STRATEGIES TO ELIMINATE RACIAL DISPARITIES IN MATERNAL HEALTH: EXAMINING THE ROLE OF PRECONCEPTION, INTERPREGNANCY, AND POSTPARTUM CHRONIC DISEASE RISK FACTORS, PATIENT EXPERIENCE, AND PROGRAM POLICY-- THROUGH A RACIAL JUSTICE LENS.

Background and Significance: In the United States, cardiovascular conditions are the leading cause of maternal morbidity and mortality. Black women are disproportionally affected. Compared to white women, Black women have higher incidence of pre-pregnancy cardiometabolic risk factors and related cardiometabolic complications during pregnancy (e.g., preeclampsia, gestational diabetes mellitus), which in turn increase the risk of postpartum cardiometabolic disease and contributes to disparities in long term cardiovascular health. Preconception and postpartum risk stratification and management of chronic disease (especially cardiometabolic risk factors) can improve subsequent pregnancy outcomes and reduce maternal health disparities. However, much of the discourse on maternal health disparities focuses on obstetric care and pregnancy, with less attention given to health and experiences before, after, and in between pregnancies, or how pregnancy—as a critical life event influences future health. For Black women, decreased access to or utilization of healthcare before, during, and after pregnancy, social determinants of health that influence chronic disease (e.g., access to healthy food), and differences in quality and experiences of care at both institutional and individual levels additionally contribute to these disparities. There is also growing consensus that racism is a root cause of maternal health disparities (and the aforementioned downstream factors) that must be named, interrogated, and addressed when inquiry aims to advance health equity. Purpose: This three paper dissertation seeks to evaluate novel opportunities to eliminate racial disparities in maternal health by 1) identifying preconception, interpregnancy, and postpartum chronic disease risk factors for cardiometabolic complications of pregnancy among racially and ethnically diverse women 2) applying critical race feminism and intersectionality to explore barriers and facilitators to postpartum primary care utilization among Black women with cardiovascular disease risk and 3) systematically reviewing the evidence related to a food and nutrition safety net program and associations with maternal and child health outcomes. Summary of Studies: The first paper is a quantitative examination of chronic disease influences on maternal morbidity, with a focus on preeclampsia. Using a high risk racially and ethnically diverse cohort (N=618), we examined the association between cardiometabolic risk factors and preeclampsia across two pregnancies. We found that obesity and chronic hypertension are modifiable risk factors that impact incident and recurrent preeclampsia risk. The second paper is a qualitative exploration of barriers and facilitators to postpartum primary care utilization and how cultural, social, and historical contexts influence postpartum primary care utilization among 18 Black mothers with cardiometabolic risk factors. We found that the concept of postpartum primary care is not well known and that racism while not always explicitly articulated, is a present factor shaping health care interactions. We also found that patient-provider communication, particularly individuation, patient centered care, trust, and belief, improve the care experience. In the third paper, we conducted a systematic review of the association between the Special Supplemental Nutrition Program for Women, Infants and Children and maternal and child health outcomes. We found that WIC is associated with improved birth outcomes, lower infant mortality, and increased child preventive care and may be associated with achieving recommended gestational weight gain. Conclusion: Advancing maternal health equity requires an exploration of intersecting biological, psychological, and social-environmental factors. Considering preventative health, particularly management of chronic disease, centering patient experience—including experiences of structural and interpersonal racism and advocating for programs and policies that address upstream determinants of health are essential targets for future research