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The National Institutes of Healths (NIH) Pathways to Prevention panel on postpartum health provides a consensus statement on the evidence, research gaps, and future priorities to prevent maternal morbidity and mortality. The panel reviewed an NIH-commissioned evidence review and workshop that included epidemiologic studies, demonstration interventions, and other maternal morbidity and mortality research to create these national recommendations. The panel concludes that a maternal morbidity and mortality crisis reflects a systemic failure of current U.S. health care, research efforts, and social policies. The panel recommends improving maternal health through a maternal morbidity and mortality prevention moonshot that adopts a comprehensive, multilevel life course conceptual framework; strengthens the research methods used within the science of maternal health; establishes and conducts national prevention, treatment, and policy interventions; and reimburses evidence-informed clinical approaches to improve maternal health across the life course. Without a national focus on fundamentally transformative interventions and other initiatives aimed at redressing structural racism and inequities in health care, current interventions and clinical advances in maternal morbidity and mortality prevention will remain tragically insufficient.

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparitys social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a womans microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black

BackgroundAssess the associations between ten severe maternal hardships and food insecurity experienced during pregnancy.MethodsData on 14,274 low-income/lower-income women (below 400% of the income to federal poverty guideline ratio) from the statewide-representative 2010-2012 California Maternal and Infant Health Assessment were used to estimate food security status prevalence. Prevalence of severe maternal hardships by food security status was estimated. Multinomial logistic regression was used to assess the associations between severe maternal hardship and food security status, adjusting for sociodemographic characteristics.ResultsFood insecurity was common among low- and lower-income pregnant women in California; 23.4% food insecure and an additional 11.5% marginally secure. In adjusted analysis, nine of ten hardships were associated with food security status. Only the respondent or someone close to the respondent having a problem with alcohol or drugs was not associated with food security status after adjusting for socioeconomic factors. Husband/partner losing a job, depressive symptoms, not having practical support and intimate partner violence were consistently associated with marginal, low and very low food security status. Each additional severe maternal hardship a woman experienced during pregnancy was associated with a 36% greater risk of reporting marginal food security (Relative Risk Ratio 1.36, 95% CI: 1.27, 1.47), 54% for low food security (Relative Risk Ratio 1.54, 95% CI: 1.44, 1.64), and 99% for very low food security (Relative Risk Ratio 1.99, 95% CI: 1.83, 2.15).ConclusionsFood security status was strongly linked with several maternal hardships that could jeopardize maternal and/or infant health. Services-including prenatal care and nutritional assistance-for a large proportion of pregnant women should address a wide range of serious unmet social needs including food insecurity.

The guide is based on project reports by the San Francisco Department of Public Health to improve and monitor perinatal health and children's health. These reports demonstrated the potential of information to help community advocacy groups, service providers, and program planners identify priorities for policy decisions and resource allocation. The first section, "Getting Started," outlines a general strategy for approaching the task of gathering information and suggests different ways of defining a target population. The second section, "Choosing Indicators," provides guidance on what information and indicators to search for. Section three, entitled, "Selecting Data Sources," guides the user in finding the sources for the information one chooses to seek. The fourth section details "Getting Data and Getting Help," and offers tips on acquiring information and working with technical advisors to analyze and interpret the data through such avenues as the Freedom of Information Act. The fifth section addresses effective display of information in "Presenting Information." The final section provides transferable techniques used in other countries of the Americas to involve community members in monitoring health needs. Four appendices provide information on: (1) maternal and child health objectives for the year 2000; (2) state sources of hospital level data; (3) U.S. standard vital records forms such as certificates of live birth and death and reports of induced termination of pregnancy and fetal death; and (4) names and addresses of state registrars of vital statistics and state health statistics offices. (Author/SD)

