Ethnic discrimination and weight outcomes among Latinx emerging adults: Examinations of an individual-level mediator and cultural moderators.

OBJECTIVES: Latinxs have the highest prevalence of obesity in the United States, which can further contribute to the pervasive disparities in morbidity and mortality. Although the experience of discrimination is associated with obesity in racial/ethnic minorities, mediators and moderators of this association, specifically among Latinx emerging adults, have been understudied. The present study investigated an individual-level mediator (eating disorder symptoms) and cultural moderators (familismo support, ethnic identity affirmation) of the association between perceived discrimination and body mass index (BMI) among Latinx emerging adults. METHOD: Secondary analysis was conducted using cross-sectional data obtained from 198 Latinx emerging adults (70% female, Mage = 20.59, SDage = 1.78). RESULTS: Participants who reported greater, as opposed to fewer, experiences of ethnic discrimination were likely to report more eating disorder symptoms, which in turn was associated with increased BMI. There was no evidence supporting familismo support or ethnic identity affirmation as moderators, suggesting that even those with high levels of familismo or ethnic identity were susceptible to the negative consequences of the experience of ethnic discrimination. CONCLUSIONS: Addressing health-compromising eating behaviors and attitudes among Latinx emerging adults might be one effective means to addressing the negative consequences of discrimination on weight-related outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The role of feature-based discrimination in driving health disparities among Black Americans.

Objective: A growing body of research finds that darker skin tone is often associated with poorer physical and mental health in Blacks. However, the psychosocial mechanisms underlying the skin tone-health link remain elusive. The present study seeks to address this knowledge gap by investigating the direct and indirect (through perceived discrimination, socioeconomic status, and self-esteem) effects of skin tone on self-reported physical and mental health.Design: An urban sample of 130 Blacks aged 35 and above completed a self-administered computerized survey as a part of larger cross-sectional study.Results: Self-esteem played a particularly important role in mediating the associations between skin tone and self-reported physical and mental health. This suggests that self-esteem could be a point of intervention to help Blacks with darker skin tone achieve better health.Conclusion: The present study highlights the important role feature-based discrimination plays in determining mental and physical health outcomes among Blacks.

Income Disparities in the Prevalence, Severity, and Costs of Co-occurring Chronic and Behavioral Health Conditions.

BACKGROUND: Behavioral health problems usually co-occur along with physical health problems, resulting in higher health care costs. These co-occurring conditions are likely to be more prevalent and serious among low income patients, affecting both the quality and costs of care. OBJECTIVE: To examine the prevalence, severity, and health care costs of co-occurring chronic and behavioral health conditions among low income people compared with higher income people. METHODS: Analysis of the 2011-2014 Medical Expenditure Panel Survey. Sample includes 146,000 persons aged 18-64 years. Regression analysis was used to examine how the combination of behavioral health conditions and chronic health conditions is associated with health care expenditures, and how this association differs by family income. RESULTS: (1) Comorbid behavioral health problems are more prevalent and serious among low income people with chronic conditions compared with higher income people; (2) among patients with co-occurring chronic and behavioral problems, average annual spending is greater among the low income patients ($9472) compared with high income patients ($7457); (3) higher costs among low income patients with co-occurring conditions reflects their poorer mental and physical health, relative to higher income patients. CONCLUSIONS: For many low income people, comorbid behavioral problems need to be understood in the social context in which they live. Simply screening low income people for behavioral health problems may not be sufficient unless there is greater understanding of the mechanisms that both cause and exacerbate chronic and behavioral health problems in the low income population.

Disparities in Self-Reported Prenatal Counseling: Does Immigrant Status Matter?

