowdsourcing , Humanos , Desertos Alimentares , Fonte de Informação , Aprendizado de MáquinaRESUMO
OBJECTIVES: To understand perinatal risks associated with social needs in pregnancy Methods. Multivariable log-binomial regression analyses adjusting for age, parity, and insurance were used to evaluate the relationship between any social need (e.g., housing, transportation, food, and intimate partner violence) and adverse perinatal outcomes (stillbirth, prematurity, maternal morbidity) in a cohort of English and Spanish-speaking patients who obtained prenatal care and birthed at our institution during a one-year period. RESULTS: Of 2,435 patients, 1,608 (66%) completed social needs screening at least once during prenatal care. The cohort was predominantly non-Hispanic Black (1,294, 80%) and publicly insured (1,395, 87%). Having one or more social need was associated with three-fold increased risk of stillbirth (aRR 3.35, 95%CI 1.31,8.6) and 14% reduction in postpartum care attendance (aRR 0.86, 95%CI 0.78-0.95) and was highest in individuals reporting transportation needs. CONCLUSIONS: Social needs during pregnancy were associated with increased risk of stillbirth.
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Violência por Parceiro Íntimo , Natimorto , Gravidez , Feminino , Humanos , Natimorto/epidemiologia , Determinantes Sociais da Saúde , Cuidado Pré-Natal , PartoRESUMO
The objective of this study was to systematically review the available empirical evidence examining associations between preterm birth (PTB) and five domains of place-based contextual social and environmental determinants, including (1) physical environment, (2) residential greenness, (3) neighborhood violence/crime, (4) food accessibility and availability, and (5) health services accessibility, among adult mothers in high-income countries. The evidence in this review suggests an adverse association between damaged physical environment, neighborhood violence/crime, lack of health services accessibility, and PTB. The existing evidence also suggests a beneficial effect of residential greenness on PTB. Further studies are needed to investigate these associations for more understanding of the direction and magnitude of these association and for potential heterogeneity by factors such as race/ethnicity, urban vs rural residence, immigration status, and social class.
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Nascimento Prematuro , Adulto , Feminino , Recém-Nascido , Humanos , Mães , Características de Residência , Meio Ambiente , RendaRESUMO
BACKGROUND: In-hospital exclusive breastfeeding (EBF) is associated with longer breastfeeding durations, yet only 64% of US newborns are EBF for 7 days. The Ten Steps to Successful Breastfeeding (Ten Steps) are a set of evidenced-based maternity practices shown to improve breastfeeding outcomes; these were updated in 2018. METHODS: Using hospital-level data from the 2018 Maternity Practices in Infant Nutrition and Care Survey (n = 2045 hospitals), we examined the prevalence of implementation of Ten Steps indicators (each step and total number of steps implemented). Using linear regression, we also examined the association between the steps and EBF prevalence adjusted for hospital characteristics and all other steps. Discharge support was not included in the models since it primarily occurs after hospital discharge. RESULTS: The most frequently implemented step was the provision of prenatal breastfeeding education (95.6%). Steps with low implementation included rooming-in (18.9%), facility policies supportive of breastfeeding (23.4%), and limited formula supplementation (28.2%). After adjusting for hospital characteristics and all other steps, limited formula supplementation (difference = 14.4: 95% confidence interval [CI]: 12.6, 16.1), prenatal breastfeeding education (difference = 7.0; 95% CI: 3.3, 10.8), responsive feeding (difference = 6.3; 95% CI: 3.7, 9.0), care right after birth (skin-to-skin; difference = 5.8; 95% CI: 4.2, 7.4), and rooming-in (difference = 2.4; 95% CI: 0.4, 4.6) were associated with higher in-hospital EBF prevalence. We found a dose-response relationship between the number of steps implemented and in-hospital EBF prevalence. CONCLUSION: Increased implementation of the updated Ten Steps may improve EBF and infant and maternal health outcomes.
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Aleitamento Materno , Prática Clínica Baseada em Evidências , Lactente , Recém-Nascido , Feminino , Humanos , Gravidez , Inquéritos e Questionários , Hospitais , Política OrganizacionalRESUMO
[This corrects the article DOI: 10.3389/fpubh.2023.1029741.].
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Introduction: Epidemiologic and public health interest in structural racism has grown dramatically, producing both increasingly sophisticated questions, methods, and findings, coupled with concerns of atheoretical and ahistorical approaches that often leave the actual production of health or disease ambiguous. This trajectory raises concerns as investigators adopt the term "structural racism" without engaging with theories and scholars with a long history in this area. This scoping review aims to build upon recent work by identifying current themes about the incorporation of structural racism into (social) epidemiologic research and practice with respect to theory, measurement, and practices and methods for trainees and public health researchers who are not already deeply grounded in this work. Methods: This review uses methodological framework and includes peer-review articles written in English published between January 2000-August 2022. Results: A search of Google Scholar, manual collection, and referenced lists identified a total of 235 articles; 138 met the inclusion criteria after duplicates were removed. Results were extracted by, and organized into, three broad sections: theory, construct measurement, and study practice and methods, with several themes summarized in each section. Discussion: This review concludes with a summary of recommendations derived from our scoping review and a call to action echoing previous literature to resist an uncritical and superficial adoption of "structural racism" without attention to already existing scholarship and recommendations put forth by experts in the field.
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Racismo , Humanos , Saúde Pública , Pesquisadores , RedaçãoRESUMO
There are inequities in HIV outcomes among Black gay, bisexual, and other sexual minority men who have sex with men (GBMSM) compared to GBMSM overall, including access to transportation to HIV care. It is unclear if the relationship between transportation and clinical outcomes extends to viral load. We assessed the relationship between transportation dependence to an HIV provider and undetectable viral load among Black and White GBMSM in Atlanta. We collected transportation and viral load information from GBMSM with HIV from 2016-2017 (n = 345). More Black than White GBMSM had a detectable viral load (25% vs. 15%) and took dependent (e.g. public) transportation (37% vs. 18%). Independent (e.g. car) transportation was associated with undetectable viral load for White GBMSM (cOR 3.61, 95% CI 1.45, 8.97) but was attenuated by income (aOR. 2.29, 95% CI 0.78, 6.71), and not associated for Black GBMSM (cOR 1.18, 95% CI 0.58, 2.24). One possible explanation for no association for Black GBMSM is that there are more competing barriers to HIV care for Black GBMSM than White GBMSM. Further investigation is needed to confirm whether 1) transportation is unimportant for Black GBMSM or 2) transportation interacts with additional factors not considered in this analysis.