Background/objectivesLittle is known about the separate or combined effects of state and national nutrition policies regulating food and beverages in schools on child overweight/obesity (OV/OB) and related racial/ethnic disparities. We investigated the influence of school nutrition policies enacted in California, independently and in combination with the United States' national policy "Healthy Hunger Free Kids Act" (HHFKA) on childhood OV/OB and racial/ethnic disparities.Subjects/methodsAn interrupted time series design was used with data from 12,363,089 child-level records on 5th- and 7th-graders in California public schools to estimate sex- and racial/ethnic-specific time trends in OV/OB prevalence during three periods: before the California nutrition policies (2002-2004); when only California policies were in effect (2005-2012); and when they were in effect simultaneously with HHFKA (2013-2016).ResultsBefore the state's policies, OV/OB prevalence increased annually among children in most subgroups. Improvements in OV/OB trends were observed for almost all groups after the California policies were in effect, with further improvements after the addition of HFFKA. The total change in annual log-odds of OV/OB, comparing the periods with both state and federal policies versus no policies, ranged from -0.08 to -0.01 and varied by grade, sex, and race/ethnicity. Within each sex and grade, the greatest changes were among African-American (-0.08 to -0.02, all p < 0.05) followed by Latino children (-0.06 to -0.01, all p < 0.05). Although disparities narrowed among these groups versus White children after the dual policy period, disparities remained large.ConclusionsState and national nutrition policies for schools may have contributed to containing the upward trend in childhood OV/OB and racial/ethnic OV/OB disparities within California. However, sizable OV/OB prevalence and disparities persist. To end the epidemic, promote healthy weight and increase health equity

OBJECTIVES:The causes of the large and persistent Black-White disparity in preterm birth (PTB) are unknown. It is biologically plausible that chronic stress across a woman's life course could be a contributor. Prior research suggests that chronic worry about experiencing racial discrimination could affect PTB through neuroendocrine, vascular, or immune mechanisms involved in both responses to stress and the initiation of labor. This study aimed to examine the role of chronic worry about racial discrimination in Black-White disparities in PTB. METHODS:The data source was cross-sectional California statewide-representative surveys of 2,201 Black and 8,122 White, non-Latino, U.S.-born postpartum women with singleton live births during 2011-2014. Chronic worry about racial discrimination (chronic worry) was defined as responses of "very often" or "somewhat often" (vs. "not very often" or "never") to the question: "Overall during your life until now, how often have you worried that you might be treated or viewed unfairly because of your race or ethnic group?" Prevalence ratios (PRs) with 95% Confidence Intervals (CI) were calculated from sequential logistic regression models, before and after adjustment for multiple social/demographic, behavioral, and medical factors, to estimate the magnitude of: (a) PTB risks associated with chronic worry among Black women and among White women; and (b) Black-White disparities in PTB, before and after adjustment for chronic worry. RESULTS:Among Black and White women respectively, 36.9 (95% CI 32.9-40.9) % and 5.5 (95% CI 4.5-6.5) % reported chronic worry about racial discrimination; rates were highest among Black women of higher income and education levels. Chronic worry was significantly associated with PTB among Black women before (PR 1.73, 95% CI 1.12-2.67) and after (PR 2.00, 95% CI 1.33-3.01) adjustment for covariates. The unadjusted Black-White disparity in PTB (PR 1.59, 95%CI 1.21-2.09) appeared attenuated and became non-signifi

Coal and oil power plant retirements reduce air pollution nearby, but few studies have leveraged these natural experiments for public health research. We used California Department of Public Health birth records and US Energy Information Administration data from 2001-2011 to evaluate the relationship between the retirements of 8 coal and oil power plants and nearby preterm (gestational age of <37 weeks) birth. We conducted a difference-in-differences analysis using adjusted linear mixed models that included 57,005 births-6.3% of which were preterm-to compare the probability of preterm birth before and after power plant retirement among mothers residing within 0-5 km and 5-10 km of the 8 power plants. We found that power plant retirements were associated with a decrease in the proportion of preterm birth within 5 km (-0.019, 95% CI: -0.031, -0.008) and 5-10 km (-0.015, 95% CI: -0.024, -0.007), controlling for secular trends with mothers living 10-20 km away. For the 0-5-km area, this corresponds to a reduction in preterm birth from 7.0% to 5.1%. Subgroup analyses indicated a potentially larger association among non-Hispanic black and Asian mothers than among non-Hispanic white and Hispanic mothers and no differences in educational attainment. Future coal and oil power plant retirements may reduce preterm birth among nearby populations.

Coal and oil power plant retirements reduce air pollution nearby, but few studies have leveraged these natural experiments for public health research. We used California Department of Public Health birth records and US Energy Information Administration data from 2001-2011 to evaluate the relationship between the retirements of 8 coal and oil power plants and nearby preterm (gestational age of <37 weeks) birth. We conducted a difference-in-differences analysis using adjusted linear mixed models that included 57,005 births-6.3% of which were preterm-to compare the probability of preterm birth before and after power plant retirement among mothers residing within 0-5 km and 5-10 km of the 8 power plants. We found that power plant retirements were associated with a decrease in the proportion of preterm birth within 5 km (-0.019, 95% CI: -0.031, -0.008) and 5-10 km (-0.015, 95% CI: -0.024, -0.007), controlling for secular trends with mothers living 10-20 km away. For the 0-5-km area, this corresponds to a reduction in preterm birth from 7.0% to 5.1%. Subgroup analyses indicated a potentially larger association among non-Hispanic black and Asian mothers than among non-Hispanic white and Hispanic mothers and no differences in educational attainment. Future coal and oil power plant retirements may reduce preterm birth among nearby populations.