Immigrant women face unique barriers to prenatal care access and patient-provider communication. Yet, few prior studies have examined U.S.-born/immigrant differences in the content of care. The purpose of this study was to investigate the roles of immigrant status, English proficiency and race/ethnicity on the receipt of self-reported prenatal counseling using nationally representative data. We used data from the Early Childhood Longitudinal Study-Birth Cohort (N ≈ 8100). We investigated differences in self-reported prenatal counseling by immigrant status, English proficiency, and race/ethnicity using logistic regression. Counseling topics included diet, smoking, drinking, medication use, breastfeeding, baby development and early labor. In additional analyses, we separately examined these relationships among Hispanic, Mexican and Non-Hispanic (NH) Asian women. Neither immigrant status nor self-reported English proficiency was associated with prenatal counseling. However, we found that being interviewed in a language other than English language by ECLS-B surveyors was positively associated with counseling on smoking (OR, 2.599; 95% CI, 1.229-5.495) and fetal development (OR, 2.408; 95% CI, 1.052-5.507) among Asian women. Race/ethnicity was positively associated with counseling, particularly among NH black and Hispanic women. There is little evidence of systematic overall differences in self-reported prenatal counseling between U.S.-born and immigrant mothers. Future research should investigate disparities in pregnancy-related knowledge among racial/ethnic subgroups.

From the West Indies to Africa: A universal generational decline in health among blacks in the United States.

Research shows that foreign-born blacks have better health profiles than their U.S.-born counterparts. Less is known, however, regarding whether black immigrants' favorable health outcomes persist across generations or whether these patterns differ across the diverse sending regions for black immigrants. In this study, we use data from the 1996-2014 waves of the March Current Population Survey (CPS) to investigate generational differences in self-rated health among blacks with West Indian, Haitian, Latin American, and African ancestry. We show that first-generation black immigrants have a lower probability of reporting fair/poor health than third/higher generation blacks. The health advantage of the first generation over the third/higher generation is slightly more prounced among the foreign-born who migrated to the United States after age 13. Second-generation immigrants with two foreign-born parents are generally less likely to report their health as fair/poor than the third/higher generation. However, we find no evidence that self-reported fair/poor health varies between second-generation immigrants with mixed nativity parents (only one foreign-born parent) and the third/higher generation. These general patterns hold across each of the ancestral subgroups in the study sample. In summary, our findings highlight a remarkable convergence in health across immigrant generations among blacks in the United States.

Equitable Artificial Intelligence in Obstetrics, Maternal-Fetal Medicine, and Neonatology.

Artificial intelligence (AI) offers potential benefits in the interconnected fields of obstetrics, maternal-fetal medicine, and neonatology to bridge disciplinary silos for a unified approach. Artificial intelligence has the capacity to improve diagnostic accuracy and clinical decision making for the birthing parent-neonate dyad. There is an inherent risk of ingrained biases in AI that perpetuate existing inequalities; thus, care must be taken to include diverse data sets with interdisciplinary collaboration that centers equitable AI implementation. As AI plays an increasingly important role in perinatal care, we advocate for its cautious, equity-focused application to benefit the perinatal dyad while avoiding the intensification of health care disparities and disciplinary silos.

Born on the wrong side of the tracks: Exploring the causal effects of segregation on infant health.

Prior research has found that a high level of residential racial segregation, or the degree to which racial/ethnic groups are isolated from one another, is associated with worsened infant health outcomes, particularly among non-Hispanic (NH) Black infant populations. However, because exposure to segregation is non-random, it is unclear whether and to what extent segregation is causally linked to infant health. To overcome this empirical limitation, we leverage exogenous variation in the placement of railroad tracks in the 19th century to predict contemporary segregation, an approach first introduced by Ananat (2011). In alignment with prior literature, we find that residential segregation has statistically significant associations with negative birth outcomes among Black infant populations in the area. Using OLS methods underestimates the negative impacts of segregation on infant health. We fail to detect comparable effects on health outcomes among NH White infant populations. Further, we identify several key mechanisms by which residential segregation could influence health outcomes among Black infant populations, including lower access to prenatal care during the first trimester, higher levels of anti-Black prejudice, greater transportation barriers, and increased food insecurity. Given that poor birth outcomes have adverse effects on adults' health and well-being, the findings suggest that in-utero exposure to residential segregation could have important implications for Black-White inequality over the life course.

