Structural Racism, Historical Redlining, and Risk of Preterm Birth in New York City, 2013-2017

Relationships between historical redlining, contemporary housing market dynamics, racial composition, and mental health in U.S. urban neighborhoods: A conditional process analysis

Historical redlining practices have been linked to a wide range of contemporary social, economic, and health outcomes, including poor mental health. Few studies, however, have investigated the contemporary factors which may explain these lasting associations. We examined features of contemporary housing markets-including property values, homeownership rates, and loan denial rates for home purchase-as possible mediators of historical redlining patterns and contemporary prevalence of poor mental health and assessed neighborhood racial composition as a moderator of these associations. Using data from the CDC PLACES Project (2020 release), American Community Survey (2013-2017), Home Mortgage Disclosure Act database (2013-2017), and Historic Redlining Scores Project, we studied 12,047 census tracts in the United States. We found significant indirect effects of historical redlining on contemporary prevalence of poor mental health via neighborhood property values, homeownership rates, and loan denial rates for home purchase. Further, the indirect effect of redlining via relative median property value was conditional on neighborhood racial composition. Our findings suggest properties in historically "A" graded neighborhoods are valued more than those in neighborhoods graded less favorably, and this apparent benefit to property values-and subsequently to residents' mental health-is greater in neighborhoods where Black residents are underrepresented.

Structural Racism-Related State Laws and Healthcare Access Among Black, Latine, and White U.S. Adults

Racialized healthcare inequities in the USA remain glaring, yet root causes are understudied. To address this gap, we created a state-level structural racism legal index (SRLI) using the Structural Racism-Related State Law Database and analyzed its association with racialized inequities in four outcomes (lacking health insurance coverage, lacking a personal doctor, avoiding care due to cost, lacking a routine check-up) from the 2013 Behavioral Risk Factor Surveillance System (N = 454,834). To obtain predicted probabilities by SRLI quartiles (Q1 = less structural racism, Q4 = more structural racism) and racialized group, we fit survey-weighted multilevel logistic models adjusted for individual- and state-level covariates. We found substantial healthcare access inequities across racialized groups within SRLI quartiles and less pronounced, but still meaningful, inequities within racialized groups across SRLI quartiles. For example, the predicted probabilities of lacking health insurance coverage across SRLI quartiles ranged from 13 to 20% among Black adults, 31 to 41% among Latine adults, and 8 to 11% among White adults. Across racialized groups in Q4 states, predicted probabilities ranged from 11% among White adults to 41% among Latine adults. Similar patterns were observed for lacking a personal doctor and avoiding care due to cost. Findings underscore the need to address structural racism in laws and policies to mitigate these inequities.

The association between four neighborhood disadvantage indices and child chronic health classifications

BACKGROUND

Neighborhood advantage/disadvantage is a social determinant of health. We aimed to examine the distribution and associations between child chronic health conditions and four commonly used indices.

METHODS

Children with outpatient visits and valid addresses (n = 115,738) were included and outcomes were categorized as having no chronic disease (N-CD), non-complex chronic disease (NC-CD), and complex chronic disease (C-CD). Four measures of neighborhood characteristics (Child Opportunity Index, Area Deprivation Index, Neighborhood Disadvantage Index, Social Vulnerability Index were calculated from census data. Separate multinomial logistic regression models were used.

RESULTS

The indices' scores were correlated (r = 0.80-0.92). Children in low opportunity or high disadvantage/deprivation/vulnerability neighborhoods were more likely to be diagnosed with C-CD than those in high opportunity or low disadvantage/deprivation/vulnerability neighborhoods. The increased odds ranged from 5% to 39%. The adjusted odds of NC-CD were found to increase by 8-31% as the neighborhood opportunity declined or the disadvantage/deprivation/vulnerability increased, across all indices. The association grew stronger as neighborhood opportunity decreased, or disadvantage/deprivation/vulnerability increased for all four indicators.

CONCLUSIONS

Each instrument was associated with medical complexity classifications, but the magnitude of the associations differed slightly. The rationale for choosing a measure of neighborhood characteristics should be based on the study's aims and population.

IMPACT

This study evaluates the associations of four commonly used neighborhood indices with medical complexity classifications. All indices were associated with study outcomes. The Area Disadvantage Index (ADI) and Child Opportunity Index (COI) demonstrated incremental increases in the odds of receiving a classification of complex chronic disease (C-CD) compared to no chronic disease (N-CD) as neighborhood opportunity decreased or the disadvantage/deprivation/vulnerability increased. Being classified with a non-complex chronic disease (NC-CD) compared to N-CD, only the association with the COI increased incrementally at each level of opportunity. Study outcomes and index characteristics must be considered when designing studies.

The Decision to Leave the Midwifery Workforce in the United States: A Qualitative Investigation

AIM

To explore the experiences of and reasons for midwives leaving practice.

DESIGN

A qualitative approach applying a social constructivism interpretative framework.

METHODS

Twenty participants were selected for interviews based on reasons for leaving midwifery practice between October 2022 and April 2023. Thematic analysis was used to identify themes, and results were checked for trustworthiness through a third coder, community engagement and member checking with two participants.

FINDINGS

One overarching theme with six subthemes characterised the experience of leaving midwifery practice. All participants reported the overarching theme: Caring for myself and my close community became incompatible with the work of midwifery. Five subthemes reflected negative aspects of midwifery work: value incongruence; racism in midwifery; not feeling respected/valued (+compensation); high workload leading to low quality of care; negative practice climate and psychosocial safety climate. The theme of strong professional commitment and identity weighed into their decision to leave. Negative experiences working in birth centres were prominent across themes.

CONCLUSIONS

Participants reported leaving the profession of midwifery when they reached an unsustainable balance between the demands of work life and personal life. The decision to leave midwifery was emotional; participants maintained a strong connection to midwifery. The leaving process supports a theoretical premise for midwifery turnover behaviour. The work life of midwives is a complex composite of challenges that are reflective of identified problems with maternity care in the United States.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Midwives are not leaving practice because they want to leave midwifery but because they are unable to meet non-work-related caring demands. Family-friendly policies, such as flexible schedules and leave policies, could help retain the midwifery workforce.

PATIENT OR PUBLIC CONTRIBUTION

Based on recommendations from representatives of historically marginalised groups within the midwifery community, we offered participants to be interviewed by a midwife of colour.

Measures of Structural Racism and Black-White Disparity in Stillbirth Rates in New York City, 2009-2018: A Population-Based Cross-Sectional Study

OBJECTIVE

To explore associations between measures of structural racism and stillbirth.

DESIGN

Population-based cross-sectional.

SETTING

New York City (NYC), USA.

POPULATION

All non-Hispanic Black and White singleton births 2009-2018.

METHODS

We modelled associations between measures of structural racism (Indices of Dissimilarity, Isolation and Concentration at the Extremes [ICE] and an Educational Inequity Ratio) and stillbirth. For indicators with evidence of interaction with race, we estimated odds ratios for stillbirth separately in 221 925 Black and 325 058 White births.

OUTCOME MEASURE

Stillbirth (fetal death at 20+ completed gestational weeks).

RESULTS

The stillbirth rate (per 1000 total births) was 13.8 in Black and 4.7 in White births. For Black mothers, residence in privileged versus disadvantaged PUMAs (Public Use Microdata Areas) (ICE Quintile 5 vs. 1) was associated with 54% greater odds of stillbirth (95% confidence interval, CI, 1.11, 2.14), and residence in more versus less isolated PUMAs (Isolation Tertile 3 vs. 1) was associated with 36% lower odds of stillbirth (95% CI 0.51, 0.82). There were no associations between measures of structural racism and stillbirth in White births.

CONCLUSIONS

ICE and Isolation were associated with stillbirth in Black but not White births, but associations were not in the expected direction, raising questions about whether and how these measures represent structural racism. NYC stillbirths comprise about 4% of the USA's stillbirths but 15% of all Black stillbirths. Hence, reductions in racial disparities in stillbirth rates in NYC will also contribute to national public health.

Manifestations of Anti-Black Racism and Worry About Pregnancy and Birthing While Black: A Cross-sectional Secondary Analysis of Giving Voice to Mothers

INTRODUCTION

Pregnancy and childbirth traditionally bring worry or a sense of anxiety and distress, particularly among Black women that face historical and contemporary anti-Black racism. We employed two frameworks to assess manifestations of anti-Black racism, structural racism and obstetric racism, as predictors of worry about pregnancy and birth within the Black reproducing community.

METHODS

In a secondary cross-sectional analysis, we analyzed data from Black women in the Giving Voice to Mothers study who completed all relevant items (n = 260). We conducted descriptive analyses and logistic regression models to explore how worry about pregnancy and birth for the Black reproducing community varies with experiences of obstetric racism and different manifestations of structural racism.

RESULTS

Approximately 71% of the sample worried about pregnancy and birth for themselves and their community. Black women who experienced obstetric racism were statistically significantly more likely to be worried about pregnancy and birth experiences compared to Black women who did not. Furthermore, when structural racism was manifested and measured as hidden resources, among Black women reporting fewer pregnancy and birthing care options for women of color, those who experienced obstetric racism during care were 15.6 times more likely to worry about pregnancy and birthing experiences than those who did not (OR 15.667; 95% CI 1.348-182.058).

CONCLUSION

The findings demonstrate the complexity of racialized harm enacted against Black women during the perinatal period and underscore the ways in which obstetric racism and contexts of structural racism powerfully shape the meaning and subsequent emotional impact of pregnancy and birthing while Black.

