Structural racism is associated with adverse postnatal outcomes among Black preterm infants

Abstract

Background Structural racism contributes to racial disparities in adverse perinatal outcomes. We sought to determine if structural racism is associated with adverse outcomes among Black preterm infants postnatally. Methods Observational cohort study of 13,321 Black birthing people who delivered preterm (gestational age 22–36 weeks) in California in 2011–2017 using a statewide birth cohort database and the American Community Survey. Racial and income segregation was quantified by the Index of Concentration at the Extremes (ICE) scores. Multivariable generalized estimating equations regression models were fit to test the association between ICE scores and adverse postnatal outcomes: frequent acute care visits, readmissions, and pre- and post-discharge death, adjusting for infant and birthing person characteristics and social factors. Results Black birthing people who delivered preterm in the least privileged ICE tertiles were more likely to have infants who experienced frequent acute care visits (crude risk ratio [cRR] 1.3 95% CI 1.2–1.4), readmissions (cRR 1.1 95% CI 1.0–1.2), and post-discharge death (cRR 1.9 95% CI 1.2–3.1) in their first year compared to those in the privileged tertile. Results did not differ significantly after adjusting for infant or birthing person characteristics. Conclusion Structural racism contributes to adverse outcomes for Black preterm infants after hospital discharge. Impact statement Structural racism, measured by racial and income segregation, was associated with adverse postnatal outcomes among Black preterm infants including frequent acute care visits, rehospitalizations, and death after hospital discharge. This study extends our understanding of the impact of structural racism on the health of Black preterm infants beyond the perinatal period and provides reinforcement to the concept of structural racism contributing to racial disparities in poor postnatal outcomes for preterm infants. Identifying structural racism as a primary cause of racial disparities in the postnatal period is necessary to prioritize and implement appropriate structural interventions to improve outcomes.

Associations Between Maternal Sociodemographics and Hospital Mortality in Newborns With Prenatally Diagnosed Hypoplastic Left Heart Syndrome

“…Perhaps most alarming was the finding that risk of death was 1.8× higher in Black compared with White infants, as well as mediation analyses demonstrating that the majority of the association (>80%) was due to unexplained or unmeasured factors or potentially structural racism described in previous studies of Black neonates. 4 This is particularly concerning, as congenital heart disease studies have found that rates of mortality remain highest in Black patients compared with patients of other races and ethnicities from birth until at least 35 years of age. 5…”

“…Perhaps most alarming was the finding that risk of death was 1.8× higher in Black compared with White infants, as well as mediation analyses demonstrating that the majority of the association (>80%) was due to unexplained or unmeasured factors or potentially structural racism described in previous studies of Black neonates. 4 This is particularly concerning, as congenital heart disease studies have found that rates of mortality remain highest in Black patients compared with patients of other races and ethnicities from birth until at least 35 years of age. 5 Limitations of the study include its retrospective design, the inability to completely control for center characteristics or to determine maternal health during pregnancy, and limited assessment of the social determinants of health potentially driving demonstrated disparities in birth outcomes.…”

Epidemiologic, Public Health, and Clinical Implications of Death Among Preterm Infants in the US

“…Specifically, combined high genetic and area-level socioeconomic risk was associated with more than 3-fold increased prevalence of obesity and more than 8-fold increased prevalence of type 2 diabetes. 15 These results point to the notion that cardiometabolic outcomes are the result of both genetic and socioeconomic exposures. Epigenetic factors are likely involved in this interplay.…”

“…Obstetricians and midwives should optimize maternal care and neonatologists and pediatricians should optimize preterm infant care, but these efforts will be insufficient to maximize preterm infant mortality prevention. Achievement of population-level improvements in outcomes will require investment in population-level interventions . Neighborhood and community programs to improve environmental, social, and economic conditions for families, with extra emphasis on systematically disadvantaged, disproportionately Black communities, will be required to drive down preterm birth rates, infant mortality among preterm infants, and racial disparities in these outcomes.…”

“…Achievement of population-level improvements in outcomes will require investment in population-level interventions. 14,15 Neighborhood and community programs to improve environmental, social, and economic conditions for families, with extra emphasis on systematically disadvantaged, disproportionately Black communities, will be required to drive down preterm birth rates, infant mortality among preterm infants, and racial disparities in these outcomes.…”