Beyond Black and White: Color and Mortality in Post Reconstruction Era North Carolina.

A growing empirical literature in economics and sociology documents the existence of differences in social and economic outcomes between mixed-race blacks and other blacks . However, few researchers have considered whether the advantages associated with mixed-race status may have also translated into differences in mortality outcomes between subgroups of blacks and how both groups compared to whites. We employ previously untapped 1880 North Carolina Mortality census records in conjunction with data from the 1880 North Carolina Population Census to examine whether mulatto, or mixed-race blacks may have experienced mortality advantages over to their colored, or non-mixed race counterparts. For men between the ages of 20-44, estimates demonstrate that all black males are more likely than whites to die. Although our results indicate that there are no statistically significant differences in mortality between mulatto and colored blacks, there are some indications that mulatto males may have enjoyed a slight mortality advantage compared to their colored counterparts. However, we find a substantial mortality advantage associated with mixed-race status among women. These findings indicate that mixed-race women, rather than men, may have accrued any mortality advantages associated with color and white ancestry.

Economic costs and cost-effectiveness of conditional cash transfers for the uptake of services for the prevention of vertical HIV transmissions in a resource-limited setting.

BACKGROUND: Prevention of mother-to-child transmission (PMTCT) is critical for halting the HIV epidemic. However, innovative approaches to improve PMTCT uptake may be resource-intensive. We examined the economic costs and cost-effectiveness of conditional cash transfers (CCTs) for the uptake of PMTCT services in the Democratic Republic of Congo. METHODS: We leveraged data from a randomized controlled trial of CCTs (n = 216) versus standard PMTCT care alone (standard of care (SOC), n = 217). Economic cost data came from multiple sources, with costs analyzed from the societal perspective and reported in 2016 international dollars (I$). Effectiveness outcomes included PMTCT uptake (i.e., accepting all PMTCT visits and services) and retention (i.e., in HIV care at six weeks post-partum). Generalized estimating equations estimated effectiveness (relative risk) and incremental costs, with incremental effectiveness reported as the number of women needing CCTs for an additional PMTCT uptake or retention. We evaluated the cost-effectiveness of the CCTs at various levels of willingness-to-pay and assessed uncertainty using deterministic sensitivity analysis and cost-effectiveness acceptability curves. RESULTS: Mean costs per participant were I$516 (CCTs) and I$431 (SOC), representing an incremental cost of I$85 (95% CI: 59, 111). PMTCT uptake was more likely for CCTs vs SOC (68% vs 53%, p < 0.05), with seven women needing CCTs for each additional PMTCT service uptake; twelve women needed CCTs for an additional PMTCT retention. The incremental cost-effectiveness of CCTs vs SOC was I$595 (95% CI: I$550, I$638) for PMTCT uptake and I$1028 (95% CI: I$931, I$1125) for PMTCT retention. CCTs would be an efficient use of resources if society's willingness-to-pay for an additional woman who takes up PMTCT services is at least I$640. In the worst-case scenario, the findings remained relatively robust. CONCLUSIONS: Given the relatively low cost of the CCTs, policies supporting CCTs may decrease onward HIV transmission and expedite progress toward ending the epidemic.

Implicit and explicit racial prejudice among medical professionals: updated estimates from a population-based study.

