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The disparity between black and white infant mortality rates increased over the last decade, despite overall improvement in infant survival. Because most black infant deaths are related to preterm delivery, the discovery of the cause of premature birth in general and excess premature birth for black infants in particular is of paramount importance for reproductive health research. Substantial theoretic support exists for maternal stress as a risk factor for preterm birth. Traumatic events early in life may sensitize the adult to contemporary stresses and increase her vulnerability to stress-induced neuroendocrine or infection/inflammatory pathways to early parturition. In addition, an individual may prematurely age as a result of cumulative stress or a major traumatic event. This "stress age," which is synonymous with the concept of weathering and similar to the concept of allostatic load, may affect parturition through chronic conditions (such as hypertension) and in poorly understood pathophysiologic mechanisms that are related to increased chronologic age. One potential measure of stress age is maternal serum dehydroepiandrosterone sulfate. Maternal stress is a potential explanatory factor for excess preterm delivery among black women because of their exposure to racism-associated stress. However, few studies have addressed this question, and results are mixed. Future etiologic research must take into account the complexities of the measurement of stress age and past and current exposures to stress, which includes internalized racism and interpersonal racism.

BACKGROUND School‐based health centers (SBHCs) provide opportunities for offering quality service to underserved populations. The objectives of this study were to: (1) document the SBHC process at different locations and evaluate their similarities and differences; (2) explore SBHC clinic staff satisfaction; and (3) identify facilitators and barriers to utilizing SBHCs. METHODS: Three Georgia SBHCs located in either predominantly Caucasian, African American, or Hispanic elementary schools were included in this study. Mixed methods data collection efforts included: (1) observational assessment of each SBHC; (2) interviews with 7 clinic administrators and staff; and (3) focus group discussions (N = 5) with parents of children that do and do not utilize SBHCs. RESULTS: Observational assessments indicated some clinics have more resources available than others. In‐depth interviews found that centers are functioning at capacity, with potential for expansion and greater workload. Focus groups revealed that parents are satisfied with services provided, the price of the care, and the convenience of the centers. However, barriers have made utilization difficult for lower income families. CONCLUSIONS: Although most SBHC goals are being met, staff realize that further development and funding must be obtained to meet the needs of their communities. [ABSTRACT FROM AUTHOR]

Complement activation is essential for select physiologic processes during pregnancy; however, excess activation has been associated with an increased risk for preterm birth (PTB). African American (AA) women experience disproportionately higher rates of inflammation-associated PTB than other groups of women; thus, the purpose of this study was to explore the relationship between complement activation and perinatal outcomes among AA women. A plasma sample was collected between 8 and 14 weeks' gestation from a cohort of healthy AA women (N= 144) enrolled in a larger PTB cohort study. Medical record review was conducted to collect information on clinical factors (cervical length, health behaviors, gestational age at delivery). Multiple regression analysis was used to explore the relationships between complement marker (C3a/Bb) concentrations and the outcomes of interest after adjusting for baseline characteristics. C3a/Bb concentrations were not significant predictors of the gestational age at delivery, cervical length, or behavioral risk factors for PTB in this sample. Complement markers may not influence pregnancy outcomes among AA women in the same way as in predominantly white populations; however, more studies are needed to define complement dysregulation and the relationship with outcomes among AA women. [ABSTRACT FROM AUTHOR]

Objectives The association of stress with pregnancy health is well-known. However, few studies take a mixed methods approach to understand the stressors contributing to a woman’s pregnancy-related stress. Among African American women, exposure to stressors during pregnancy likely contributes to disparities in pregnancy health outcomes. This work aimed to understand the types and magnitude of stressors African American women are exposed to during pregnancy. Methods Using a mixed methods research design, we developed and administered the Healthy Pregnancy Stress Scale to measure stressors within the stress environment of African American women living in poverty. Results Exploratory factor analysis with one random split-half sample (N = 85) identified a two-factor model. Factor 1, defined as general pregnancy stressors, had significant loadings for ten items that ranged in magnitude from 0.319 to 0.724. Factor 2, defined as relationship strain, had significant loadings for three items ranging in magnitude from 0.613 to 0.856. Confirmatory factor analysis in the second random split-half sample (N = 88) showed a strong fit for the two factor model with factor loadings similar in magnitude. Standard fit statistics and those that adjust for item non-normality suggested an adequate fit to the data (RMSEA = 0.057, CFI = 0.947, TLI = 0.932; Satorra-Bentler RMSEA = 0.037, CFI = 0.972, TLI = 0.965). Conclusions for Practice Our measurement tool may provide a way to determine differences in pregnancy stress experiences across diverse populations of women. Future research should include a test for construct validity by correlating the scale with other measures that should have a specific directional relationship in diverse populations. [ABSTRACT FROM AUTHOR]