The fields of health equity and human rights have different languages, perspectives, and tools for action, yet they share several foundational concepts. This paper explores connections between human rights and health equity, focusing particularly on the implications of current knowledge of how social conditions may influence health and health inequalities, the metric by which health equity is assessed. The role of social conditions in health is explicitly addressed by both 1) the concept that health equity requires equity in social conditions, as well as in other modifiable determinants, of health; and 2) the right to a standard of living adequate for health. The indivisibility and interdependence of all human rights--civil and political as well as economic and social--together with the right to education, implicitly but unambiguously support the need to address the social (including political) determinants of health, thus contributing to the conceptual basis for health equity. The right to the highest attainable standard of health strengthens the concept and guides the measurement of health equity by implying that the reference group for equity comparisons should be one that has optimal conditions for health. The human rights principles of non-discrimination and equality also strengthen the conceptual foundation for health equity by identifying groups among whom inequalities in health status and health determinants (including social conditions) reflect a lack of health equity; and by construing discrimination to include not only intentional bias, but also actions with unintentionally discriminatory effects. In turn, health equity can make substantial contributions to human rights 1) insofar as research on health inequalities provides increasing understanding and empiric evidence of the importance of social conditions as determinants of health; and, more concretely, 2) by indicating how to operationalize the concept of the right to health for the purposes of measure

Obesity is a major risk factor for chronic disease and can decrease longevity, quality of life, and economic productivity. Compelling ethical, human rights, and practical reasons exist for addressing social disparities in obesity, which requires systematically applying a disparities perspective to obesity research and relevant policy. A disparities perspective guides us to consider multiple dimensions and levels of social advantage and disadvantage and how those advantages and disadvantages produce disparities in obesity and its consequences.

Social differences in health can be reduced, but only if solutions can be identified to address their root causes. The greatest potential lies in solutions that will help people choose health. That means both strengthening individuals’ ability to make healthy choices and removing obstacles to choosing health. It also means creating more opportunities to be healthy. The human impact of health is clear: Health is essential to well-being and full participation in society, and ill health can mean suffering, disability and loss of life. The economic impacts of health have become increasingly apparent. If current trends continue, medical care costs, now about 16 percent of the Gross Domestic Product (GDP),1 will reach 20 percent of GDP by 2015.2 The costs of medical care and insurance are now out of reach for many households, pushing some into bankruptcy. These costs are draining employers’ resources, threatening the bottom line of many American businesses. Federal, state and local health care spending is straining government budgets. Our society’s aging and the obesity epidemic will further increase costs of care.

There is little consensus about the meaning of the terms "health disparities," "health inequalities," or "health equity." The definitions can have important practical consequences, determining the measurements that are monitored by governments and international agencies and the activities that will be supported by resources earmarked to address health disparities/inequalities or health equity. This paper aims to clarify the concepts of health disparities/inequalities (used interchangeably here) and health equity, focusing on the implications of different definitions for measurement and hence for accountability. Health disparities/inequalities do not refer to all differences in health. A health disparity/inequality is a particular type of difference in health (or in the most important influences on health that could potentially be shaped by policies); it is a difference in which disadvantaged social groups-such as the poor, racial/ethnic minorities, women, or other groups who have persistently experienced social disadvantage or discrimination-systematically experience worse health or greater health risks than more advantaged social groups. ("Social advantage" refers to one's relative position in a social hierarchy determined by wealth, power, and/or prestige.) Health disparities/inequalities include differences between the most advantaged group in a given category-e.g., the wealthiest, the most powerful racial/ethnic group-and all others, not only between the best- and worst-off groups. Pursuing health equity means pursuing the elimination of such health disparities/inequalities.