Weight-based discrimination and cortisol output: A systematic review

Discrimination based on weight status (or weight-related discrimination/stigma) may be related to greater physical and mental health concerns via physiological and psychological phenotypes of stress. Cortisol output, a biomarker of stress, has been measured in relation to weight stigma and weight-related discrimination. This systematic review aims to synthesize existing research on the relationship between weight-related discrimination and cortisol output, evaluate methodological approaches for measuring these constructs, and identify research gaps regarding contextual factors influencing this relationship. A comprehensive search was conducted across multiple databases (PsycINFO, Scopus, ProQuest, and PubMed) from February 1 to July 1, 2024, resulting in 11 eligible studies that examined weight discrimination in relation to cortisol levels. Studies were assessed for quality using the NHLBI Study Quality Assessment Tool, and inter-rater reliability for coding was established at 90 %. The findings revealed a range of sample sizes (45-4341) and diverse participant characteristics, including variations in age, race, and body mass index (BMI). About half (N = 5) of the included studies reported a positive relation between weight stigma and cortisol output. The review also uncovered significant limitations in current methodologies, particularly concerning contextual factors and other marginalized identities, such as socioeconomic status and food insecurity, along with measuring other forms of discrimination in tandem with weight stigma, such as racial discrimination. These findings underscore the need for future research to adopt a more intersectional approach in examining the multifaceted nature of weight stigma and how it relates to a greater stress response in multiple marginalized identities, as well as including longitudinal modeling of weight stigma's impact on biomarkers for stress.

How and Why Does Redlining Matter for Present-Day Health? Critical Perspectives on Causality, Cartography, and Capitalism

Recent years have seen an explosion of public health research on associations between historical redlining maps created by a US government agency, the Home Owners' Loan Corporation (HOLC), and present-day outcomes. Yet precisely how and why HOLC's surveys help us understand the underpinnings of present-day racial inequities remains unclear. We apply an interdisciplinary perspective to assess the contributions and limitations of this literature, particularly with regard to causal mechanisms and theoretical explanations. While research often frames HOLC redlining as a measure of structural racism that directly shapes present-day outcomes, we look instead to racial capitalism to understand how and why racialized housing policies are implemented. We argue that the HOLC maps represent symptoms, not causes, of systematic disinvestment in Black communities, that redlining was not produced by the federal government in isolation but was shaped by public‒private collaboration and infused with capitalist logics, and that redlining interacted with many other forms of racialized housing dispossession to shape present-day riskscapes. We conclude by offering conceptual and methodological recommendations for public health researchers, including suggestions for data sources other than HOLC maps. (Am J Public Health. 2025;115(5):769-779. https://doi.org/10.2105/AJPH.2024.308000).

Stigmatizing and Positive Language in Birth Clinical Notes Associated With Race and Ethnicity

Importance

Language used in clinical documentation can reflect biases, potentially contributing to health disparities. Understanding associations between patient race and ethnicity and documentation of stigmatizing and positive language in clinical notes is crucial for addressing health disparities and improving patient care.

Objective

To examine associations of race and ethnicity with stigmatizing and positive language documentation in clinical notes from hospital birth admission.

Design, Setting, and Participants

This cross-sectional study included birthing patients at 2 metropolitan hospitals in the Northeastern US between 2017 and 2019. Eligible participants were admitted for labor and birth and had at least 1 free-text clinical note. Analysis was conducted using natural language processing. Data were analyzed between March and December 2024.

Exposures

Patient race and ethnicity, categorized into mutually exclusive groups of Asian or Pacific Islander, Black, Hispanic, and White.

Main Outcome and Measures

Presence of 4 stigmatizing language categories (marginalized language or identities, difficult patient, unilateral or authoritarian decisions, and questioning patient credibility) and 2 positive language categories (preferred and/or autonomy, power and/or privilege).

Results

Among the 18 646 patients included in the study (mean [SD] age, 30.5 [6.2] years), 2121 were Black (11.4%), 11 078 were Hispanic (59.4%), and 4270 were White (22.9%). The majority (10 559 patients [56.6%]) were insured by Medicaid. Compared with White patients, Black patients had higher odds of having any stigmatizing language (model 2: odds ratio [OR], 1.25; 95% CI, 1.05-1.49; P < .001), after adjustment for demographic characteristics. Black patients also had higher odds of any positive language documented (model 2: OR, 1.18; 95% CI, 1.05-1.32; P = .006). Hispanic patients had lower odds of documented positive language (model 2: OR, 0.90; 95% CI, 0.82-0.99; P = .03). Asian or Pacific Islander patients had lower odds of language documented in the power and/or privilege category (model 2: OR, 0.71; 95% CI, 0.57-0.88; P = .002).

Conclusions and Relevance

In this cross-sectional study examining clinical notes of 18 646 patients admitted for labor and birth, there were notable disparities in how stigmatizing and positive language was documented across racial and ethnic groups. This underscores the necessity for improving documentation and communication practices to reduce the use of stigmatizing language.

Historic Structural Racism and Perceived Stress in Adolescents

PURPOSE

This study is the first to examine the impact of structural racism from historic redlining practices on present-day perceived stress in adolescents.

METHODS

Data come from the Study of Adolescent to Adult Neural Development. Adolescents aged 15-17 years (N = 213) completed the Perceived Stress Scale (PSS-14). Regression models examined associations between redlining scores, a measure of residential security risk, and PSS-14. Structural equation modeling was used to examine the indirect effect of present-day neighborhood inequities.

RESULTS

After adjusting for covariates, adolescents living in high redlined tracts (52.1%) reported higher PSS-14 values than those living in ungraded tracts (β: 2.47, 95% confidence interval: 0.35, 4.59). Analyses subset to non-Hispanic Black adolescents showed similar results. There was an indirect effect of redlining on perceived stress through neighborhood poverty (p = .043).

DISCUSSION

Findings indicate that institutional discriminatory lending practices from the early 20th century continue to impact present-day neighborhood poverty, resulting in increased adolescent stress.

Association of Residential Segregation With Mortality in the U.S., 2018-2022

INTRODUCTION

This study aimed to examine the association of county-level racial and economic residential segregation with mortality rates in the U.S. between 2018 and 2022.

METHODS

Residential segregation was measured by the Index of Concentration at the Extremes and categorized into quintiles. Outcomes included 2018-2022 county-level age-adjusted mortality rates from all causes and the top 10 causes. Multilevel linear mixed modeling was clustered at the state level and adjusted for county's poverty, metropolitan status, and racial composition.

RESULTS

A total of 3,129 counties were included. County-level age-adjusted mortality rates decreased as the segregation level decreased for all causes (from 1,078.8 deaths in the most segregated counties to 734.92 deaths in the least segregated counties per 100,000 persons per year) and for 10 leading causes. Adjusted rate ratios showed dose-response associations between segregation and mortality from all causes and 9 out of 10 leading causes. Using the least segregated counties as the reference group, the adjusted rate ratios (aRR) for all-cause mortality was 1.25 (95% CI=1.22, 1.28), 1.20 (1.17, 1.22), 1.13 (1.11, 1.15), and 1.09 (1.08, 1.10) for the first (most segregated) through the fourth quintile of segregation, respectively.

CONCLUSIONS

Racial and economic residential segregation was positively associated with mortality rates at the county level in the contemporary U.S. Future studies should elucidate the mechanisms underlying associations to inform evidence-based interventions and improve the health of the entire population.

Association of Historical Redlining With Gestational Diabetes Mellitus: The Mediating Role of BMI and Area Deprivation Index

OBJECTIVE

We investigated the association between historic redlining and risk of gestational diabetes mellitus (GDM) and whether this relationship is mediated by maternal obesity and area-level deprivation.

RESEARCH DESIGN AND METHODS

This retrospective study included 86,834 singleton pregnancies from Kaiser Permanente Southern California's health records (2008-2018). Redlining was assessed using digitized Home Owners' Loan Corporation (HOLC) maps, with patients' residential addresses geocoded and assigned HOLC grades (A, B, C, or D) based on their geographic location within HOLC-graded zones. For GDM case patients, exposure was assigned based on address at diagnosis date; for noncase patients, it was assigned based on address during the 24th to 28th gestational week. Health records were combined with area deprivation index (ADI) from 2011 to 2015 census data. Mixed-effect logistic regression models assessed associations between redlining and GDM, with mediation by BMI and ADI evaluated using inverse odds ratio weighting. Models were adjusted for maternal age, education, race and ethnicity, neighborhood-level income, and smoking status.

RESULTS

Among the 10,134 (11.67%) GDM case patients, we found increased risk of GDM in B ("still desirable," adjusted odds ratio [aOR] 1.20, 95% CI 0.99-1.44), C-graded ("definitely declining," aOR 1.22, 95% CI 1.02-1.47), and D-graded ("hazardous," i.e., redlined, aOR 1.30, 95% CI 1.08-1.57) neighborhoods compared with the "best"-graded zone. Prepregnancy BMI and ADI mediated 44.2% and 64.5% of the increased GDM risk among mothers in redlined areas.

CONCLUSIONS

Historic redlining is associated with an increased risk of GDM, mediated by maternal obesity and neighborhood deprivation. Future research is needed to explore the complex pathways linking redlining to pregnancy outcomes.

Historical redlining and criminal offending trajectories from adolescence to adulthood

PURPOSE

Area-level research finds higher contemporary crime rates in historically redlined communities. However, there is a lack of multilevel research assessing the relationship between living in a historically redlined area, individual patterns of criminal offending over time, and whether this relationship varies for different racial-ethnic groups.

METHODS

Data are from Waves I, III, IV, and V of the National Longitudinal Study of Adolescent to Adult Health (n = 7843; ages 11-44), including recently digitized 1930s redlining maps from the Home Owners' Loan Corporation. Using age-based growth curve models, we estimate rates of criminal offending for non-Hispanic Black, Hispanic, and non-Hispanic White Americans who live inside (vs. outside) formerly redlined areas from adolescence to adulthood.

RESULTS

Starting in adolescence, Black and Hispanic respondents typically report more criminal offenses than White peers, regardless of redlining. As respondents transition to adulthood, reports of criminal offenses approach zero at an exponential rate. However, declines in criminal offenses are lagged by two years, on average, for Black and Hispanic respondents who live in redlined areas, relative to White and non-redlined counterparts.

CONCLUSIONS

Findings suggest formerly redlined urban areas may still promote criminal behavior, particularly for Black and Hispanic adolescents transitioning to adulthood. Future research and policy should address the long-term consequences of institutionalized segregation for public safety and community well-being.