Preterm birth (PTB, <37 completed weeks' gestation) is one of the leading obstetrical problems in the United States, affecting approximately one of every nine births. Even more concerning are the persistent racial disparities in PTB, with particularly high rates among African Americans. There are several recognized pathophysiologic pathways to PTB, including infection and/or exaggerated systemic or local inflammation. Intrauterine infection is a causal factor linked to PTB thought to result most commonly from inflammatory processes triggered by microbial invasion of bacteria ascending from the vaginal microbiome. Trials to treat various infections have shown limited efficacy in reducing PTB risk, suggesting that other complex mechanisms, including those associated with inflammation, may be involved in the relationship between microbes, infection, and PTB. The complement system, a key mediator of the inflammatory response, is an innate defense mechanism involved in both normal physiologic processes that occur during pregnancy implantation and processes that promote the elimination of pathogenic microbes. Recent research has demonstrated an association between this system and PTB. The purpose of this article is to present a mechanistic model of inflammation-associated PTB, which hypothesizes a relationship between the microbiome and dysregulation of the complement system. Exploring the relationships between the microbial environment and complement biomarkers may elucidate a potentially modifiable biological pathway to PTB. [ABSTRACT FROM AUTHOR]

A life course conceptual framework for MCH research demands new tools for understanding population health and measuring exposures. We propose a method for measuring population-based socio-environmental trajectories for women of reproductive age. We merged maternal longitudinally-linked births to Georgia-resident women from 1994 to 2007 with census economic and social measures using residential geocodes to create woman-centered socio-environmental trajectories. We calculated a woman's neighborhood deprivation index (NDI) at the time of each of her births and, from these, we calculated a cumulative NDI. We fit Loess curves to describe average life course NDI trajectories and binomial regression models to test specific life course theory hypotheses relating cumulative NDI to risk for preterm birth. Of the 1,815,944 total live births, we linked 1,000,437 live births to 413,048 unique women with two or more births. Record linkage had high specificity but relatively low sensitivity which appears non-differential with respect to maternal characteristics. Georgia women on average experienced upward mobility across the life course, although differences by race, early life neighborhood quality, and age at first birth produced differences in cumulative NDI. Adjusted binomial models found evidence for modification of the effect of history of prior preterm birth and advancing age on risk for preterm birth by cumulative NDI. The creation of trajectories from geocoded maternal longitudinally-linked vital records is one method to carry out life course MCH research. We discuss approaches for investigating the impact of truncation of the life course, selection bias from migration, and misclassification of cumulative exposure. [ABSTRACT FROM AUTHOR]

Stillbirths (fetal deaths occurring at ≥20 weeks' gestation) are approximately equal in number to infant deaths in the United States and are twice as likely among non-Hispanic black births as among non-Hispanic white births. The causes of racial disparity in stillbirth remain poorly understood. A population-based case-control study conducted by the Stillbirth Collaborative Research Network in 5 US catchment areas from March 2006 to September 2008 identified characteristics associated with racial/ethnic disparity and interpersonal and environmental stressors, including a list of 13 significant life events (SLEs). The adjusted odds ratio for stillbirth among women reporting all 4 SLE factors (financial, emotional, traumatic, and partner-related) was 2.22 (95% confidence interval: 1.43, 3.46). This association was robust after additional control for the correlated variables of family income, marital status, and health insurance type. There was no interaction between race/ethnicity and other variables. Effective ameliorative interventions could have a substantial public health impact, since there is at least a 50% increased risk of stillbirth for the approximately 21% of all women and 32% of non-Hispanic black women who experience 3 or more SLE factors during the year prior to delivery. [ABSTRACT FROM PUBLISHER]