Problems with measuring socioeconomic status (SES)—frequently included in clinical and public health studies as a control variable and less frequently as the variable(s) of main interest—could affect research findings and conclusions, with implications for practice and policy.Wecritically examine standard SES measurement approaches, illustrating problems with examples from new analyses and the literature. For example, marked racial/ethnic differences in income at a given educational level and in wealth at a given income level raise questions about the socioeconomic comparability of individuals who are similar on education or income alone. Evidence also shows that conclusions about nonsocioeconomic causes of racial/ethnic differences in health may depend on the measure—eg, income, wealth, education, occupation, neighborhood socioeconomic characteristics, or past socioeconomic experiences—used to “control for SES,” suggesting that findings from studies that have measured limited aspects of SES should be reassessed. We recommend an outcome- and social group–specific approach to SES measurement that involves (1) considering plausible explanatory pathways and mechanisms, (2) measuring as much relevant socioeconomic information as possible, (3) specifying the particular socioeconomic factors measured (rather than SES overall), and (4) systematically considering how potentially important unmeasured socioeconomic factors may affect conclusions. Better SES measures are needed in data sources, but improvements could be made by using existing information more thoughtfully and acknowledging its limitations.

Objective. We explored methods and potential applications of a systematic approach to studying and monitoring social disparities in health and health care. Methods. Using delayed or no prenatal care as an example indicator, we (1) categorized women into groups with different levels of underlying social advantage; (2) described and graphically displayed rates of the indicator and relativegroup size for each social group; (3) identified and measured disparities, calculating relative risks and rate differences to compare each group with its a priori most-advantaged counterpart; (4) examined changes in rates and disparities over time; and (5) conducted multivariate analyses for the overall sample and “atrisk” groups to identify particular factors warranting attention. Results. We identified at-risk groups and relevant factors and suggest ways to direct efforts for reducing prenatal care disparities. Conclusions. This systematic approach should be useful for studying and monitoring disparities in other indicators of health and health care.

Objectives To investigate Latina-White differences in birth outcomes in California from 2003 to 2010, looking for evidence of the often-cited "Latina paradox" and assessing the possible role of socioeconomic factors in observed differences. MethodsUsing statewide-representative data from the California Maternal and Infant Health Assessment, an annual population-based postpartum survey, we compared rates of preterm birth (PTB) and low birth weight (LBW) in five groups: U.S.-born non-Latina Whites ("Whites"), U.S.-born Mexican-Americans, U.S.-born non-Mexican Latinas, Mexican immigrants, and non-Mexican Latina immigrants. Logistic regression models examined the relative likelihood of PTB and LBW for women in each Latina subgroup compared with Whites, before and after adjustment for socioeconomic and other covariates. Results In unadjusted analyses, women in each Latina subgroup appeared more likely than White women to have PTB and LBW, although the increased likelihood of LBW among Mexican immigrants was statistically non-significant. After adjustment for less favorable socioeconomic characteristics among Latinas compared with Whites, observed differences in the estimated likelihoods of PTB or LBW for Latina subgroups relative to Whites were attenuated and (with the exception of PTB among U.S.-born Mexican Americans) no longer statistically significant. Conclusions We found no evidence of a "Latina paradox" in birth outcomes, which some have cited as evidence that social disadvantage is not always health-damaging. As observed in several previous studies, our findings were non-paradoxical: consistent with their socioeconomic disadvantage, Latinas had worse birth outcomes than non-Latina White women. Policy-makers should not rely on a "Latina paradox" to ensure good birth outcomes among socioeconomically disadvantaged Latina women.

The decrease in adolescent birth rates in the United States has been slower among Latinas than among other ethnic/racial groups. Limited research has explored how socioeconomic opportunities influence childbearing among Latina adolescents. We conducted in-depth interviews with 65 pregnant foreign- and US-born Latina women (31 adolescents; 34 adults) in two California counties. We assessed perceived socioeconomic opportunities and examined how family, immigration and acculturation affected the relationships between socioeconomic opportunities and adolescent childbearing. Compared with women who delayed childbearing into adulthood, pregnant adolescents described having few resources for educational and career development and experiencing numerous socioeconomic and social barriers to achieving their goals. Socioeconomic instability and policies limiting access to education influenced childbearing for immigrant adolescents. In contrast, family disintegration tied to poverty figured prominently in US-born adolescents childbearing. Limited socioeconomic opportunities may play a large role in persistently high pregnancy rates among Latina adolescents.

