Acknowledging and Addressing Allostatic Load in Pregnancy Care

No relationship found between dental fluctuating asymmetry, birthweight, and birth term in two modern North American samples

OBJECTIVE

Deciduous dental crowns primarily develop during gestation and early infancy and embody early life stress exposures. Composite measures of dental fluctuating asymmetry (DFA) generated from the deciduous teeth may therefore indicate cumulative gestational stress in developmental origins of health and disease (DOHaD) studies. This study examines whether higher composite measures of deciduous DFA are associated with low birthweight and prematurity, two aspects of birth phenotype consistently associated with increased morbidity and mortality risks in adulthood.

SUBJECTS AND METHODS

We evaluated associations between composite deciduous DFA, birthweight, and birth term in two contemporary North American samples: an autopsy sample from New Mexico (n = 94), and sample from a growth cohort study in Burlington, Ontario (n = 304). Dental metric data for each sample was collected from postmortem CT scans and dental casts, respectively. Composite DFA was estimated using buccolingual (BL) and mesiodistal (MD) crown diameters from paired deciduous teeth.

RESULTS

Contrary to expectations, the results of linear regression indicated no significant relationship between birthweight and DFA, or birth term and DFA, in either sample.

CONCLUSIONS

Deciduous DFA does not predict aspects of birth phenotype associated with gestational stress. Birthweight and birth term are plastic relative to the more developmentally stable deciduous dentition, which may only subtly embody early life stress. We suggest that deciduous DFA should be utilized with caution in DOHaD studies until its relationship with gestational stress is clarified.

Ethics of Predicting and Preventing Preterm Birth

Preterm birth (PTB) occurs disproportionately among women who are minoritized and who live and work in poverty. This disadvantage occurs as a result of societal norms and policies that affect how people are treated and determine their access to a broad range of resources. Research that takes social context into account offers the best opportunity for identifying approaches to prevent PTB. The experience and knowledge of women from groups experiencing high rates of PTB can provide important insights for research design and for determining the feasibility and acceptability of potential interventions.

Prenatal stress and hair cortisol in a sample of Latina women

BACKGROUND

Stress during pregnancy adversely impacts maternal and infant health. Dysregulation of the hypothalamic pituitary axis is a mediator of the relationship between stress and health. Evidence supporting an association between prenatal chronic stress and cortisol is limited, and the majority of research published has been conducted amongst White participants, who experience less chronic stress than people of color.

AIM

This study investigated associations between various measures of prenatal stress and hair cortisol concentrations which is a biomarker of the integrated stress response in a sample of Latina participants during the third trimester of pregnancy.

METHOD

Pregnant women (n=45) were surveyed with scales measuring chronic stress, perceived stress, pregnancy-related and pregnancy-specific anxiety. Hair samples were collected as an objective neuroendocrine measure of chronic stress. Linear regression analyses were performed to assess associations between stress measures and hair cortisol. Pre-pregnancy BMI, smoking during pregnancy, and steroid use during pregnancy were used as covariates in adjusted models.

RESULTS

Chronic stress, operationalized as maternal reports of neighborhood/housing strain, daily activities and relationship strain, discrimination, and financial strain, was significantly associated with higher hair cortisol concentrations. No significant associations were found between hair cortisol and perceived stress, pregnancy-related anxiety, nor pregnancy-specific anxiety in adjusted models.

CONCLUSION

Chronic stress may be a more robust correlate of physiological stress, as measured by hair cortisol in pregnancy, than other common measures of prenatal stress and anxiety.

Nursing student perceptions of racism and health disparities in the United States: A critical race theory perspective

BACKGROUND

Limited research has been done on nursing students' awareness of racial disparities and their readiness to address bias and racism in clinical practice.

PURPOSE

This study investigated nursing students' perceptions of how racial disparities affect health outcomes, including maternal outcomes, in the United States.

METHODS

Interpretive description was used and supported by the critical race theory as a framework to guide the data collection, analysis, and interpretation to understand participants' perceptions surrounding racism and health disparities.

DISCUSSION

Nurse educators should guide students to look beyond individual behavioral and risk factors and consider systemic issues as a leading contributors to health disparities.

CONCLUSION

The most critical finding was the lack of participants' understanding of systemic racism and its impact on health disparities. While they often attributed racial disparities to low socioeconomic status and lack of education, they did not understand the relationships between social determinants of health and systemic racism.