Background: Prior research provides evidence of implicit and explicit anti-Black prejudice among US physicians. However, we know little about whether racialized prejudice varies among physicians and non-physician healthcare workers relative to the general population. Methods: Using ordinary least squares models and data from Harvard's Project Implicit (2007-2019), we assessed the associations between self-reported occupational status (physician, non-physician healthcare worker) and implicit (N = 1,500,268) and explicit prejudice (N = 1,429,677) toward Black, Arab-Muslim, Asian, and Native American populations, net of demographic characteristics. We used STATA 17 for all statistical analyses. Findings: Physicians and non-physician healthcare workers exhibited more implicit and explicit anti-Black and anti-Arab-Muslim prejudice than the general population. After controlling for demographics, these differences became non-significant for physicians but remained for non-physician healthcare workers (ß = 0.027 and 0.030, p < 0.01). Demographic controls largely explained anti-Asian prejudice among both groups, and physicians and non-physician healthcare workers exhibited comparatively lower (ß = -0.124, p < 0.01) and similar levels of anti-Native implicit prejudice, respectively. Finally, white non-physician healthcare workers exhibited the highest levels of anti-Black prejudice. Interpretation: Demographic characteristics explained racialized prejudice among physicians, but not fully among non-physician healthcare workers. More research is needed to understand the causes and consequences of elevated levels of prejudice among non-physician healthcare workers. By acknowledging implicit and explicit prejudice as important reflections of systemic racism, this study highlights the need to understand the role of healthcare providers and systems in generating health disparities. Funding: UW-Madison Centennial Scholars Program, Society of Family Planning Research Fund, UW Center for Demography and Ecology, the County Health Rankings and Roadmaps Program and the National Institutes of Health (NIH).

Personal- vs. Group-Level Discrimination and Physical and Mental Health Outcomes Among Black Adolescents.

BACKGROUND: The negative health consequences of personal experiences of racial discrimination (personal-level discrimination) has been well-documented across developmental stages, including adolescence, in Black individuals. There is also some evidence suggesting perceiving other Black individuals experiencing racial discrimination (group-level discrimination) can protect one's health in Black adults. METHODS: This study examined the role of personal- and group-level discrimination in Black adolescent health. The study was a secondary analysis of survey data collected from 186 Black adolescents that included reports of discrimination, physical function, anxiety, and depression. RESULTS: Black adolescents who reported greater, as opposed to lower, personal-level discrimination were more likely to experience poorer physical and mental health outcomes. While group-level discrimination was also associated with physical health outcomes, it was not directly associated with mental health outcomes. Importantly, across all three health outcomes, awareness of group-level discrimination mitigated the negative health consequences of personal-level discrimination. Among adolescents who reported low levels of group-level discrimination, personal-level discrimination was associated negatively with physical function and positively with anxiety and depressive symptoms. Among adolescents who reported high levels of group-level discrimination, there was no association between personal-level discrimination and any of the health outcomes. DISCUSSION: Consistent with prior research with Black adults, awareness of high group-level discrimination may protect Black adolescents from the negative health consequences of personal-level discrimination. The pattern of the results is also consistent with the literature of the personal-group discrimination discrepancy (PGDD) and psychological wellbeing. Future research should investigate the psychological mechanisms implicated in PGDD (e.g., external attribution of discrimination and intragroup comparison) as potential coping strategies for Black adolescents against the negative health consequences of personal-level discrimination.

Source of Prenatal Care and Nonreceipt of Postpartum Health Care in the United States.

Background: Prior work finds that receiving prenatal care is positively associated with receiving postpartum health care. However, less is known about whether postpartum health care receipt varies by the source of prenatal care. Materials and Methods: This study analyzed data from the 2011-2017 U.S. National Survey of Family Growth to examine associations between the source of prenatal care (private care facility, public/community health facility, other source, or no prenatal care) and nonreceipt of postpartum health care using weighted multivariable logistic regression models. This analysis did not require institutional review board approval. Results: Of the total estimation sample (N = 1,190), 10.8% of respondents reported not receiving postpartum health care. There were no statistically significant differences in nonreceipt of postpartum health care between women who received prenatal care from a public/community health facility or other source and those who attended a private facility. However, women who received no prenatal care had a higher likelihood of not receiving postpartum health care compared with those who attended a private facility (adjusted odds ratio 8.7, 95% confidence interval 4.3-17.5). Conclusions: Receiving prenatal care, regardless of the source, reduced the likelihood of a woman not receiving postpartum health care within a year after delivery. Interventions aimed at women who did not receive any prenatal care may be critical for improving postpartum health care use and subsequently preventing adverse maternal outcomes.