Objective: We seek to expand on a biopsychosocial framework underlying the etiology of excess preterm birth experienced by African-American women by exploring short inter-pregnancy intervals as a partial explanatory factor.Design: We conducted a qualitative analyses of published studies that met specified criteria for assessing the association of inter-pregnancy interval and preterm birth.Methods: We determine whether inter-pregnancy interval is associated with preterm birth, what the underlying causal mechanism may be, whether African-American women are more likely than Caucasian women to have short intervals, and whether achieving an optimal interval will result in reduced African-American-Caucasian gap in preterm births.Main Outcome Measures: Crude and adjusted odds ratios for preterm birth, with the referent group being the interval closest to the 'ideal' of 18-23 months and the exposed group having intervals <12 months or some subset of that inter-pregnancy interval. Results. Inter-pregnancy interval less than six months increases preterm birth by about 40%. The mechanism may be through failure to replenish maternal nutritional stores. While there may not be an interaction between race and short inter-pregnancy interval, short intervals can explain about 4% of the African-American-Caucasian gap in preterm birth because African-American women are approximately 1.8 times as likely to have inter-pregnancy intervals of less than six months. Limited studies indicate that optimal intervals can be achieved through appropriate counseling and health care.Conclusions: Excess risk for preterm birth may be reduced by up to 8% among African-Americans and up to 4% among Caucasians through increasing inter-pregnancy intervals to the optimal length of 18-23 months. [ABSTRACT FROM AUTHOR]

Objective: To give an overview of the literature for evidence of nutrient deficiencies as contributors to the disparity in preterm birth (PTB) between African-American and Caucasian women.Design: Structured literature survey.Methods: We searched MEDLINE to identify observational and experimental studies that evaluated the relation between nutrient intake and/or supplementation and PTB. For nutrients for which studies supported an association, we searched MEDLINE for studies of the prevalence of deficiency in the USA by race.Main Outcome Measures: Summarized findings on nutrients for which there is both evidence of a role in PTB and variability in the prevalence of deficiency by race.Results: Nutrient deficiencies for which there are varying levels of evidence for an association with PTB and a greater burden among African-American compared with Caucasian women include deficiencies of iron, folic acid, zinc, vitamin D, calcium and magnesium, and imbalance of ω-3 and ω-6 polyunsaturated fatty acids. There are inadequate high-quality studies that investigate the role of nutrient deficiencies in PTB, their potential interaction with other risks, the proportion of excess risk for which they account, and whether supplementation can reduce the risk of, and racial disparities in, PTB in US populations.Conclusion: Deficiencies of several nutrients have varying levels of evidence of association with PTB and are of greater burden among African-American compared with Caucasian women. Although further research is needed, strategies that improve the nutritional status of African-American women may be a means of addressing a portion of the racial disparity in PTB. [ABSTRACT FROM AUTHOR]

Background: Average daily steps (ADS) are a low-technology measurement of activity that is useful for exercise prescription. However, research demonstrates poor validity for ADS as a measure of exercise capability. We present a superior low-technology measure of exercise capability, which is easily applied by practitioners in clinical or nonclinical settings. Methods: Based on analysis of baseline data from an intervention study to test a sustainable approach to long-term physical activity improvement for employed African American women, between 2005 and 2008, we examined exercise tolerance metabolic equivalents (METs) and ADS of 158 participants and generated an alternative measure of exercise capacity. We conducted regression analysis to determine the impact of key health indicators on exercise capacity and examined associations between our predictive model and true (MET) exercise performance. Results: Using our predictive equation, 79.33% of participants were correctly categorized (very high, high, medium) based on our tool, with 10 women (6.67%) mischaracterized by one level higher than actual MET achievement and 21(14.00%) mischaracterized as one category lower than actual MET achievement. In contrast, using ADS alone resulted in 22.15% correctly categorized participants. Conclusions: The proposed tool is superior to existing low-technology measures of exercise capacity while retaining strong utility in nonclinical and low-resource settings. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility-wide vaccination strategies than in residents of facilities without vaccination strategies. DESIGN: Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey. SETTING: One thousand one hundred seventy-four participating nursing homes sampled systematically with probability proportional to bed size. PARTICIPANTS: Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004. MEASUREMENTS: Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility-level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels. RESULTS: Overall in the Untied States, vaccination coverage was higher for Caucasian and African-American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations ( P=.14), verbal consent allowed for vaccinations( P=.39), and routine review of facility-wide vaccination rates ( P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high ( P=.009, P=.002, and P=.002, respectively). CONCLUSION: The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African-American residents, narrowing the national vaccination racial gap. [ABSTRACT FROM AUTHOR]