Examination of Maternal Allostatic Load Among Postpartum Women With Distinct Postpartum Symptom Typologies

BACKGROUND

An increased allostatic load (cumulative physiologic wear and tear of the body) can lead to adverse health outcomes. Symptom experiences are known to influence allostatic load. Yet, the relationships between postpartum symptom typologies and maternal allostatic load remain unknown.

METHODS

We used Community Child Health Network data and included participants with allostatic load data at 6, 12, or 24 months postpartum. Bivariate and multivariate analyses were conducted to examine associations between postpartum symptom typologies and (a) overall allostatic load, (b) allostatic load subscales for body systems (neuroendocrine, cardiovascular, metabolic, and inflammatory), and (c) individual biomarkers within the subscale.

RESULTS

Overall allostatic load at 12 months postpartum was different by symptom typologies before (p = .042) and after adjusting for confounders (p = .029). Postpartum women in typology 5 (high overall) had the highest adjusted overall allostatic load (M = 4.18, SE = .27). At 12 months, adjusted allostatic load for the cardiovascular subscale was higher in typologies 3 (moderate-high sleep symptoms, M = 1.78, SE = .13) and 5 (high overall, M = 1.80, SE = .17). Within the cardiovascular subscale, those in typology 3 had higher adjusted odds for a clinically significant level of pulse rate (aOR = 2.01, CI = 1.22, 3.31).

CONCLUSION

Postpartum women who experienced high symptom severity across all symptoms (typology 5) at 6 months had higher overall allostatic load at 12 months postpartum. Typologies 3 and 5 had the highest symptom severity in sleep-related symptoms and higher cardiovascular subscale scores. Postpartum symptom management should target symptom burden in an effort to reduce allostatic load thereby improving postpartum women's health outcomes.

Spatial Patterning of Spontaneous and Medically Indicated Preterm Birth in Philadelphia

Preterm birth (PTB) remains a key public health issue that disproportionately affects Black individuals. Since spontaneous PTB (sPTB) and medically indicated PTB (mPTB) may have different causes and interventions, we quantified racial disparities for sPTB and mPTB, and we characterized the geographic patterning of these phenotypes, overall and according to race/ethnicity. We examined a pregnancy cohort of 83,952 singleton births at 2 Philadelphia hospitals from 2008-2020, and classified each PTB as sPTB or mPTB. We used binomial regression to quantify the magnitude of racial disparities between non-Hispanic Black and non-Hispanic White individuals, then generated small area estimates by applying a Bayesian model that accounts for small numbers and smooths estimates of PTB risk by borrowing information from neighboring areas. Racial disparities in both sPTB and mPTB were significant (relative risk of sPTB = 1.83, 95% confidence interval: 1.70, 1.98; relative risk of mPTB = 2.20, 95% confidence interval: 2.00, 2.42). The disparity was 20% greater in mPTB than sPTB. There was substantial geographic variation in PTB, sPTB, and mPTB risks and racial disparity. Our findings underscore the importance of distinguishing PTB phenotypes within the context of public health and preventive medicine. Future work should consider social and environmental exposures that may explain geographic differences in PTB risk and disparities.

The effect of pregnant women's status of receiving preconception care on pregnancy stress

In the study, we aimed to determine the effect of pregnant women's status of receiving preconception care on their pregnancy stress. This is a descriptive, correlational, and cross-sectional design study, we were conducted with the participation of 409 pregnant women between June-December 2019. The Pregnancy Stress Rating Scale total score mean was found to be 30.72 ± 20.26. Individuals who received medication and vitamins as part of preconceptional care had significantly higher scores (p < 0.05; p < 0.001) compared to those who did not receive them for total pregnancy stress, postpartum social support, infant health, and infant identity-care stress. Similarly, individuals who received medical treatment and regular checkups had significantly higher scores (p < 0.05) compared to those who did not for total pregnancy stress, postpartum social support, infant identity-care, body image and psychological state during pregnancy stress scores. In addition, individuals who maintained a healthy lifestyle had significantly higher scores (p < 0.05; p < 0.001) compared to others for infant health, infant identity-care, and psychological distress during pregnancy. It was determined that women who made preparations for their pregnancy experienced more stress related to their babies (baby's health, baby's identity and care), psychological status in pregnancy, prenatal and postnatal social support, and body image.