Associations Between Measures of Structural Racism and Acute Ischemic Stroke Incidence in the United States

BACKGROUND AND OBJECTIVES

Racial differences in socioeconomic characteristics are believed to be secondary to structural racism. While socioeconomic factors explain some of the racial disparity in stroke incidence at an individual level, little is known about the association between societal-level structural racism and incidence of acute ischemic stroke (AIS). We aimed to determine whether the geographic racial disparity in stroke incidence across the United States is associated with structural racism.

METHODS

We performed a national, population-based analysis of 71,078,619 adults (844,406 with incident AIS) aged 65 years and older who were enrolled in Medicare from January 1, 2016, to December 31, 2019. The primary exposure was a composite score calculated from 8 county-level measures of structural racism (segregation indices [delta, dissimilarity, isolation], Gini index, housing discrimination, educational attainment, employment, and income) that account for validated domains of structural racism based on an ecosocial model. The primary outcome was incident AIS. Marginal Cox models with data clustered at the county level were used to estimate the hazard ratio (HR) of AIS incidence, comparing Black individuals with White individuals. Separate marginal Cox models tested associations between each measure of structural racism and AIS incidence, with further testing to screen for interaction with the race variable.

RESULTS

The composite structural racism score identified significant geographic variation in structural racism across the United States (mean 0.818, SD 2.874, interquartile range 3.02). Black individuals had a 19% increased hazard of AIS compared with White individuals (HR 1.19, 95% CI 1.14-1.25, p < 0.0001). All constituent measures of structural racism, except for housing discrimination, were associated with AIS incidence independently of race. Each SD increase in the composite structural racism score was associated with an 18% increased incidence in AIS in the total population. This association interacted with race (p = 0.03), with a greater magnitude of association for White (HR 1.19, 95% CI 1.13-1.25, p < 0.0001) vs Black (HR 1.09, 95% CI 1.03-1.16, p = 0.0073) individuals.

DISCUSSION

There is significant county-level geographic variation in structural racism across the United States, and increasing levels of structural racism are associated with increased incidence of AIS, regardless of race.

Racial and ethnic disparities in fecundability: a North American preconception cohort study

STUDY QUESTION

To what extent are there racial and ethnic disparities in fecundability in North America?

SUMMARY ANSWER

In a North American preconception cohort study, we observed large differences in fecundability across racial and ethnic groups.

WHAT IS KNOWN ALREADY

Several studies in the United States (USA) have shown that Black women tend to wait longer for fertility treatment and are less likely to seek medical care for infertility than White women. Among those who seek infertility treatment, there are large racial disparities in access to treatment and treatment success rates. However, research has been limited and conflicting on the extent to which fertility measures such as fecundability (per-cycle probability of conception) vary by race and ethnicity.

STUDY DESIGN, SIZE, DURATION

We examined the associations of race and ethnicity with fecundability in Pregnancy Study Online (PRESTO), a prospective preconception cohort study of US and Canadian residents aged 21-45 years who were actively trying to conceive without the use of fertility treatment at enrollment (2013-2024). We restricted the analysis to 18 573 participants with fewer than 12 cycles of pregnancy attempt time at enrollment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants self-reported data on race and ethnicity on a baseline questionnaire and completed bimonthly follow-up questionnaires for up to 12 months to update data on pregnancy status. We estimated fecundability ratios (FRs) and 95% confidence intervals (CI) using proportional probabilities regression models. We stratified by pregnancy attempt time at enrollment, reproductive history, country of residence, age, and educational attainment. In sensitivity analyses, we applied inverse probability of continuation weights to account for differential loss-to-follow-up. We also calculated the cumulative incidence of infertility during 12 cycles of attempt time by race and ethnicity using life-table methods to account for censoring.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared with non-Hispanic White participants, fecundability was appreciably lower among participants who identified as non-Hispanic Black (FR = 0.60, 95% CI: 0.52-0.70), non-Hispanic American Indian/Alaskan Native/Indigenous (FR = 0.70, 95% CI: 0.44-1.11), non-Hispanic multiracial (FR = 0.89, 95% CI: 0.81-0.99), or Hispanic other/unknown race (FR = 0.77, 95% CI: 0.65-0.90). Results were similar when we performed various sensitivity analyses including: application of inverse probability of continuation weights to account for differential loss-to-follow-up; stratification by age and educational attainment; and restriction of analyses to (i) participants with <3 cycles of pregnancy attempt time at enrollment, (ii) nulligravid participants without an infertility history, and (iii) US residents. The 12-cycle cumulative incidence of infertility (i.e. clinical definition) among participants with <2 cycles of attempt time at entry also differed meaningfully by race and ethnicity (33.2% among non-Hispanic Black participants and 29.7% among Hispanic other/unknown race participants vs 16.4% among non-Hispanic White participants).

LIMITATIONS, REASONS FOR CAUTION

Due to limited numbers, we grouped participants into broad racial and ethnic groups within which there is considerable heterogeneity. Such groupings will obscure any differences in fecundability that exist between subgroups. Differential loss-to-follow-up was an important source of selection bias, though findings did not vary appreciably when we applied inverse probability of continuation weights. PRESTO is an internet-based convenience sample of pregnancy planners of higher-than-average socioeconomic status and is, therefore, not representative of all individuals who conceive, which may limit generalizability.

WIDER IMPLICATIONS OF THE FINDINGS

These descriptive data indicate the strong need for additional studies to carefully measure and better understand the mechanisms underlying disparities in fecundability, including the effects of structural racism and discrimination, as well as programs and policies to advance reproductive health equity. As more research is conducted on the drivers of these disparities, greater efforts should be made to increase fertility awareness, enhance preconception health, expand access to fertility treatments, and improve patient care among underserved populations to reduce the burden of subfertility among those affected.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the Eunice Kennedy Shriver National Institute for Child Health and Human Development (R01-HD086742; T32-HD052458) and the National Institute on Minority Health and Health Disparities (K01-MD013911). In the past three years, L.A.W. served as a consultant for AbbVie, Inc. and the Gates Foundation. She was also a member of the steering committee for AbbVie on Abnormal Uterine Bleeding and Fibroids, where payments were made to Dr Wise. Her study, PRESTO, received in-kind donations from Kindara.com (fertility apps) and Swiss Precision Diagnostics (home pregnancy tests). C.N. received payments to her institution from the National Institute on Minority Health and Health Disparities K01-MD013911. The other authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

N/A.

Patient-provider relationships and long COVID: A cross-sectional survey about impact on quality of life

BACKGROUND

In the United States (U.S.), it is estimated that 17.6 % of adults have experienced Long COVID, a condition where symptoms newly develop and linger after initial COVID-19 infection. Long COVID is associated with significantly reduced quality of life (QoL), and patient-provider relationships have been shown to influence QoL for patients in general.

OBJECTIVE

The objective for this study was to better understand the role of patient-provider relationships in shaping QoL among U.S. adults with Long COVID.

METHODS

This study carried out an online survey among U.S. adult with Long COVID (N = 792).

RESULTS

Respondents with at least a bachelor's degree reported higher QoL, and older respondents were more likely to report lower QoL; trust in providers was a significant predictor of higher QoL, while dismissal of Long COVID symptoms was associated with lower QoL (all p < .05).

CONCLUSIONS

Healthcare providers should be aware of the importance of trust in the relationship with their Long COVID patients and the impact this may have on patients' QoL. Researchers and policy makers should include an increasing focus on training for providers who treat patients with Long COVID in order to strengthen patient-provider relationships.

Intersectional analysis for science and technology

Intersectionality describes interdependent systems of inequality related to sex, gender, race, age, class and other socio-political dimensions. By focusing on the compounded effects of social categories, intersectional analysis can enhance the accuracy and experimental efficiency of science. Here we extend intersectional approaches that were predominantly developed in the humanities, social sciences and public health to the fields of natural science and technology, where this type of analysis is less established. Informed by diverse global and disciplinary examples-from enhancing facial recognition for diverse user bases to mitigating the disproportionate impact of climate change on marginalized populations-we extract methods to demonstrate how quantitative intersectional analysis functions throughout the research process, from strategic considerations for establishing research priorities to formulating research questions, collecting and analysing data and interpreting results. Our goal is to offer a set of guidelines for researchers, peer-reviewed journals and funding agencies that facilitate systematic integration of intersectional analysis into relevant domains of science and technology. Precision in research best guides effective social and environmental policy aimed at achieving global equity and sustainability.

Using spatial Bayesian models to estimate associations between structural racial discrimination and disparities in severe maternal morbidity

INTRODUCTION

The United States maternal health crisis is especially profound in Georgia, disproportionately affecting Black birthing people. In Georgia, 35% of all births are to Black-identifying people, with rates of severe maternal morbidity (SMM) significantly exceeding national averages.

METHODS

The sample population comprised Georgia linked live birth/fetal death certificate and hospital discharge data for deliveries from 2013 to 2021. Structural racial discrimination (SRD) was defined at the county level using four domains. We estimated county-specific rates of SMM using Bayesian conditional autoregressive Poisson models and compared the rate difference in SMM for Black versus white birthing people across domain-specific strata of SRD.

RESULTS

The sample included 709,335 deliveries to Black and white birthing people. The prevalence of SMM was higher among births to Black individuals compared to white counterparts (3.2% vs. 1.7%), with a mean risk difference of 13.1 per 1000 deliveries between race groups. Results of the SRD-SMM regression demonstrated larger Black-white racial disparities in counties with the highest concentration of resource deprivation compared to the highest concentration of affluence (B: 4.5, 95% CI: 1.1, 8.0). Similarly, in counties with a greater polarization of Black and low-income residents, the disparity was larger compared to counties with greater racial and income homogeneity (B: 3.84, 95% CI: 0.22, 7.44).

CONCLUSIONS

Our results highlight the nuanced relationship between structural racism and health outcomes in Georgia. SMM rates were higher among Black birthing people compared to their white counterparts.