Racial disparities in post-operative pain experience and treatment following cesarean birth.

OBJECTIVE: To evaluate racial/ethnic differences in post-operative pain experience and opioid medication use (morphine milligram equivalent) in the first 24 h following cesarean birth. METHODS: This study was a single-center retrospective cohort of birthing persons who underwent cesarean deliveries between 1/1/16 and 12/31/17. A total of 2,228 cesarean deliveries were analyzed. The primary outcome was average pain, which was the mean of all documented self-reported pain scores (0-10 scale) during the first 24 h post-delivery. The secondary outcome included oral morphine equivalents used in the first 24 h post-delivery. Linear regression was performed to examine whether the race/ethnicity of the birthing parent was associated with mean pain scores and oral morphine equivalents, controlling for confounding variables. RESULTS: In multivariate analyses non-Hispanic Black birthing persons reported higher mean pain scores (Coefficient: 0.61, 95% confidence interval [0.39-0.82], p < .001]) than non-Hispanic White birthing persons, but received similar quantities of morphine milligram equivalent (Coefficient: -0.98 mg, 95% confidence interval [-5.93-3.97], p = .698]). Non-Hispanic Asian birthing persons reported similar reported mean pain scores to those of non-Hispanic White birthing persons (Coefficient: 0.02 mg, 95% confidence interval [-0.17-0.22], p = .834]), but received less morphine milligram equivalent (Coefficient: -5.47 mg, 95% confidence interval [-10.05 to -0.90], p = .019). When controlling for reported mean pain scores, both non-Hispanic Black (Coefficient: -6.36 mg, 95% confidence interval [-10.97 to -1.75], p = .007) and non-Hispanic Asian birthing persons (Coefficient: -5.66 mg, 95% confidence interval [-9.89 to -1.43], p = .009) received significantly less morphine milligram equivalents. CONCLUSION: Despite reporting higher mean pain scores, non-Hispanic Black birthing persons did not receive higher quantities of morphine milligram equivalent. Non-Hispanic Asian birthing persons received lower quantities of morphine milligram equivalent despite reporting similar pain scores to non-Hispanic White birthing persons. These differences suggest disparities in post-operative pain management for birthing persons of color in our study population.

Exploring financial stress and resource deprivation as barriers to preferred contraceptive use in Wisconsin in 2021.

OBJECTIVE: This study assessed a broad array of socioeconomic barriers in relation to preferred contraceptive use during a time of exacerbated personal and social financial strain (the COVID-19 pandemic). STUDY DESIGN: Using statewide data collected in early 2021 through the Survey of the Health of Wisconsin, we conducted bivariate analyses exploring the relationship between socioeconomic resources and preferred contraceptive use among Wisconsin women. RESULTS: The survey garnered 1889 responses, with a response rate of 34%. The sample for the current study (N = 247) included only adult women of reproductive age who reported current contraceptive use. Nearly one-third (32.8%) of contraceptive users reported that they were not using their preferred method. We found that greater resource deprivation, including housing instability (had to relocate: p = 0.004; unable to pay rent and/or mortgage: p = 0.008), food insecurity (ran out of food: p = 0.003; worried about running out of food: p = 0.008), and greater financial stress (p < 0.001), were significantly associated with lowered likelihood of using one's preferred contraceptive method. CONCLUSIONS: Findings indicated that people lacking socioeconomic resources, including adequate food and housing, may be unable to access their preferred contraceptive method(s). Amidst competing demands on time and resources, the inability to obtain preferred contraceptive method(s) may represent system-wide barriers as well as people's lowered ability to prioritize and access care in light of socioeconomic struggles. IMPLICATIONS: Health care providers and health systems should work to address structural barriers to care and bolster community resources in ways that promote patients' reproductive autonomy. There is also a need for continued research on specific socioeconomic determinants of preferred contraceptive use and potential solutions that bolster community resources.