Social Determinant Pathways to Hypertensive Disorders of Pregnancy Among Nulliparous U.S. Women

BACKGROUND

Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality in the United States and impact Black mothers at disproportionately higher rates. Hypertensive disparities among racialized groups are rooted in systemic inequalities, and we hypothesize that clinical markers of allostatic load capture embodied disparities in stressors that can link upstream social determinants of health with downstream hypertensive outcomes.

METHODS

We analyzed observational cohort data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (n = 6,501) and developed a structural equation model linking latent social determinants of health, longitudinal markers of allostatic load across gestation, and hypertensive pregnancy outcomes in a multigroup framework.

RESULTS

Non-Hispanic Black mothers-to-be (n = 1,155) showed higher rates of hypertensive disorders of pregnancy (32%) than non-Hispanic white women (n = 5,346, 23%). Among both groups, the social environment showed stronger direct effects on allostatic markers than via behaviorally mediated dietary, exercise, or smoking pathways. Demographic aspects of the social environment (e.g., household income, partnered status) were the most salient predictor of hypertensive risk and showed stronger effects among Black women.

CONCLUSIONS

Embodied stress rooted in the social environment is a major path driving maternal hypertensive disparities in the United States, with effects that vary across racialized groups. These pathway findings underscore the greater impact of systemic stressors relative to individual health behaviors. More comprehensive and detailed analyses of sociostructural domains are needed to identify promising avenues for policy and intervention to improve maternal health.

Discrimination and adverse birth outcomes among Latina women: The protective role of social support

OBJECTIVE

Interpersonal discrimination has been associated with adverse birth outcomes among Black populations, but few studies have examined the impact of discrimination among Latinx/Hispanic populations in the United States, especially in conjunction with resources that could be protective. The present study examined (a) if exposure to discrimination is associated with adverse birth outcomes for Latina/Hispanic women and (b) if prenatal social support buffers these links.

METHOD

In two independent prospective studies of Latina/Hispanic women in Southern California (N = 84 and N = 102), the relation between maternal experience of discrimination and birth outcomes (length of gestation and birth weight) was examined. Additionally, social support was tested as a moderator of these relations.

RESULTS

In both Studies 1 and 2, exposures to discrimination predicted adverse birth outcomes. Specifically, lifetime experiences of major discrimination predicted lower birth weight. Additionally, in Study 2, chronic experiences of everyday discrimination were linked to lower birth weight. In Study 1, major discrimination also predicted shorter gestational length. Importantly, in both studies, the presence of prenatal social support buffered associations between discrimination and poorer birth outcomes.

CONCLUSIONS

Findings implicate discrimination as an important risk factor for adverse birth outcomes among women of Latina/Hispanic descent. Further policies, practice, and research on reducing discrimination and enhancing factors that promote resilience such as social support are needed to facilitate healthy births among Latina/Hispanic women, mitigate intergenerational harm of discrimination-related stress, and advance health equity at birth and across the lifespan. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Essential Nursing Actions to Reduce Inequities for Black Women in the Perinatal Period

Perinatal nurses play a critical role in the care of, advocacy for, and research with Black women in the perinatal period. Despite awareness of inequities in the perinatal health care system that stem from racism in the United States, many nurses report feeling detached from the crisis. In this critical commentary, we provide a five-step nursing action guide to address this health disparity that is aligned with the Future of Nursing report and the American Nurses Association Code of Ethics. We recommend nursing activities in each step: understand drivers of health inequities among Black women, reflect on implicit bias, use respectful care frameworks with Black women, conduct ethical research, and advocate for change. The article includes a sharable and printable action sheet that can be used in the work environment to remind nurses of their roles in enacting change.

Allostatic load in children: The cost of empathic concern

Early-life adversity affects long-term health outcomes but there is considerable interindividual variability in susceptibility to environmental influences. We proposed that positive psychological characteristics that reflect engagement with context, such as being concerned about people or performance on tasks (i.e., empathic concern), could moderate the interindividual variation in sensitivity to the quality of the early environment. We studied 526 children of various Asian nationalities in Singapore (46.6% female, 13.4% below the poverty line) with longitudinal data on perinatal and childhood experiences, maternal report on empathic concern of the child, and a comprehensive set of physiological measures reflecting pediatric allostatic load assessed at 6 y of age. The perinatal and childhood experiences included adversities and positive experiences. We found that cumulative adverse childhood experience was positively associated with allostatic load of children at 6 y of age at higher levels of empathic concern but not significantly associated at lower levels of empathic concern. This finding reveals evidence for the importance of empathic concern as a psychological characteristic that moderates the developmental impact of environmental influences, serving as a source for vulnerability to adversities in children.