Variation in the Use of Guideline-Based Care by Prenatal Site: Decomposing the Disparity in Preterm Birth for Non-Hispanic Black Women

INTRODUCTION

Despite longstanding status as a public health priority, preterm birth rates continue to be higher among non-Hispanic Black women compared with other racial and ethnic groups. A growing body of literature highlights the site of care as a key factor in pregnancy outcomes. Although research shows that many individuals do not receive guideline-based prenatal care, little is known about site-level variation in the use of recommended prenatal services and its potential relationship with Black-White preterm birth disparities.

METHODS

In this cross-sectional cohort study, we analyzed variation in site-level use of 4 key prenatal services: tetanus, diphtheria, and pertussis (Tdap) vaccination, [per the CDC website] and screening for bacteriuria, diabetes, and group Beta streptococcus, using administrative data from New York State Medicaid and the American Community Survey. We used multivariable logistic regressions to estimate the odds of attending a low-use site (mean <2 services per patient) by race and ethnicity, controlling for age, high-poverty residential address, and low prenatal care attendance. We performed Fairlie decomposition analyses to quantify the contribution of individual and site-level factors to the observed difference in preterm birth rates among Black and White non-Hispanic women.

RESULTS

Site-level use of recommended prenatal services ranged from an average of 1 to 3.6 services per patient. Non-Hispanic Black women had more than twice the odds (adjusted odds ratio, 2.42; 95% CI, 2.32-2.52) of attending a low-use site compared with non-Hispanic White women. Among factors in the decomposition analysis, site-level screening for bacteriuria and diabetes accounted for the highest proportion of the explained variance in the observed preterm birth rates for non-Hispanic Black (10.7%) and non-Hispanic White (6.7%) women.

DISCUSSION

Results from this research support immediate improvement in guideline-based prenatal care to narrow the gap in preterm birth for non-Hispanic Black women. Research is needed to identify and correct site-level barriers to recommended prenatal services.

Living Dead: Trans Cooperations with Mad Necropolitics and the Mad Trans Coalitions that Might Replace Them

Trans subjectivities continue to be included in major compendia of mental illness, despite recent moves to depathologize "cross-gender identification." Regardless, the inclusion of "gender dysphoria" is often framed as a formal mechanism to support access to gender affirming care as transgender subjectivities are re-conceptualized as part of sex/gender diversity and away from madness. The latter permits trans individuals to evade sanist oppressions. However, moves to disassociate from mad individuals also often serve to condone sanism. For instance, a contemporary policy landscape often sees transgender advocates arguing for the "medical necessity" of gender affirming care for gender dysphoria as a "recognized medical condition," thereby skirting the inclusion of gender dysphoria as a psychiatric condition and implying that gender dysphoria carries a special ontological status that separates it from madness (reified as "mental illness"). More though, this framework endorses material violences toward mad individuals that are often advanced via the workings of the state to consign marginalized constituents to death by withholding the means of life, i.e., necropolitics. In the following, I argue that trans disassociations from madness often endorses or assents to mad necropolitics. Drawing from Mbembe's (Necropolitics. Duke University Press, Durham, 2019) framework, I suggest that medicalizing trans narratives, despite being used to object to anti-trans laws in contemporary context, ideologically support mad "death worlds" organized through the U.S.A. welfare state and prison industrial complex. However, I also suggest alternative strategies, i.e., intersectional collaboration, that may uplift mad and/or trans communities.

Historical redlining and survival among children, adolescents, and young adults with cancer diagnosed between 2000-2019 in Seattle and Tacoma, Washington

BACKGROUND

Historical redlining has been associated with inferior survival in adult-onset cancers. However, its relationship with pediatric, adolescent, and young-adult-onset cancer outcomes is unknown.

METHODS

This study identified incident cancer among individuals <40 years of age living in Seattle and Tacoma between 2000-2019 via the population-based Cancer Surveillance System. The authors determined case redlining status using Home Owners' Loans Corporation data overlaid with 2000 and 2010 census tracts. Kaplan-Meier methods and multivariable Cox proportional hazards models were used to determine 5- and 10-year overall survival and hazard ratio (HR) of death according to redlined status. Cox models adjusted for patient and tumor characteristics and area-level poverty; interaction between redlining and area-level poverty was also assessed.

RESULTS

Among 4355 cases (median age at diagnosis 32 years), overall survival at 5 years was lower (85.1%; 95% confidence interval [CI], 83.5%-86.5%) among individuals residing in redlined neighborhoods compared with those in unexposed neighborhoods (90.3%; 95% CI, 89.0%-91.5%). Survival differences persisted at 10 years. The unadjusted hazard of death for redlined exposed individuals with cancer was higher than redlined unexposed (hazard ratio [HR], 1.62; 95% CI, 1.39-1.89). In the fully adjusted model, mortality remained higher for redlined cases (HR, 1.32; 95% CI, 1.12-1.56). There did not appear to be effect modification from area-level poverty in the relationship between redlining and death (p = .49).

CONCLUSIONS

Among young individuals with cancer, residence at diagnosis in previously redlined neighborhoods was associated with lower survival compared with those residing in nonredlined neighborhoods, supporting the hypothesis that structural racism exerts persistent effects on contemporary health outcomes.

The long-run effect of historical redlining practices on social vulnerability in U.S. cities

Historical redlining practices in the United States date back to the 1930s and have continued to impact cities socially, environmentally, and economically since then. This study explores current social vulnerability inequity among former HOLC (Home Owners' Loan Corporation) neighborhoods with four color-coded grades in 196 U.S. digitized cities. Social vulnerability measurements for each historical HOLC neighborhood were calculated using 2018 census tract-level social vulnerability data through areal apportionment. Kruskal-Wallis tests were employed to compare four grades of former HOLC neighborhoods regarding overall social vulnerability index (SVI), four thematic SVIs (Social economic status, Household composition and disability, Minority status and language, and Housing type and transportation), and SVIs for fifteen social vulnerability factors. After applying multiple comparison corrections, the results indicate significant differences among four HOLC grades concerning overall social vulnerability, four themes, and most of social vulnerability factors. In general, grade A (green) neighborhoods exhibit the lowest vulnerability, while grade D (red) neighborhoods have the highest vulnerability. A similar pattern of social vulnerability inequity persists even after adjusting for inter-city differences in baseline social factors using the city-normalized SVI (CSVI). This finding suggests that urban planners and policymakers should work to reduce social vulnerability inequity across neighborhoods of different grades.

Mental health disparities among maternal populations following heatwave exposure in North Carolina (2011-2019): a matched analysis

Background

The increasing incidence of extreme heat due to climate change poses a significant threat to maternal mental health in the U.S. We examine the association of acute exposure to heatwaves with maternal mental health conditions in North Carolina from 2011 to 2019.

Methods

We incorporate a matched analysis design using NC Hospital Discharge Data to examine emergency department admissions for psychiatric conditions during the warm season (May to September), matching heatwave periods with non-heatwave unexposed periods at the zip code tabulation area (ZCTA) level. We stratify the sample to examine effect modification across the rural-urban continuum, physiographic regions, measurements of neighborhood racial and economic inequality, and individual-level sociodemographic factors (e.g., age, race/ethnicity, and insurance type).

Findings

Our sample of 324,928 emergency department visits by pregnant individuals has a mean age of 25.8 years (SD: 5.84), with 9.3% (n = 30,205) identifying as Hispanic. Relative risk (RR) estimates and 95% confidence intervals (CI) indicate significant increases in maternal mental health burdens following heatwave exposure. Acute heatwave periods were associated with a 13% higher risk of severe mental illness (RRSMI: 1.13, CI: 1.08-1.19, p: <0.0001), while prolonged exposure to moderate-intensity heatwaves was associated with 37% higher risk (RRSMI: 1.37, CI: 1.19-1.58, p: <0.001). Individual factors (e.g., advanced maternal age and insurance providers) and neighborhood-level characteristics, like low socioeconomic status, racialized and economic segregation, rurality, and physiographic region, further modified the risk of adverse maternal mental health outcomes.

Interpretation

Our results add to the growing evidence of the impact of extreme heat on maternal mental health, particularly among vulnerable subpopulations. Additionally, findings emphasize the influence of socioeconomic and environmental contexts on mental health responses to heatwave exposure.

Funding

This work was supported by the Faculty Early Career Development Program (CAREER) award (grant #2044839) from the National Science Foundation and the National Institute of Environmental Health Sciences (NIEHS) award (grant #5R03ES035170-02).

Exposure to Racism and Adverse Pregnancy Outcomes for Black Women: A Systematic Review and Meta-Analysis

Research suggests that stress due to racism may underlie the disproportionately high rates of adverse pregnancy outcomes experienced by Black women in the US. Study objectives: (1) Identify forms of systemic racism affecting pregnancy outcomes and (2) increase understanding about the role of racism in adverse pregnancy outcomes for Black women. A systematic review was conducted to explore the relationship between systemic racism and pregnancy outcomes for Black women. Searches were performed using EBSCO Academic Search Complete, CINAHL Complete, and Consumer Health Complete first between January to April 2021 and subsequently between November 2023 to January 2024. Included studies were observational, written in English, had full-text availability, examined at least one form of systemic racism and pregnancy outcome, and reported results for Black women. A meta-analysis was performed using a random effects model, summary effect estimates were pooled by pregnancy outcome. The I2 statistic was used to measure heterogeneity between studies. A total of 32 studies were included in the review. Significant pooled effects of exposure to systemic racism were observed for preterm birth 0.30 (95% CI 0.12-0.48), small for gestational age 0.31 (95% CI 0.05-0.58), and low birth weight 0.24 (95% CI 0.11-0.37). Among studies that compared results by race, exposure to systemic racism had a significant and rather large effect on preterm birth for Black women (ds = 0.62; 95% CI 0.06-0.41). Exposure to systemic racism has a significant effect on preterm birth, small for gestational age, and low birth weight for Black women. Having knowledge of how racism contributes to stress and poor pregnancy outcomes can help health professionals improve delivery of quality care to Black women. Future research should continue identifying forms of racism positively related to adverse pregnancy outcomes.