In birth certificate data for Massachusetts resident births from 1978 to 1982, 12-27% of births purportedly under 31 weeks of gestation were probably misclassified, i.e. had birthweight greater than or equal to 2500 g. Correcting for maldistribution of births removed 34% and 23%, respectively, of black and white births with reported gestational ages less than 36 weeks but with implausible weights. Percentages of unknown and incomplete reports of last menstrual period were also significantly higher for blacks. After adjustment, preterm black infants weighed less than whites at each gestational age. The proportion of infants less than 2500 g born at term (greater than or equal to 37 weeks gestation) was higher (although not significantly) among blacks. These findings are consistent with hypotheses that low socioeconomic status negatively affects the rate of intrauterine growth. [ABSTRACT FROM AUTHOR]

Introduction: This study measures effects on the receipt of preventive care among children enrolled in Georgia's Medicaid or Children's Health Insurance Program associated with the implementation of new elementary school-based health centers. The study sites differed by geographic environment and predominant race/ethnicity (rural white, non-Hispanic; black, small city; and suburban Hispanic).Methods: A quasi-experimental treatment/control cohort study used Medicaid/Children's Health Insurance Program claims/enrollment data for children in school years before implementation (2011-2012 and 2012-2013) versus after implementation (2013-2014 to 2016-2017) of school-based health centers to estimate effects on preventive care among children with (treatment) and without (control) access to a school-based health center. Data analysis was performed in 2017-2019. There were 1,531 unique children in the treatment group with an average of 4.18 school years observed and 1,737 in the control group with 4.32 school years observed. A total of 1,243 Medicaid/Children's Health Insurance Program-insured children in the treatment group used their school-based health centers.Results: Significant increases in well-child visits (5.9 percentage points, p<0.01) and influenza vaccination (6.9 percentage points, p<0.01) were found for children with versus without a new school-based health center. This represents a 15% increase from the pre-implementation percentage (38.8%) with a well-child visit and a 25% increase in influenza vaccinations. Increases were found only in the 2 school-based health centers with predominantly minority students. The 18.7 percentage point (p<0.01) increase in diet/counseling among obese/overweight Hispanic children represented a doubling from a 15.3% baseline.Conclusions: Implementation of elementary school-based health centers increased the receipt of key preventive care among young, publicly insured children in urban areas of Georgia, with potential reductions in racial and ethnic disparities. [ABSTRACT FROM AUTHOR]

Abstract: Residential isolation segregation (a measure of residential inter-racial exposure) has been associated with rates of preterm birth (<37 weeks gestation) experienced by Black women. Epidemiologic differences between very preterm (<32 weeks gestation) and moderately preterm births (32–36 weeks) raise questions about whether this association is similar across gestational ages, and through what pathways it might be mediated. Hierarchical Bayesian models were fit to answer three questions: is the isolation-prematurity association similar for very and moderately preterm birth; is this association mediated by maternal chronic disease, socioeconomic status, or metropolitan area crime and poverty rates; and how much of the geographic variation in Black–White very preterm birth disparities is explained by isolation segregation? Singleton births to Black and White women in 231 U.S. metropolitan statistical areas in 2000–2002 were analyzed and isolation segregation was calculated for each. We found that among Black women, isolation is associated with very preterm birth and moderately preterm birth. The association may be partially mediated by individual level socioeconomic characteristics and metropolitan level violent crime rates. There is no association between segregation and prematurity among White women. Isolation segregation explains 28% of the geographic variation in Black–White very preterm birth disparities. Our findings highlight the importance of isolation segregation for the high-burden outcome of very preterm birth, but unexplained excess risk for prematurity among Black women is substantial. [Copyright &y& Elsevier]