Disparities in the provision of perinatal care based on patient race in the United States

BACKGROUND

In the United States, there are significant health inequities in perinatal care. This study examined differences in perinatal care provided to women based on the birthing person's designated race, within a large and diverse cohort of women.

METHODS

This retrospective electronic medical record review identified patients receiving perinatal care within a large hospital system between January 2012 and September 2018 and examined associations between maternal designated race/ethnicity (Hispanic or non-Hispanic [NH] Black, Asian or White) and various provider treatment decisions.

RESULTS

The study sample (N = 7056) was comprised of 36% Hispanic, 34% NH White, 21% NH Black, and 4% NH Asian women, aged 29.7 ± 6.3 years; 53% of the sample had private insurance, and 45% had Medicaid. Few differences by race were seen in perinatal care based on guidelines or expert recommendations (nondiscretionary care). Discretionary care, however, varied by race: Compared with NH White women, NH Black women were less likely to receive a prenatal depression screen (OR 0.8 [95% CI: 0.7, 0.9]) and more likely to have a urine drug test when denying drug use (OR 1.6 [95% CI 1.3, 2.0]), whereas Hispanic (OR 0.6 [95% CI: 0.5, 0.8]) and NH Asian (0.4 [95% CI 0.2, 0.9]) women were less likely to have a urine drug test completed when denying drug use.

DISCUSSION

Perinatal care differs by maternal race/ethnicity, particularly when guidelines or expert recommendations are absent. Greater efforts need to be made to identify and mitigate providers' implicit and explicit biases; expanded professional guidelines may offer some protections against inequitable, discretionary care.

Addressing Adverse Childhood and Adult Experiences During Prenatal Care

Adverse childhood and adult experiences can affect health outcomes throughout life and across generations. The perinatal period offers a critical opportunity for obstetric clinicians to partner with patients to provide support and improve outcomes. This article draws on stakeholder input, expert opinion, and available evidence to provide recommendations for obstetric clinicians' inquiry about and response to pregnant patients' past and present adversity and trauma during prenatal care encounters. Trauma-informed care is a universal intervention that can proactively address adversity and trauma and support healing, even if a patient does not explicitly disclose past or present adversity. Inquiry about past and present adversity and trauma provides an avenue to offer support and to create individualized care plans. Preparatory steps to adopting a trauma-informed approach to prenatal care include initiating education and training for practice staff, prioritizing addressing racism and health disparities, and establishing patient safety and trust. Inquiry about adversity and trauma, as well as resilience factors, can be implemented gradually over time through open-ended questions, structured survey measures, or a combination of both techniques. A range of evidence-based educational resources, prevention and intervention programs, and community-based initiatives can be included within individualized care plans to improve perinatal health outcomes. These practices will be further developed and improved by increased clinical training and research, as well as through broad adoption of a trauma-informed approach and collaboration across specialty areas.

Race and socioeconomic status interact with HPV to influence survival disparities in oropharyngeal squamous cell carcinoma

BACKGROUND

HPV-related oropharyngeal squamous cell carcinoma (OPSCC) is associated with a favorable prognosis, yet patients of color and low socioeconomic status (SES) continue to experience inferior outcomes. We aim to understand how the emergence of HPV has impacted race and SES survival disparities in OPSCC.

METHODS

A retrospective cohort of 18,362 OPSCC cases from 2010 to 2017 was assembled using the SEER (Surveillance, Epidemiology, and End Results) database. Cox proportional regression and Fine and Gray regression models were used to calculate hazard ratios (HRs) adjusting for race, SES, age, subsite, stage, and treatment.

RESULTS

Black patients had lower overall survival than patients of other races in HPV-positive and HPV-negative OPSCC (HR 1.31, 95% CI 1.13-1.53 and HR 1.23, 95% CI 1.09-1.39, respectively). Higher SES was associated with improved survival in all patients. Race had a diminished association with survival among high SES patients. Low SES Black patients had considerably worse survival than low SES patients of other races.