Rethinking Bias to Achieve Maternal Health Equity: Changing Organizations, Not Just Individuals.

In this article, we address the limitations of existing implicit bias interventions as a strategy for achieving maternal health equity. We then focus on how institutionally sanctioned racial stereotyping harms Black maternal health and marginalizes a key group in the fight for health equity-Black physicians. Finally, we provide strategies to address racial bias in perinatal health care and structural barriers impeding Black physicians' success.

Pregnancy-related weight among immigrant and US-born mothers: The role of nativity, maternal duration of residence, and age at arrival.

OBJECTIVES: The goals of this study were to examine the associations between nativity and pregnancy-related weight and to assess the associations between maternal duration of residence and age at arrival in the United States on pregnancy-related weight among immigrants. METHODS: Using logistic regression and data from the Early Childhood Longitudinal Study-Birth Cohort, we assessed differences in preconception weight and gestational weight gain between US-born and immigrant women (N = 7000). We then analyzed differences in both outcomes by duration of residence among immigrants (n = 1850) and examined whether the identified relationships varied by age at arrival in the United States. RESULTS: Compared to US-born mothers, immigrants were less likely to be classified as obese prior to pregnancy (odds ratio 0.435, 95% confidence interval, 0.321-0.590) or experience excessive gestational weight gain (odds ratio 0.757, 95% confidence interval, 0.614-0.978). Among the immigrant sub-sample, living in the United States for 10-15 years (odds ratio 2.737, 95% confidence interval, 1.459-5.134) or 16+ years was positively associated with both preconception obesity (odds ratio 2.918, 95% confidence interval, 1.322-6.439) and excessive gestational weight gain (odds ratio 1.683, 95% confidence interval, 1.012-2.797, 16+ years only). There was some evidence that the duration of residence was positively associated with preconception obesity, but only among women who had moved to the United States at age 18 years and older. CONCLUSION: In sum, while immigrants are less likely than US-born mothers to experience preconception obesity or excessive gestational weight gain, these outcomes vary among the former group by duration of US residence.

Pregnancy-Related Weight and Postpartum Depressive Symptoms: Do the Relationships Differ by Race/Ethnicity?

Background: There are significant racial/ethnic disparities in the prevalence of postpartum depression. Prior research in the general population suggests that weight status is related to depression and that this relationship varies by race/ethnicity. However, few studies have investigated whether race/ethnicity moderates the relationship between pregnancy-related weight and postpartum depressive symptoms (PPDS). The objective of this study is to examine the relationship between pregnancy-related weight and maternal PPDS overall and by race/ethnicity. Materials and Methods: This study used data from the Early Childhood Longitudinal Study-Birth Cohort (n ≈ 6950). Ordinary least-squares and logistic regression was used to examine whether pregnancy-related weight, including preconception weight status and gestational weight gain (GWG), was associated with PPDS measured using the Center for Epidemiologic Studies-Depression Scale (CES-D). Stratified analyses were used to assess whether these relationships varied by race/ethnicity. Results: Preconception obesity (body mass index [BMI] ≥30 kg/m2) was associated with higher levels of PPDS (ß = 0.601, 95% confidence interval [CI], 0.149-1.053). GWG adequacy was not associated with PPDS. Among non-Hispanic (NH) whites, preconception obesity was positively associated with PPDS (ß = 1.016, 95% CI, 0.448-1.584). In contrast, among Hispanics, preconception overweight (25 kg/m2 ≤ BMI <30 kg/m2) was associated with lower levels of PPDS (ß = -0.887, 95% CI, -1.580 to -0.195). There were no statistically significant relationships between pregnancy-related weight and PPDS among NH black or Asian women, but both groups were significantly more likely than NH whites to report PPDS. Conclusion: Whether and how pregnancy-related weight is associated with PPDS varies by race/ethnicity. Addressing preconception weight could help reduce overall levels of PPDS among NH whites but would likely fail to mitigate racial/ethnic disparities in postpartum mental health.