Black/African American Women's Woes: Women's Perspectives of Black/African American Maternal Mortality in the USA

BACKGROUND

Despite advances in perinatal care in the USA, maternal mortality is on the rise, and maternal death is higher than in any other high-income country. Maternal mortality in the USA is a persistent public health concern. This issue disproportionately affects Black/African American women, with their likelihood of pregnancy-related death being three times more likely compared to White women. This study aimed to explore the resources needed for Black/African American women to address the relatively higher maternal mortality rates recorded for them.

METHODS

An anonymous link with demographic and open-ended questions was sent to US women 18 years and older to participate in the study. A total of 140 participants responded to the survey. We retained a final sample of 118 responses after eliminating responses with missing data. Descriptive statistics are reported for closed-ended items. Open-ended responses were analyzed using content analysis procedures, where we coded and categorized the data into themes.

RESULTS

Six themes were identified from the study data: (1) Diversity, Equity, and Inclusion (DEI) training for health providers focused on racial bias and discrimination, (2) Advocacy, (3) Provider selection, (4) Researching doctors and delivery hospitals to inform women's birthing decision-making, (5) Women's care-seeking behaviors, and (6) Addressing the Social Determinants of Health.

CONCLUSION

Based on the study's findings, we recommend DEI training for healthcare professionals providing direct care to pregnant and postpartum women, advocacy and resource-awareness training for pregnant Black/African American women and their spouses/partners, or a family member, to assist them in their pregnancy and birthing journeys.

Using internet-assisted geocoding of 1940 census addresses to reconstruct enumeration districts for use with redlining and longitudinal health datasets

Many historical administrative documents, such as the 1940 census, have been digitized and thus could be merged with geographic data. Merged data could reveal social determinants of health, health and social policy milieu, life course events, and selection effects otherwise masked in longitudinal datasets. However, most exact boundaries of 1940 census enumeration districts have not yet been georeferenced. These exact boundaries could aid in analysis of redlining and other geographic and social contextual factors important for health outcomes today. Our objective is to locate and map a large set of 1940 enumeration districts. We use online resources and algorithmic solutions to locate and georeference unknown 1940 enumeration districts. We geocode addresses using the OpenCage API and construct "virtual" enumeration districts by using a convex hull algorithm on those geocoded addresses. We also merge in Home Owners' Loan Corporation (HOLC) redlining maps from the 1930s to demonstrate how 1940 enumeration districts could be used in future work to examine the association between historic redlining and current health. We geocode 7,228,656 1940 census addresses from the largest 191 US cities in 1940 that contained 84% of the 1940 US urban population from the Geographic Reference File and construct 34,472 virtual enumeration districts in areas that had HOLC redlining maps. 18,340 virtual enumeration districts were previously unmapped, covering cities containing an additional 40% of the 1940 US urban population. Where virtual enumeration districts match with previously mapped districts, 96.8% of paired districts share HOLC redlining categorization. Researchers can use algorithmic methods to quickly process, geocode, merge, and analyze large scale repositories of historical documents that provide important data on social determinants of health. These 1940 enumeration district maps could be used with studies such as the Health and Retirement Study, Panel Study for Income Dynamics, and Wisconsin Longitudinal Study.

Overdose as a complex contagion: modelling the community spread of overdose events following law enforcement efforts to disrupt the drug market

BACKGROUND

The opioid overdose mortality crisis in the USA is an ongoing public health epidemic. Ongoing law enforcement strategies to disrupt local unregulated drug markets can have an iatrogenic effect of increasing overdose by driving consumers towards new suppliers with unpredictable drug products of unknown potency.

METHODS

Cross-sectional study using point-level information on law enforcement opioid-related drug seizures from property room data, opioid-related non-fatal overdose events from emergency medical services and block group-level social determinants of health data from multiple sources. Using an endemic-epidemic spatiotemporal regression model, we estimated the degree to which exposure to drug supply disruptions triggers future overdose events within small space-time distances in Indianapolis, Indiana.

RESULTS

Neighbourhoods with more structural racism, economic deprivation or urban blight were associated with higher rates of non-fatal overdose. Exposure to an opioid-related drug seizure event had a significant and positive effect on the epidemic probability of non-fatal overdose. An opioid seizure that occurred within 250 m and 3 days, 250 m and 7 days, and 250 m and 14 days of an overdose event increased the risk of a new non-fatal overdose by 2.62 (rate ratio (RR)=2.62, 95% CI 1.87 to 3.67), 2.17 (RR=2.17, 95% CI 1.87 to 2.59) and 1.83 (RR=1.83, 95% CI 1.66 to 2.02), respectively. Similar spatiotemporal patterns were observed in a smaller spatial bandwidth.

CONCLUSIONS

Results demonstrated that overdoses exhibit a community spread process, which is exacerbated following law enforcement strategies to disrupt the unregulated drug market. We discuss decriminalisation and increasing resources that promote safer drug use to combat this public health crisis.

Maintaining disorder: estimating the association between policing and psychiatric hospitalization among youth in New York City by neighborhood racial composition, 2006-2014

PURPOSE

To assess whether neighborhood-level measures of policing are spatio-temporally associated with psychiatric hospialization among adolescents and young adults in New York City, and whether this association varies by neighborhood racial composition.

METHODS

We derived population-based measures of policing from the New York City Police Department (NYPD), psychiatric hospitalization from Statewide Planning and Research Cooperative System (SPARCS) data, and socio-demographic data from the American Community Survey (ACS), aggregated by month and ZIP Code Tabulation Area (ZCTA) from 2006 to 2014. Multi-level negative binomial regression models assessed hospitalization-time of youth aged 10-24 as the dependent variable and the rate of policing events as the primary independent variable, adjusting for neighborhood poverty, unemployment, and educational attainment. Multiplicative interaction was assessed between policing and tertiles of the percentage of Black residents.

RESULTS

A total of 11,900,192 policing incidents and 2,118,481 person-days of hospitalization were aggregated to 19,440 ZCTA-months. After adjusting for neighborhood-level sociodemographic characteristics, an increase in one policing incident per 1,000 residents was associated with a 0.3% increase in the rate of youth psychiatric hospitalization time (IRR 1.003 [1.001-1.005]). Neighborhood racial composition modified this effect; not only was the rate of psychiatric hospitalization and policing higher in neighborhoods with a higher proportion of Black residents, but the association between these was also significantly higher in neighorhoods with a larger share of Black residents compared with predominantly non-Black neighborhoods.

CONCLUSION

Neighborhoods experiencing higher rates of policing during the study period experienced higher burdens of psychiatric hospitalization among adolescent and young adult residents. This association was larger in neighborhoods of color which have been disproportionately targeted by "hot spot" and order-maintenance policing practices and policies.

Association of historical redlining and present-day racialised economic segregation with health-care utilisation among individuals with rheumatic conditions in Massachusetts and surrounding areas of the USA: a retrospective cohort study

BACKGROUND

Structural racism lies at the root of inequities; however its impact on rheumatology care is understudied. Redlining was a US federal government-sponsored practice that mapped areas with high concentrations of Black and immigrant residents as hazardous for investment. We aimed to investigate the association of historical redlining and present-day racialised economic segregation, on health-care utilisation among individuals with rheumatic conditions in the US state of Massachusetts and surrounding areas.

METHODS

This retrospective observational cohort study used multihospital data from the Mass General Brigham Research Patient Data Registry to identify individuals aged ≥ 18 years living in Massachusetts and surrounding areas, with two or more International Classification of Diseases codes for a rheumatic condition. Individuals were included if they received care between Jan 1, 2000, and May 1, 2023, at rheumatology practices affiliated with Mass General Brigham (Boston, MA, USA). Addresses were geocoded and overlaid with 1930s Home Owners' Loan Corporation (HOLC) redlining files. The Index of Concentration at the Extremes (ICE) for combined racial and income polarisation was constructed from US Census data. We used multilevel, multinomial logistic regression models to examine the odds of health-care utilisation separately by historical HOLC grade (A [best] to D [hazardous]) and ICE quintile (most deprived [1] to most privileged [5] race and income), adjusting for demographics, insurance, and comorbidities. People with lived experience of a rheumatic condition were not involved in the design or implementation of this study.

FINDINGS

The cohort comprised 5597 individuals; 3944 (70·5%) of 5597 patients were female, 1653 (29·5%) were male, 657 (11·7%) were Black, 224 (4·0%) were Hispanic, and the median age was 63 (50-73) years. 1295 (23·1%) of 5597 individuals lived in the most historically redlined areas (HOLC D) and 1780 (31·8%) lived in areas with the most concentrated present-day racialised economic deprivation (ICE quintile 1). Individuals in historically redlined areas (HOLC D) had greater odds of having four or more missed appointments (odds ratio [OR] 1·78 [95% CI 1·21-2·61]; p=0·0033) and of three or more emergency department visits (2·69 [1·48-4·89]; p=0·0011) compared with those in the most desirable neighbourhoods (HOLC A). Individuals in areas with highly concentrated racial and economic deprivation (ICE quintile 1) had greater odds of four or more missed appointments (OR 2·11 [95% CI 1·65-2·71]; p<0·0001) and of three or more emergency department visits (2·97 [2·02-4·35]; p<0·0001) versus those in areas with highly concentrated privilege (ICE quintile 5).

INTERPRETATION

Historical redlining could be a structural determinant of inequities in present-day health-care utilisation patterns. Policy interventions that dismantle structural racism could reduce inequities in access to care for individuals with rheumatic conditions.

FUNDING

Bristol Myers Squibb Foundation.

Redlining in New York City: impacts on particulate matter exposure during pregnancy and birth outcomes

BACKGROUND

Evidence suggests historical redlining shaped the built environment and health outcomes in urban areas. Only a handful of studies have examined redlining's association with air pollution and adverse birth outcomes in New York City (NYC). Additionally, no NYC-specific studies have examined the impact of redlining on birth weight.

METHODS

This longitudinal cohort study analysed data from the National Institute of Health Environmental Influences on Child Health Outcomes Programme to investigate the extent to which maternal residence in a historically redlined neighbourhood is associated with fine particulate matter (PM2.5) exposure during pregnancy using multivariable regression models. Additionally, we examined how maternal residence in a historically redlined neighbourhood during pregnancy influenced birth weight z-score, preterm birth and low birth weight.