CONCLUSION

Race and SES interact variably across cohorts. High SES was protective of the negative effects of race, although there remains a disparity in outcomes among Black and non-Black patients, even in high SES populations. The persistence of survival disparities suggests that the HPV epidemic has not improved outcomes equally across all demographic groups.

DHA Supplementation During Pregnancy Enhances Maternal Vagally Mediated Cardiac Autonomic Control in Humans

BACKGROUND

DHA is an essential omega-3 (ω-3; n-3) fatty acid that has well-established benefits for the fetus. DHA also has the potential to influence the health of the mother, but this area is understudied.

OBJECTIVES

The objective of this secondary analysis was to determine if DHA was related to maternal heart rate (HR) and heart rate variability (HRV) metrics in a large cohort of pregnant women.

METHODS

In the parent trial (1R01HD086001) eligible participants (≥18 y old, English speaking, carrying a singleton pregnancy, 12-20 wk of gestation) were randomly assigned to consume 200 mg/d or 800 mg/d DHA for the duration of their pregnancy (n = 300). Weight, blood pressure, and magnetocardiograms (MCGs) were collected at 32 wk and 36 wk of gestation (n = 221). Measures of HR and HRV in time-, frequency-, and nonlinear-domains were determined from the isolated maternal MCG. Treatment group and timepoint were examined as predictors in association with HR and HRV metrics using random-intercept mixed-effects ANOVA unadjusted and adjusted models accounting for weight and dietary DHA intake.

RESULTS

Women receiving the higher dose of DHA (800 mg/d) during pregnancy had lower HR, lower sympathetic index, higher vagally mediated HRV indices, and greater HRV complexity when compared with the women who received the lower dose (200 mg/d; all P < 0.05). All the dose relations remained significant even after controlling for the effect of time, maternal weight, and dietary DHA intake.

CONCLUSIONS

DHA supplementation increases vagal tone in pregnant women. Longitudinal studies examining the potential link between DHA, enhanced vagal tone, and reported reduction in early preterm birth are warranted.

Prenatal allostatic load and preterm birth: A systematic review

Objective

Allostatic load refers to cumulative neuroendocrine burden and has been postulated to mediate and moderate physiological and psychological stress-related responses. This may have important implications for the risk of preterm birth. This systematic review examines the evidence on the association between prenatal allostatic load and preterm birth.

Data sources

A comprehensive search of seven electronic databases was conducted from inception to August 23, 2022 to identify all English-language observational and mixed methods studies examining allostatic load and preterm birth with no year or geographic restrictions.

Study eligibility criteria

Studies were included if they measured allostatic load, evaluated as the cumulative effect of any combination of more than one allostatic load biomarker, during pregnancy. Studies must have observed preterm birth, defined as &lt; 37 weeks' gestational age, as a primary or secondary outcome of interest.

Study appraisal and synthesis methods

The Quality In Prognosis Studies tool was used to evaluate risk of bias within included studies. A narrative synthesis was conducted to explore potential associations between allostatic load and preterm birth, and sources of heterogeneity.

Results

Three prospective cohort studies were identified and revealed mixed evidence for an association between allostatic load and preterm birth. One study reported a statistically significant association while the other two studies reported little to no evidence for an association. Heterogeneity in when and how allostatic load was measured, limitations in study design and cohort socio-demographics may have contributed to the mixed evidence.

Conclusions

This review provides insight into key individual-, community-, and study-level characteristics that may influence the association between allostatic load and preterm birth. Knowledge gaps are identified as foci for future research, including heterogeneity in allostatic load biomarkers and allostatic load index algorithms as well as pregnancy-specific considerations for allostatic load measurement. Further investigation of the allostatic load framework in the context of perinatal mental health is needed to advance understandings of maternal, infant, and child health.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020208990, PROSPERO, identifier: CRD42020208990.

Causes of health inequities

PURPOSE OF REVIEW

A renewed focus on U.S. racial and ethnic maternal health disparities has arisen following high-profile incidents of police violence and antiracism protests which coincided with the coronavirus disease 2019 pandemic, which has exerted a disproportionate effect on minority communities. Understanding the causes of disparities is pivotal for developing solutions.

