Assessing the association of county-level structural racism and social and economic deprivation with women’s prenatal care utilization and adverse birth outcomes

There is a growing body of research showing community- and state-level indicators of structural racism and social and economic deprivation are associated with prenatal care utilization and adverse birth outcomes among African American women. However, even after controlling for individual characteristics and community poverty, racial inequities in prenatal care utilization and adverse birth outcomes are still present. There is limited research on the effect of structural racism and social and economic deprivation when measured at the county-level on adverse birth outcomes. This study contributes to previous research by using a novel conceptualization and measurement of structural racism and social and economic deprivation to better understand racial inequities in prenatal care utilization and adverse birth outcomes. Cross-sectional birth record data (2009-2013) from women residing in California (n= 531,170) were linked to county-level data gathered from the American Community Survey (2009-2013) to conduct multilevel analyses. This study was guided by the ecosocial theory and was centered on examining the association of exposures to structural racism (e.g., residential segregation and African American and White ratios in political participation) and embodied racial inequities in adverse birth outcomes between African American and White women through two mediated pathways: (1) social and economic deprivation, and (2) prenatal care utilization. Outcome variables in this study were infants’ birth weight (measured in grams) and gestational age (measured in weeks). Women receiving less than adequate prenatal care (i.e., initiating prenatal care after the first trimester and attending 79% or less of recommended appointments) served as a secondary outcome variable. Structural racism was measured by residential segregation indices (i.e., dissimilarity, isolation, and concentration) and African American and White ratios in the number of persons incarcerated for felonies and in board of supervisor positions at the county-level. Social and economic deprivation was measured by two African American to White ratios: in having a professional and/or management job, and in having a high school diploma or higher at the county-level. Chapters 4 and 5 are two papers included in this dissertation that sought to answer the following research questions: (1) Are both traditional and novel indicators of county-level structural racism associated with adverse birth outcomes among African American and White women?; (2) Do both traditional and novel measures of county-level structural racism account for racial inequities seen in adverse birth outcomes among African American and White women?; and (3) Do county-level indicators of social and economic deprivation account for racial inequities seen in African American and White women’s prenatal care utilization? Among women included in the study sample, African American women birthed infants of lower average birth weight and earlier average gestational age, with corresponding higher percentages of infants meeting criteria for low birth weight and preterm birth in comparison to White women. Additionally, African American women, compared to White women, were more likely to have less than adequate prenatal care utilization. Traditional indicators of structural racism (i.e., isolation and dissimilarity) were associated with African American and White women’s infants’ birth weight and gestational age, after controlling for individual characteristics and county-level poverty. There was a significant interaction between race (i.e., African American) and traditional indicators of structural racism (i.e., isolation) with infants’ gestational age, where African American women who lived in counties with high isolation birthed infants at earlier gestational ages. The main effect of race on infants’ birth weight and gestational age remained significant across all models. Novel indicators of structural racism were associated with infants’ birth weight among both African American and White women. There were no statistically significant interactions between race and novel indicators of structural racism with infants’ birth weight. Only one indicator of social and economic deprivation was associated with women’s prenatal care utilization, adjusting for individual characteristics and county-level poverty. Findings indicate increasing the number of African Americans by one to every 100 Whites in professional jobs at the county-level, increased women’s likelihood of having less than adequate prenatal care by 1.03 odds. Race remained significant after accounting for individual-level factors and county poverty; however, there were no significant interactions between race and African American to White ratios in professional jobs. Findings from this study highlight the utility of county-level measures of structural racism and social and economic deprivation in understanding factors related to prenatal care utilization and adverse birth outcomes among African American and White women. Future studies should examine more comprehensive approaches to measure structural racism and social and economic deprivation to better understand the structural influences affecting racial inequities in prenatal care utilization and adverse birth outcomes