Under the skin: using theories from biology and the social sciences to explore the mechanisms behind the black-white health gap.

Equity and social well-being considerations make Black-White health disparities an area of important concern. Although previous research suggests that discrimination- and poverty-related stressors play a role in African American health outcomes, the mechanisms are unclear. Allostatic load is a concept that can be employed to demonstrate how environmental stressors, including psychosocial ones, may lead to a cumulative physiological toll on the body. We discuss both the usefulness of this framework for understanding how discrimination can lead to worse health among African Americans, and the challenges for conceptualizing biological risk with existing data and methods. We also contrast allostatic load with theories of historical trauma such as posttraumatic slavery syndrome. Finally, we offer our suggestions for future interdisciplinary research on health disparities.

The effects of community-based distribution of family planning services on contraceptive use: The case of a national scale-up in Malawi.

RATIONALE: Although many sub-Saharan African countries have scaled-up pilot projects of community-based distribution (CBD) of family planning services, the effects of the scaled-up CBDs on contraceptive use remain unclear. OBJECTIVE: We leveraged a national scale-up of Malawi's Learning and Innovation Population and Family Planning pilot to evaluate the effects of a scale-up of CBDs on contraceptive use. We also investigated whether education and income, two important determinants of contraceptive use behaviors, moderate the effects of the scaled-up CBDs. METHOD: We used the 2000/2004 and 2010/2016 Malawi Demographic and Health Surveys (N = 57,978) and difference-in-differences analyses to estimate the effects of the 2005 national scale-up of CBDs on modern contraceptive use. We used rural and urban communities as the intervention and comparison groups because the national CBDs were implemented only in rural communities. Contraceptive use is defined as the current use of any modern contraceptive method (e.g., pills) and was modelled using multilevel logistic regression. RESULTS: Prior to the implementation of the national scale CBDs (2000/2004), the probability of using contraceptives was 21.5% in rural communities and 26.3% in urban communities. After the scale-up (2010/2016), the probability of using contraceptives increased in both rural and urban communities but was greater in rural communities (44.9% vs. 42.9%). The effect attributable to the national scale CBDs was 6.8 percentage points (95% CI [3.3, 9.7]). The effects of the national CBDs were greater among uneducated and low-income women. CONCLUSIONS: These findings suggest that national CBDs increase overall contraceptive use, particularly in rural communities, and that poor and uneducated women benefit more from family planning interventions that reduce communication and financial barriers.

Unpacking Racial/Ethnic Disparities in Prenatal Care Use: The Role of Individual-, Household-, and Area-Level Characteristics.

OBJECTIVE: To identify the contributions of individual-, household-, and area-level characteristics to disparities in the use of prenatal care (PNC). METHODS: This study used individual-level data from the 2001 Early Childhood Longitudinal Study-Birth Cohort linked to county-level U.S. Census data (N ≈ 5,200). I used nonlinear regression decomposition to quantify the contributions of several groups of factors-maternal health and pregnancy characteristics, preconception health behaviors, insurance coverage, PNC location, socioeconomic status (SES), and the social/economic and healthcare environments-to PNC disparities. RESULTS: Relative to whites, blacks and Hispanics were less likely to initiate first-trimester PNC and to have adequate PNC. The models explained 61.20%-79.90% and 52.15%-79.09% of the disparities in PNC initiation and adequacy, respectively. The most important factor was SES, which explained 50.68%-79.92% of the black-white gap and 37.50%-49.51% of the Hispanic-white gap in PNC use. Location of care, insurance status, and pregnancy characteristics also made significant contributions to these disparities. CONCLUSION: SES is a key driver of inequality in PNC, particularly black-white inequality. Addressing socioeconomic factors may improve PNC use among minorities.