RECENT FINDINGS

Social determinants of health must be addressed during clinical care; however, race must be used with caution in clinical decision-making. Medicaid expansion has been associated with a decrease in severe maternal morbidity and mortality, especially for racial and ethnic minority women. Indirect obstetric causes are the leading cause of maternal death.

SUMMARY

Policy-level changes and investment in marginalized communities are required to improve access to quality maternity care at all stages, including preconception, interconception, prenatal, intrapartum and postpartum for 12 months after delivery. Improvements in hospital quality and implementation of evidence-based bundles of care are crucial. Clinicians should receive training regarding susceptibility to implicit bias. To support the research agenda, better collection of race and ethnicity data and anesthesia care indicators is a priority (see Video, Supplemental Digital Content 1 {Video abstract that provides an overview of the causes racial and ethnic disparities in maternal health outcomes.} http://links.lww.com/COAN/A85).

"As Long as I Got a Breath in My Body": Risk and Resistance in Black Maternal Embodiment

"Mothering while black" in Cleveland, Ohio is a radical act. This highly segregated, highly unequal urban environment is replete with the chronic stressors that degrade well-being and diminish survival for Black mothers and their infants; specifically, a maternal mortality rate two and a half times that of their white counterparts and an infant mortality rate nearly three times that of infants born to white mothers. In the midst of such tragedy and disadvantage, Black mothers strive to love and care for their children in ways that mitigate the toxicity of structural racism. The seventeen pregnant and postpartum Black women in this ethnographic study describe transformational experiences with what we label "betterment:" whereby they center their children's perspective and needs, reconsider their social networks, and focus on the future with an unflinching understanding of the constraints of structural racism. Locating betterment alongside other examples of maternal embodiment and through the rich theoretical lens of Black feminist scholars these participant narratives suggest that the toxic effects of racism and the means to resist them are embodied by Black mothers. A nuanced understanding of Black motherhood disrupts public discourses of blame and responsibility that obscure our collective duty to dismantle structural racism.

Society for Maternal-Fetal Medicine Consult Series #62: Best practices in equitable care delivery-Addressing systemic racism and other social determinants of health as causes of obstetrical disparities

The Centers for Disease Control and Prevention define social determinants of health as "the conditions in the places where people live, learn, work, and play" that can affect health outcomes. Systemic racism is a root cause of the power and wealth imbalances that affect social determinants of health, creating disproportionate rates of comorbidities and adverse outcomes in the communities of racial and ethnic minority groups. Focusing primarily on disparities between Black and White individuals born in the United States, this document reviews the effects of social determinants of health and systemic racism on reproductive health outcomes and recommends multilevel approaches to mitigate disparities in obstetrical outcomes.

Better Understanding of the Metamorphosis of Pregnancy (BUMP): protocol for a digital feasibility study in women from preconception to postpartum

The Better Understanding the Metamorphosis of Pregnancy (BUMP) study is a longitudinal feasibility study aimed to gain a deeper understanding of the pre-pregnancy and pregnancy symptom experience using digital tools. The present paper describes the protocol for the BUMP study. Over 1000 participants are being recruited through a patient provider-platform and through other channels in the United States (US). Participants in a preconception cohort (BUMP-C) are followed for 6 months, or until conception, while participants in a pregnancy cohort (BUMP) are followed into their fourth trimester. Participants are provided with a smart ring, a smartwatch (BUMP only), and a smart scale (BUMP only) alongside cohort-specific study apps. Participant centric engagement strategies are used that aim to co-design the digital approach with participants while providing knowledge and support. The BUMP study is intended to lay the foundational work for a larger study to determine whether participant co-designed digital tools can be used to detect, track and return multimodal symptoms during the perinatal window to inform individual level symptom trajectories.

Examining educational attainment and allostatic load in non-Hispanic Black women

Background

Research suggests that non-Hispanic Black (henceforth, Black) women and people with lower educational attainment have higher levels of allostatic load (AL). This study sought to determine the association between educational attainment and AL among a large sample of Black women.

Methods

We analyzed data among 4177 Black women from the National Health and Nutrition Examination Survey years 1999–2018. AL score was defined as the total for abnormal measures of eight biomarkers. We further categorized participants with AL score greater than or equal to 4 as having high AL. We calculated mean estimates of total allostatic load scores using generalized linear models. We performed modified Poisson Regression models with robust variance estimation to estimate prevalence ratios (PRs) of high allostatic load and their associated 95% confidence intervals (CIs) by educational attainment.