RESULTS

Our air pollution model showed that living in a historically redlined census tract or an ungraded census tract was associated with increased PM2.5 exposure during pregnancy. We also found living in a historically redlined census tract or an ungraded census tract was associated with a lower birth weight z-score. This finding remained significant when controlling for individual and census tract-level race, ethnicity and income. When we controlled PM2.5 in our models assessing the relationship between redlining grade and birth outcome, our results did not change.

DISCUSSION

Our study supports the literature linking redlining to contemporary outcomes. However, our research in ungraded tracts suggests redlining alone is insufficient to fully explain inequality in birth outcomes and PM2.5 levels today.

Impact of being underweight before pregnancy on preterm birth by race/ethnicity and insurance status in California: an analysis of birth records

BACKGROUND

The US still has a high burden of preterm birth (PTB), with important disparities by race/ethnicity and poverty status. There is a large body of literature looking at the impact of pre-pregnancy obesity on PTB, but fewer studies have explored the association between underweight status on PTB, especially with a lens toward health disparities. Furthermore, little is known about how weight, specifically pre-pregnancy underweight status, and socio-economic-demographic factors such as race/ethnicity and insurance status, interact with each other to contribute to risks of PTB.

OBJECTIVES

The objective of this study was to measure the association between pre-pregnancy underweight and PTB and small for gestational age (SGA) among a large sample of births in the US. Our secondary objective was to see if underweight status and two markers of health disparities - race/ethnicity and insurance status (public vs. other) - on PTB.

STUDY DESIGN

We used data from all births in California from 2011 to 2017, which resulted in 3,070,241 singleton births with linked hospital discharge records. We ran regression models to estimate the relative risk of PTB by underweight status, by race/ethnicity, and by poverty (Medi-cal status). We then looked at the interaction between underweight status and race/ethnicity and underweight and poverty on PTB.

RESULTS

Black and Asian women were more likely to be underweight (aRR = 1.0, 95% CI: 1.01, 1.1 and aRR = 1.4, 95% CI: 1.4, 1.5, respectively), and Latina women were less likely to be underweight (aRR = 0.7, 95% CI: 0.7, 0.7). Being underweight was associated with increased odds of PTB (aRR = 1.3, 95% CI 1.3-1.3) and, after controlling for underweight, all nonwhite race/ethnic groups had increased odds of PTB compared to white women. In interaction models, the combined effect of being both underweight and Black, Indigenous and People of Color (BIPOC) statistically significantly reduced the relative risk of PTB (aRR = 0.9, 95% CI: 0.8, 0.9) and SGA (aRR = 1.0, 95% CI: 0.9, 1.0). The combined effect of being both underweight and on public insurance increased the relative risk of PTB (aRR = 1.1, 95% CI: 1.1, 1.2) but there was no additional effect of being both underweight and on public insurance on SGA (aRR = 1.0, 95% CI: 1.0, 1.0).

CONCLUSIONS

We confirm and build upon previous findings that being underweight preconception is associated with increased risk of PTB and SGA - a fact often overlooked in the focus on overweight and adverse birth outcomes. Additionally, our findings suggest that the effect of being underweight on PTB and SGA differs by race/ethnicity and by insurance status, emphasizing that other factors related to inequities in access to health care and poverty are contributing to disparities in PTB.

Systemic racism and Non-Hispanic Black to Non-Hispanic White disparities in infant mortality at the county level

OBJECTIVE

To use a novel measure of systemic racism to examine its relationship with Non-Hispanic Black (NHB) to Non-Hispanic White (NHW) racial disparities in infant mortality across U.S. counties.

STUDY DESIGN

In this cross-sectional study, a composite, multi-dimensional measure of systemic racism at the county level was developed using confirmatory factor analysis based on indicators across five dimensions of systemic racism. Using linear regression analysis, we examined the relationship between the systemic racism factor scores and the NHB to NHW racial disparities in county-level infant mortality rates. Additionally, we performed a multi-level analysis of infant mortality, with births nested within counties by running a random intercept model that controlled for factors at both the individual and county levels to take into account the clustered nature of the data.

RESULTS

There were 325 counties that met inclusion criteria for the county level analysis and 1181 counties for the individual level analysis. Each one standard deviation increase in the Systemic Racism Index was associated with an increase of 10.4% in the Non-Hispanic Black to Non-Hispanic White infant mortality rate ratio at the county level (aOR 1.104, 95% CI [1.061-1.148]). After controlling for individual level clinical factors and county level factors, each one standard deviation increase in the systemic racism index score was associated with a decrease of 3.5% in the NHW infant mortality rate (aOR 0.965, 95% CI [0.943-0.988]).

CONCLUSION

Systemic racism is significantly associated with differences between counties in the magnitude of their Non-Hispanic Black to Non-Hispanic White racial disparities in infant mortality rates.

Enhancing Equity in Genomics: Incorporating Measures of Structural Racism, Discrimination, and Social Determinants of Health

The everyday harms of structural racism and discrimination, perpetuated through institutions, laws, policies, and practices, constitute social determinants of health, but measures that account for their debilitating effects are largely missing in genetic studies of complex diseases. Drawing on insights from the social sciences and public health, we propose critical methodologies for incorporating tools that measure structural racism and discrimination within genetic analyses. We illustrate how including these measures may strengthen the accuracy and utility of findings for diverse communities, clarify elusive relationships between genetics and environment in a racialized society, and support greater equity within genomics and precision health research. This approach may also support efforts to build and sustain vital partnerships with communities and with other fields of research inquiry, centering community expertise and lived experiences and drawing on valuable knowledge from practitioners in the social sciences and public health to innovate biomedical and genomic study designs aimed at community health priorities.

The association between pre-pregnancy and first-trimester hair cortisol and preterm birth: a causal inference model

Adverse life events and chronic psychological distress before and during pregnancy have frequently been associated with preterm birth but the biological underpinnings remain unclear. We investigated the association between corticosteroid levels in pre-pregnancy and first-trimester hair and the risk of preterm birth. We followed N = 1,807 pregnant women from a prospective pre-birth cohort study in Lima, Perú. Hair samples were taken at the end of the first pregnancy trimester. The two most proximal 3 cm segments to the scalp (representing pre-pregnancy and first-trimester) were analyzed to obtain hair cortisol and cortisone concentrations (HCC and HCNC). Preterm birth was defined as birth < 37 completed gestational weeks. We constructed four generalized propensity scores for pre-pregnancy and first-trimester HCC and HCNC to create corresponding inverse probability weights before fitting marginal structural models for estimating the effect of HCC and HCNC on preterm birth risk. Pre-pregnancy Log HCC was not independently associated with preterm birth risk (RR = 0.97; 95%CI: 0.79, 1.19), nor was pre-pregnancy Log HCNC (RR = 0.84; 95%CI: 0.58, 1.20). In the first trimester, a one SD increase in Log HCC was associated with a 37% increased risk of preterm birth (95%CI: 1.11, 1.69), whereas Log HCNC was not significantly associated with preterm birth risk (RR = 1.20; 95%CI: 0.87, 1.65). Our findings show that chronic corticosteroid levels in early pregnancy are causally linked to preterm birth risk in pregnant Peruvian women. This finding contributes to understanding the biological underpinnings of preterm birth better to enhance its prevention.

Impact of neighborhood disadvantage on posttrauma outcomes after sexual assault

In the United States, 8,000,000 people seek emergency care for traumatic injury annually. Motor vehicle collisions (MVCs) and sexual assault are two common sources of trauma, with evidence that reduced neighborhood-level socioeconomic characteristics increase posttraumatic pain and stress after an MVC. We evaluated whether neighborhood disadvantage was also associated with physical and mental posttrauma outcomes after sexual assault in a sample of adult women (N = 656) who presented for emergency care at facilities in the United States following sexual assault and were followed for 1 year. Neighborhood characteristics were assessed via the Area Deprivation Index, and self-reported pain, anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms were collected at 6 weeks posttrauma. Adjusted log-binomial regression models examined the association between each clinical outcome and neighborhood disadvantage. Women in more disadvantaged neighborhoods were more likely to be non-White and have lower annual incomes. At 6 weeks posttrauma, the prevalence of clinically significant pain, anxiety, and depressive symptoms more than doubled from baseline (41.7% vs. 18.8%, 62.4% vs. 23.9%, and 55.2% vs. 22.7%, respectively); 40.7% of women also reported PTSD symptoms. Black, Hispanic, and lower-income participants were more likely to report pre- and postassault pain, anxiety, and depression. After adjusting for race, ethnicity, and income, no significant association existed between neighborhood disadvantage and any outcome, ps = .197 - .859. Although neighborhood disadvantage was not associated with posttrauma outcomes, these findings highlight the need for continued research in diverse populations at high risk of adverse physical and mental health symptoms following sexual assault.

The Legacy of Redlining: Increasing Childhood Asthma Disparities through Neighborhood Poverty

Rationale: Identifying the root causes of racial disparities in childhood asthma is critical for health equity. Objectives: To determine whether the racist policy of redlining in the 1930s led to present-day disparities in childhood asthma by increasing community-level poverty and decreasing neighborhood socioeconomic position (SEP). Methods: We categorized census tracts at the birth address of participants from the Children's Respiratory and Environmental Workgroup birth cohort consortium into categories A, B, C, and D as defined by the Home Owners Loan Corporation, with D being the highest perceived risk. Surrogates of present-day neighborhood-level SEP were determined for each tract, including the percentage of low-income households, the CDC's Social Vulnerability Index, and other tract-level variables. We performed causal mediation analysis, which, under the assumption of no unmeasured confounding, estimates the direct and mediated pathways by which redlining may cause asthma disparities through tract-level mediators adjusting for individual-level covariates. Measurements and Main Results: Of 4,849 children, the cumulative incidence of asthma through age 11 was 26.6%, and 13.2% resided in census tracts with a Home Owners Loan Corporation grade of D. In mediation analyses, residing in Grade-D tracts (adjusted odds ratio = 1.03 [95% confidence interval = 1.01, 1.05]) was significantly associated with childhood asthma, with 79% of this increased risk mediated by percentage of low-income households; results were similar for the Social Vulnerability Index and other tract-level variables. Conclusions: The historical structural racist policy of redlining led to present-day asthma disparities in part through decreased neighborhood SEP. Policies aimed at reversing the effects of structural racism should be considered to create more just, equitable, and healthy communities.