Results

Black women with a college degree or higher had the lowest prevalence of high allostatic load (31.8% vs. 42.7%, 36.3%, 36.6%), and age adjusted mean allostatic load scores (mean = 1.90 vs. mean = 2.34, mean = 1.99, mean = 2.05) when compared to Black women with less than a high school diploma, high school diploma or GED, and some college or associates degree respectively. Even after accounting for age, poverty-to-income ratio, smoking, congestive heart failure, and heart attack, Black college graduates had an 14.3% lower prevalence of high allostatic load (PR = 0.857, 95% CI 0.839–0.876) when compared to Black women with lower educational attainment.

Conclusions

Black women with a baccalaureate degree or higher educational attainment had lower allostatic load compared to Black women with less than a high school education. This finding further confirms higher education is a social determinant of health. Future research should explore differences in AL by more granular degree types.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01641-0.

Racial/Ethnic Inequities in Paid Parental Leave Access

Purpose: Severe racial inequities in maternal and infant health in the United States are caused by the many forms of systemic racism. One manifestation of systemic racism that has received little attention is access to paid parental leave. The aim of this article is to characterize racial/ethnic inequities in access to paid leave after the birth of a child.

Methods: We analyzed data on women who were employed during pregnancy (n=908) from the Bay Area Parental Leave Study of Mothers, a survey of mothers who gave birth in the San Francisco Bay Area in 2016–2017. We examined differences in access to government- and employer-paid leave, the duration of leave taken, and the percent of usual pay received while on leave. To explore these differences, we further examined knowledge of paid leave benefits and sources of information.

Results: Non-Hispanic (NH) black and Hispanic women had significantly less access to paid leave through their employers or through government programs than their NH white and Asian counterparts. Relative to white women, Asian, Hispanic, and black women received 0.9 (p<0.05), 2.0 (p<0.01), and 3.6 (p<0.01) fewer weeks, respectively, of full-pay equivalent pay during their parental leaves. Despite inequitable access to paid leave, the duration of parental leave taken did not differ by race/ethnicity.

Conclusions: Inequitable access to paid parental leave through both employers and government programs exacerbates racial inequities at birth. This form of structural racism could be addressed by policies expanding access to paid leave.

Society for Maternal-Fetal Medicine Special Statement: COVID-19 research in pregnancy: progress and potential

The COVID-19 global pandemic has broad implications for obstetrical care and perinatal outcomes. As we approach the 2-year mark into an unprecedented international pandemic, this review presents the progress and opportunities for research related to COVID-19 and pregnancy. Research is the basis for evidence-based clinical guidelines, and we aim to provide the structure and guidance for framing COVID-19-related obstetrical research. This structure will pertain not only to this pandemic but future ones as well.

Social Determinants of Health in Neurology

Neurologic health disparities are created and perpetuated by structural and social determinants of health. These factors include, but are not limited to, interpersonal bias, institutional factors that lead to disparate access to care, and neighborhood-level factors, such as socioeconomic status, segregation, and access to healthy food. Effects of these determinants of health can be seen throughout neurology, including in stroke, epilepsy, headache, amyotrophic lateral sclerosis, multiple sclerosis, and dementia. Interventions to improve neurologic health equity require multilayered approaches to address these interdependent factors that create and perpetuate disparate neurologic health access and outcomes.

The contribution of racism-related stress and adversity to disparities in birth outcomes: evidence and research recommendations

Currently, racial and ethnic differences in adverse birth outcomes and infant mortality are some of the largest and most persistent health disparities in the United States. This narrative review article synthesizes existing literature to present a conceptual model of how racism-related stress and adversity are critical determinants of such disparities. We describe how historical and ongoing racism has created conditions wherein women of color are disproportionately exposed to chronic, multilayered stress and adversity and how the biological consequences of exposure to these stressors confers risk for adverse birth outcomes. Next, we identify important priorities and considerations for future research, including the heterogeneity of racism-related stressors, biomarkers and mechanisms, chronicity and sensitive periods of exposure, developmental programming of lifespan health, resilience, and community-engaged research methodologies.

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Historical and ongoing racism has created conditions wherein women of color are disproportionately exposed to stress and adversity.