The role of neighborhood on preterm birth among a high-risk group of birthing people in Boston, MA

BACKGROUND

Preterm birth (PTB) is associated with adverse short- and long-term health. There are known racial, ethnic, and socioeconomic inequities in PTB. Because of historical de jure and modern-day de facto segregation and neighborhood divestment, neighborhoods are a source of structural racism and disenfranchisement and a potential target for policies and interventions to reduce PTB inequity. However, the role of neighborhoods on PTB, specifically among high-risk birthing people, is largely unexplored.

METHODS

The Boston Birth Cohort is a longitudinal birth cohort of birthing people-infant dyads at a safety-net hospital in Boston, MA between 2000 and 2018. The primary outcome was preterm birth at 35 weeks or prior. The primary predictor was neighborhood defined by census tract. We used generalized linear mixed effects models to test our hypothesis that neighborhood accounts for a signficiant proportion of PTB risk among socially at-risk birthing people.

RESULTS

In multilevel models, neighborhoods were a significant predictor of preterm birth, yet accounted for only 3% of the variability in outcome. In models stratified by race, individual-level factors such as prior preterm birth, nativity status, and advanced birthing person age were significant predictors of PTB.

CONCLUSIONS

Neighborhood is a significant, though small, predictor of preterm birth in a high-risk birthing population. These findings suggest that individual-level interventions, rather than neighborhood-level policies, may be more effective in reducing preterm birth among high-risk birthing populations.

Associations between historical and contemporary measures of structural racism and leukocyte telomere length: The Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

We assessed the link between two manifestations of structural racism-historical redlining and contemporary racial residential segregation-and baseline and 10-year changes in leukocyte telomere length (LTL).

METHODS

We used data on Black and Hispanic/Latinx participants from Exams I and V of the Multi-Ethnic Study of Atherosclerosis Stress Ancillary Study (N = 741, age range = 45-84 years). LTL was defined as the ratio of telomeric DNA to a single copy gene (T/S), and 10-year changes were adjusted for regression to the mean. We used 1930s Home Owners' Loan Corporation maps to assign three historical redlining grades (A&B: best/still desirable, C: declining, D: hazardous/redlined) to participants' neighborhoods (census-tracts) at baseline. The Getis-Ord Gi∗ statistic was used to evaluate census-tract level baseline residential segregation (low/moderate/high).

RESULTS

In mixed-effects regression models accounting for neighborhood clustering, individual characteristics, and current neighborhood environments, those living in highly segregated Black neighborhoods had 0.08 shorter baseline LTL (95% CI: -0.13, -0.04), than those residing in the least segregated neighborhoods. We did not find a relationship between residing in segregated neighborhoods and 10-year LTL changes, and associations between residing in historically redlined neighborhoods and both baseline LTL and 10-year changes in LTL were null. Across discriminatory disinvestment trajectories examined, individuals residing in highly segregated but non-redlined neighborhoods had 0.6 shorter baseline LTL than individuals residing in non-redlined neighborhoods with low/moderate segregation (95% CI: -0.12, -0.01).

CONCLUSIONS

Our results highlight the impact of racial segregation on cellular aging and underscore the need to ameliorate structural inequities within segregated neighborhoods.

A Review of the Public Health Literature Examining the Roles of Socioeconomic Status and Race/Ethnicity on Health Outcomes in the United States

This review of reviews examines the role of socioeconomic status (SES) indicators on health inequities among different racial and ethnic groups in the United States (US) between 2019 and 2023. Of the 419 articles, 27 reviews met the inclusion criteria and were aggregated into seven categories: COVID-19 and respiratory pandemic disparities; neighborhoods, gentrification, and food environment; surgical treatments; mental, psychological, and behavioral health; insurance, access to care, and policy impact; cancers; and other topics. The findings revealed a documented impact of SES indicators on racial/ethnic health inequities, with racial/ethnic minority communities, especially Black Americans, consistently showing poor health outcomes associated with lower SES, regardless of the outcome or indicator examined. These findings call attention to the importance of policies and practices that address socioeconomic factors and systemic racial/ethnic inequities affecting the social determinants of health affecting racial/ethnic inequities to improve health outcomes in the US population.

Lasting Legacy: The Enduring Relationship Between Racially Restrictive Housing Covenants and Health and Wellbeing

Racially restrictive covenants in housing deeds, commonplace in Minnesota for houses built from the 1910s to the 1950s, provided a foundation for the myriad of policies that made it difficult for people of color to obtain housing. Though covenants were ruled illegal in 1968, their legacy continues to shape neighborhoods. The Mapping Prejudice Project's efforts in Hennepin County, Minnesota, produced the first systematic documentation of racially restrictive covenants. We use this novel data set to explore the relationship between historic covenants and current health and wellbeing outcomes. Using regression analysis to control for neighborhood level covariates, we compare previously covenanted neighborhoods to neighborhoods without covenants. Today, previously covenanted neighborhoods have higher life expectancy and lower rates of obesity, diabetes, coronary heart disease, and asthma than neighborhoods without racially restrictive covenants. Additionally, previously covenanted neighborhoods have less upward mobility for children from poorer households, and there are larger gaps in upward mobility between white and Black children. These findings contribute to a growing literature that shows racist policies, even decades after they are legally enforceable, leave an imprint on neighborhoods. Using the novel data from the Mapping Prejudice Project, we provide statistical analysis that confirms qualitative and anecdotal evidence on the role of racial covenants in shaping neighborhoods.

Racialized environments and syringe services program implementation: County-level factors

OBJECTIVE

Racialized health inequities in substance use-related harms might emerge from differential access to syringe service programs (SSPs). To explore this, we examined the association between county-level racialized environments, other factors, and (1) SSP presence, and (2) per capita syringe and (3) naloxone distribution.

METHODS

2021 US National Survey of SSP data (n=295/412;72 % response rate) was used to identify SSP presence and the sum of syringes and naloxone doses distributed in 2020 by county. Study measures included racial residential segregation (RRS; i.e., divergence and dissimilarity indexes for Black:Non-Hispanic White & Hispanic:Non-Hispanic White) and covariates (i.e., demographic proportions, urban/suburban/rural classifications, 2020 US presidential Republican vote share, and overdose mortality from 2019). We used logit Generalized Estimating Equations to determine factors associated with county-level SSP presence, and zero inflated negative binomial regression models to determine factors associated with per capita syringe and naloxone distribution.

RESULTS

SSPs were reported in 9 % (283/3106) of US counties. SSP presence was associated with higher divergence and dissimilarity indexes, urban and suburban counties, higher opioid overdose mortality, and lower 2020 Republican presidential vote share. Per capita syringes distributed was associated with lower RRS (divergence and Hispanic:White dissimilarity), lower racially minoritized population proportions and rural counties, while per capita naloxone distribution was associated with lower Hispanic and "other" population proportions, and rural counties.

CONCLUSIONS

Racialized environments are associated with SSP presence but not the scope of those programs. Preventing HIV and HCV outbreaks, and overdose deaths requires addressing community level factors that influence SSP implementation and accessibility.

Associations between Historical Redlining and the Risk of Pregnancy Complications and Adverse Birth Outcomes in Massachusetts, 1995-2015

Objective: To assess the impact of historical redlining on the risk of pregnancy complications and adverse birth outcomes in Massachusetts (MA) from 1995 to 2015. Methods: In total, 288,787 pregnant people from the MA Birth Registry had information on parental characteristics, pregnancy factors, and redlining data at parental residences at the time of delivery. Historic redlining data were based on MA Home Owners' Loan Corporation (HOLC) security maps, with grades assigned (A "best," B "still desirable," C "definitely declining," and D "hazardous"). We used covariate-adjusted binomial regression models to examine associations between HOLC grade and each chronic condition and pregnancy/birth outcome. Results: Living in HOLC grades B through D compared with A was associated with an increased risk of entering pregnancy with chronic conditions and adverse pregnancy/birth outcomes. The strongest associations were seen with pregestational diabetes (adjusted risk ratio [RR] Grade D: 1.7, 95% confidence interval [CI]: 1.3, 2.4) and chronic hypertension (adjusted RR Grade D: 1.5, 95% CI: 1.1, 1.9). Conclusions: Historical redlining policies from the 1930s were associated with adverse pregnancy outcomes and chronic conditions; associations were strongest for chronic conditions in pregnancy.

Historical redlining, neighborhood disadvantage, and reports of child maltreatment in a large urban county

BACKGROUND

Child protective services (CPS) reports are spatially concentrated in disadvantaged neighborhoods and Black children are more likely than White children to reside in these neighborhoods. Entrenched patterns of racial residential segregation reflect the lasting impact of historical redlining - a racist practice spearheaded by the federally sponsored Home Owners' Loan Corporation (HOLC) in the 1930s that assigned worst risk grades to minoritized neighborhoods. Research has established links between historically redlined areas and the present-day wellbeing of children and families; however, little is known about the relationship between historical redlining and CPS report rates in neighborhoods.

OBJECTIVE

Using census tracts as a proxy for neighborhood, this study examines the relationship between historical redlining and the number of CPS reports within neighborhoods.

PARTICIPANTS, SETTING, AND METHOD

This study combines data on HOLC risk grades and sociodemographic data from the American Community Survey with the aggregate number of CPS reports per census tract in Los Angeles County, CA (n = 1137).

RESULTS

We used Bayesian conditionally autoregressive models to examine the relationship between historical redlining score (A = 1, B = 2, C = 3, D = 4) and the number of CPS reports within neighborhoods. In the unadjusted model, each unit increase in redlining score is associated with a 21.6 % higher number of CPS reports (95 % CI; 1.140, 1.228). In adjusted models that included concentrated disadvantage, each unit increase in redlining score is associated with a 7.3 % higher number of CPS reports (95 % CI; 1.021, 1.136).