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The consequences of exposure to racism-related stress and adversity can confer risk for health conditions implicated in adverse birth outcomes and alter maternal physiology associated with fetal development and timing of parturition.

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Conjointly studying racism-related stress, biologic profiles, and birth outcomes is a priority for future research.

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It is important to identify factors that mitigate the impact of racism-related stress and adversity on birth outcomes.

A way forward in the maternal mortality crisis: addressing maternal health disparities and mental health

Our objective was to review the role of maternal health disparities and mental health in the maternal mortality crisis in the USA, and discuss how perinatal care quality improvement in these areas is a critical lever for reducing maternal death. This paper summarizes content from a plenary talk delivered at the 2020 Biennial Meeting of the International Marcé Society for Perinatal Mental Health, in commemoration of the Society's 40th anniversary. The talk synthesized literature on two characteristics of the maternal mortality crisis in the US: (1) wide racial and ethnic disparities in maternal mortality and severe morbidity and (2) the impact of mental health and substance use disorders on maternal death, and introduced a framework for how health care quality gaps contribute to both of these issues. The US remains an outlier among similar nations in its alarmingly high rates of maternal mortality. Achieving significant progress on this measure will require confronting longstanding racial and ethnic disparities that exist throughout the pregnancy-postpartum continuum, as well as addressing the under-reported issue of maternal self-harm. Suicide and overdose are leading but under-recognized causes of death among pregnant and postpartum women in some states. Health care delivery failures, including inadequate risk assessment, care coordination, and communication, are identified in the literature on drivers of maternal health disparities and self-harm. Many of the same steps to improve quality of perinatal care can help to reduce health disparities and address the essential role of mental health in maternal well-being.

Insights into fear: A phenomenological study of Black mothers

AIM

The aim of the study was to explore the lived experience of stress as described by Black childbearing women.

DESIGN

A phenomenological approach was used.

METHODS

Seven mothers who met inclusion criteria participated in both individual and group interviews between August 2018 and August 2019. Each session was audio recorded and professionally transcribed. Consistent with van Manen's phenomenological approach, three rounds of reflective transcript analysis were conducted over several months.

RESULTS

Several stress themes were identified from the data. However, the most pervasive theme was the fear of having a son and keeping him safe. In this paper, the themes of Living in Fear and Living with Fear are detailed.

CONCLUSION

Previous research has found that Black populations in America fear for their safety. This study identified a pervasive and profound fear for their children, specifically sons who are at a higher risk of being killed in normal daily activities. Mothers also expressed fears about their responsibility to keep them safe by providing the right tools.

IMPACT

Although scientists have long studied poor pregnancy outcomes for Black American women, the disparity persists. This study sought to identify stressors acknowledged by Black mothers themselves. For the first time, Black mothers stated that their primary stress is fear for their children's lives. The role this fear has in adverse pregnancy outcomes, if any, is yet to be determined.

Antepartum Depression and Preterm Birth: Pathophysiology, Epidemiology, and Disparities due to structural racism

PURPOSE OF REVIEW

Informed by the evidence of links between physiology of stress and parturition, we review recent epidemiologic evidence (2015-2020) of antenatal depression as a risk factor for preterm birth (PTB). We also explain racial/ethnic disparities in depression and preterm birth as a consequence of structural racism.

RECENT FINDINGS

Epidemiologic evidence is consistent in linking antepartum depression with an elevated risk of PTB. Antidepressant usage has been linked with an elevated risk of PTB. However, recent evidence suggests that severity of depression is the underlying driver of the elevated risk attributed to antidepressant usage. The number of depressive symptoms, as a proxy for severity of maternal stress, may be a more informative predictor of PTB than criterion based predictors. Across various study designs, measurement modalities, and populations, antenatal depression predicts an elevated risk of delivering preterm. The physiology of stress provides a plausible explanation for this observation. Excessive stress-induced elevations in maternal and then fetal HPA hormones can alter maternal and fetal homeostasis and hasten the timing of parturition. Antenatal depression and exposure to structural racism are two stressors that can trigger the maternal stress response. Chronically elevated levels of stress hormones among women of color in the USA provide a likely physiologic explanation for Black-White disparities in the risk of PTB. Focusing on the number of depressive symptoms as the more informative predictor of PTB raises several questions. We consider these questions as well as directions for future research in the context of recent advances in the field.