CONCLUSION

Housing policy reforms through a racial equity lens should be considered as a part of a national strategy to prevent child maltreatment.

Methodologic Strategies for Quantifying Associations of Historical and Contemporary Mortgage Discrimination on Population Health Equity: A Systematic Review

BACKGROUND

Mortgage discrimination refers to the systematic withholding of home mortgages from minoritized groups. In recent years, there has been an increase in empirical research investigating associations of historical and contemporary mortgage discrimination on contemporary  outcomes. Investigators have used a variety of measurement methods and approaches, which may have implications for results and interpretation.

PURPOSE

We conducted a systematic review of peer-reviewed literature that has quantified links between both historical and current mortgage discrimination with contemporary adverse environmental, social, and health outcomes. Our goals were to document the methodology used to measure and assign mortgage discrimination, to assess implications for results and interpretation, and to make recommendations for future work.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, literature searches were conducted in September 2022 using terms that combined concepts of mortgage discrimination, health, and neighborhood environment.

RESULTS

In total, 45 papers fit the eligibility criteria. In these, researchers investigated associations between mortgage discrimination and: (1) health outcomes (N = 28); (2) environmental and social exposures including heat, air pollution, greenspace, soil lead levels, and crime (N = 12); and (3) built environment features, including presence of retail alcohol, fast food, and tobacco stores (N = 5). Eleven included studies used Home Mortgage Discrimination Act (HMDA) data to identify racialized bias in mortgage discrimination or redlining, and 34 used Homeowner Loan Corporation (HOLC) maps. The construction and parametrization of mortgage discrimination or redlining and the spatial assignment of HOLC grades to contemporary addresses or neighborhoods varied substantially across studies.

CONCLUSIONS

Results from our review suggest the need for careful consideration of optimal methods to analyze mortgage discrimination such as HOLC spatial assignment or HMDA index parametrization, contemplation of covariates, and place-based knowledge of the study location.

Instruments for racial health equity: a scoping review of structural racism measurement, 2019-2021

Progress toward racial health equity cannot be made if we cannot measure its fundamental driver: structural racism. As in other epidemiologic studies, the first step is to measure the exposure. But how to measure structural racism is an ongoing debate. To characterize the approaches epidemiologists and other health researchers use to quantitatively measure structural racism, highlight methodological innovations, and identify gaps in the literature, we conducted a scoping review of the peer-reviewed and gray literature published during 2019-2021 to accompany the 2018 published work of Groos et al., in which they surveyed the scope of structural racism measurement up to 2017. We identified several themes from the recent literature: the current predominant focus on measuring anti-Black racism; using residential segregation as well as other segregation-driven measures as proxies of structural racism; measuring structural racism as spatial exposures; increasing calls by epidemiologists and other health researchers to measure structural racism as a multidimensional, multilevel determinant of health and related innovations; the development of policy databases; the utility of simulated counterfactual approaches in the understanding of how structural racism drives racial health inequities; and the lack of measures of antiracism and limited work on later life effects. Our findings sketch out several steps to improve the science related to structural racism measurements, which is key to advancing antiracism policies.

Neighborhood Child Opportunity and Preterm Birth Rates by Race and Ethnicity

Importance

In the US, infants born to non-Hispanic Black birthing parents are 50% more likely to be born preterm than those born to non-Hispanic White birthing parents, and individual-level factors do not fully account for this inequity. Neighborhood context, rooted in historic patterns of structural racism, may facilitate understanding patterns of inequity in preterm birth.

Objective

To estimate the association between neighborhood opportunity level, measured by the Child Opportunity Index (COI), and preterm birth among infants in Massachusetts.

Design, Setting, and Participants

In this cross-sectional, population-based study, Massachusetts birth certificates from 3 large metropolitan areas (Boston, Springfield, and Worcester) were linked to US Census tract-level data from the COI, and log binomial regression models and generalized estimating equations were fit to examine associations of different levels of opportunity with preterm birth. Singleton infants born in Massachusetts between February 1, 2011, and December 31, 2015, were included. Analyses were originally conducted in 2019 and updated in 2024.

Exposure

Level of child opportunity (measured by the COI) at the US Census tract level. Race and ethnicity were ascertained from the birth certificate, as reported by the birthing parent.

Main Outcomes and Measures

Live birth before 37 completed weeks' gestation.

Results

The analytic dataset included 267 553 infants, of whom 18.9% were born to Hispanic, 10.1% to non-Hispanic Asian or Pacific Islander, 10.1% to non-Hispanic Black, and 61.0% to non-Hispanic White birthing parents. More than half of infants born to non-Hispanic Black and Hispanic birthing parents were born into very low opportunity neighborhoods, and in crude models, this was associated with greater prevalence of preterm birth relative to very high opportunity neighborhoods (prevalence ratio, 1.44; 95% CI, 1.37-1.52). After adjustment for covariates, infants born into very low opportunity neighborhoods still had a greater prevalence of preterm birth (prevalence ratio, 1.16; 95% CI, 1.10-1.23).

Conclusions and Relevance

In this cross-sectional study of neighborhood opportunity and preterm birth, elevated risk associated with exposure to a very low opportunity neighborhood, coupled with the disproportionate exposure by race and ethnicity, points to a modifiable factor that may contribute to racial and ethnic inequities in preterm birth. Future research should investigate interventions that seek to address neighborhood opportunity.

Historical Redlining, Contemporary Gentrification, and Severe Maternal Morbidity in California, 2005-2018

Importance

Historically redlined neighborhoods may experience disinvestment, influencing their likelihood of gentrification, a process of neighborhood (re-)development that unequally distributes harms and benefits by race and class. Understanding the combined outcomes of redlining and gentrification informs how the mutually constitutive systems of structural racism and racial capitalism affect pregnancy outcomes.

Objective

To examine if historical redlining and contemporary gentrification is associated with increased severe maternal morbidity (SMM) odds.

Design, Setting, and Participants

This cross-sectional study used data from a statewide population-based sample of all live hospital births at 20 weeks' gestation or more between 2005 and 2018 in California. Analysis was conducted from March 2023 to January 2024.

Exposure

Redlining (as characterized by the federal Home Owners' Loan Corporation mortgage security maps) and displacement (using present-day sociodemographic and housing market information).

Main Outcomes and Measures

Mixed-effects logistic regression models were used to assess the association of census tract-level exposure to historical redlining and contemporary gentrification with increased SMM odds, adjusting for sociodemographic and pregnancy related factors. Outcome classification was based on the Centers for Disease Control and Prevention SMM index, which defines SMM as having any of the 21 procedures and diagnoses based on the International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

Results

The study sample included 1 554 837 births (median [SD] maternal age, 29.0 [6.4] years; 3464 American Indian or Alaskan Native [0.2%], 224 774 Asian [14.5%], 132 240 Black [8.5%], 880 104 Hispanic [56.6%], 312 490 White [20.1%]), with 22 993 cases of SMM (1.4%). Residents in historically redlined neighborhoods that were undergoing gentrification or displacement were more likely to be Black, Hispanic, and American Indian or Alaskan Native. Independent of individual-level characteristics, SMM odds were greater for individuals living in redlined neighborhoods that experienced displacement (OR, 1.21; 95% CI, 1.14-1.28) and in redlined neighborhoods undergoing gentrification (OR, 1.21; 95% CI, 1.13-1.29) compared with those in continuously advantaged neighborhoods.

Conclusions and Relevance

Findings from this cross-sectional study demonstrate that the legacies of redlining, intertwined with current dynamics of displacement and gentrification, affect SMM. Place-based sociopolitical mechanisms that inequitably distribute resources may be important intervention points to address structural drivers of adverse pregnancy outcomes and their racial inequities.

Environmental Racism and Child Health

Environmental racism poses a significant threat to child health. It is a major contributor to disproportionate exposure to environmental hazards that are linked to adverse health outcomes. This narrative review shows the profound impact that environmental racism poses to healthy child development through 3 examples. Historical redlining provides compelling evidence of how historical policies continue to influence neighborhoods' physical and social conditions. Exploring chemicals in beauty products reveals how anti-Black perceptions of beauty work to expose children of color to endocrine-disrupting chemicals. Finally, by exploring childhood lead exposure, we see how decades of inequitable implementation of lead exposure prevention policies contribute to persistent disparities in the United States today. Fixing these structural issues is complex and will require political will and investment. Yet, individual clinicians play an important role in their local communities in protecting children from the harms of environmental racism, through education, genuine collaboration with the community, and advocacy.

The Relationships Among Neighborhood Disadvantage, Mental Health and Developmental Disabilities Diagnoses, and Race/Ethnicity in a U.S. Urban Location

Childhood health disparities by race have been found. Neighborhood disadvantage, which may result from racism, may impact outcomes. The aim of the study is to describe the distribution of mental health (MH) and developmental disabilities (DD) diagnosis across Child Opportunity Index (COI) levels by race/ethnicity. A cross-sectional study using 2022 outpatient visit data for children < 18 years living in the Louisville Metropolitan Area (n = 115,738) was conducted. Multivariable logistic regression analyses examined the association between diagnoses and COI levels, controlling for sex and age. Almost 18,000 children (15.5%) had a MH or DD (7,905 [6.8%]) diagnosis. In each COI level, the prevalence of MH diagnosis was lower for non-Hispanic (N-H) Black than for N-H White children. In adjusted analyses, there were no significant associations between diagnoses and COI for non-White children for MH or DD diagnoses. The odds of receiving a MH [OR: 1.74 (95% CI: 1.62, 1.87)] and DD [OR: 1.69 (95% CI: 1.51, 1.88)] diagnosis were higher among N-H White children living in Very Low compared to Very High COI areas. Current findings suggest that COI does not explain disparities in diagnosis for non-White children. More research is needed to identify potential multi-level drivers such as other forms of racism. Identifying programs, policies, and interventions to reduce childhood poverty and link children and families to affordable, family-centered, quality community mental and physical health resources is needed to ensure that families can build trusting relationships with the providers while minimizing stigma.