The decrease in adolescent birth rates in the United States has been slower among Latinas than among other ethnic/racial groups. Limited research has explored how socioeconomic opportunities influence childbearing among Latina adolescents. We conducted in-depth interviews with 65 pregnant foreign- and US-born Latina women (31 adolescents; 34 adults) in two California counties. We assessed perceived socioeconomic opportunities and examined how family, immigration and acculturation affected the relationships between socioeconomic opportunities and adolescent childbearing. Compared with women who delayed childbearing into adulthood, pregnant adolescents described having few resources for educational and career development and experiencing numerous socioeconomic and social barriers to achieving their goals. Socioeconomic instability and policies limiting access to education influenced childbearing for immigrant adolescents. In contrast, family disintegration tied to poverty figured prominently in US-born adolescents' childbearing. Limited socioeconomic opportunities may play a large role in persistently high pregnancy rates among Latina adolescents.

BackgroundThough wide disparities in wealth have been documented across racial/ethnic groups, it is largely unknown whether differences in wealth are associated with health disparities within racial/ethnic groups.MethodsData from the Survey of Consumer Finances (2004, ages 25-64) and the Health and Retirement Survey (2004, ages 50+), containing a wide range of assets and debts variables, were used to calculate net worth (a standard measure of wealth). Among non-Hispanic black, Hispanic and non-Hispanic white populations, we tested whether wealth was associated with self-reported poor/fair health status after accounting for income and education.ResultsExcept among the younger Hispanic population, net worth was significantly associated with poor/fair health status within each racial/ethnic group in both data sets. Adding net worth attenuated the association between education and poor/fair health (in all racial/ethnic groups) and between income and poor/fair health (except among older Hispanics).ConclusionsThe results add to the literature indicating the importance of including measures of wealth in health research for what they may reveal about disparities not only between but also within different racial/ethnic groups.

ObjectivesU.S. Latinas have a persistently high rate of teenage childbearing, which is associated with adverse outcomes for both mother and child. This study was designed to investigate the roles of socioeconomic factors and acculturation in teenage childbearing in this population.MethodsLogistic regression was used to analyze the association of measures of acculturation (language spoken at home, nativity, and age at immigration) and respondents' parents' education with age at first birth in a stratified sample of post-partum women in California.ResultsThe unadjusted odds ratio for teenage birth for Latinas versus non-Latina Whites was 5.2 (95% CI 4.1-6.6). Nativity was not significantly associated with teen birth, but speaking Spanish at home was positively associated and immigrating at a later age was negatively associated with teen birth. Overall, these measures of acculturation accounted for 17% (95% CI 8-28%) of the difference in odds of teen birth between Latinas and non-Latina Whites. Higher levels of education among respondents' parents had differentially protective effects across the racial/ethnic groups. Controlling for disparities in respondents' parents' education without changing its differential effects across racial/ethnic groups reduced the odds ratio for Latinas compared to non-Latina Whites by 30% (95% CI 14-60%).ConclusionThese findings call into question common assumptions about the protective effect of acculturation on teen fertility and suggest that improving childhood socioeconomic factors among Latinas may decrease teen childbearing.

We explored how different socioeconomic and racial/ethnic groups in the United States might fare in an influenza pandemic on the basis of social factors that shape exposure, vulnerability to influenza virus, and timeliness and adequacy of treatment. We discuss policies that might differentially affect social groups' risk for illness or death. Our purpose is not to establish the precise magnitude of disparities likely to occur; rather, it is to call attention to avoidable disparities that can be expected in the absence of systematic attention to differential social risks in pandemic preparedness plans. Policy makers at the federal, state, and local levels should consider potential sources of socioeconomic and racial/ethnic disparities during a pandemic and formulate specific plans to minimize these disparities.

Objectives: Stress due to experiences of racism could contribute to African-American women’s adverse birth outcomes, but systematic efforts to measure relevant experiences among childbearing women have been limited. We explored the racism experiences of childbearing African-American women to inform subsequent development of improved measures for birth outcomes research. Methods: Six focus groups were conducted with a total of 40 socioeconomically diverse African-American women of childbearing age in four northern California cities. Results Women reported experiencing racism (1) throughout the lifecourse, with childhood experiences seeming particularly salient and to have especially enduring effects (2) directly and vicariously, particularly in relation to their children; (3) in interpersonal, institutional, and internalized forms; (4) across different life domains; (5) with active and passive responses; and (6) with pervasive vigilance, anticipating threats to themselves and their children. Conclusions This exploratory study’s findings support the need for measures reflecting the complexity of childbearing African-American women’s racism experiences. In addition to discrete, interpersonal experiences across multiple domains and active/passive responses, which have been measured, birth outcomes research should also measure women’s childhood experiences and their potentially enduring impact, perceptions of institutionalized racism and internalized negative stereotypes, vicarious experiences related to their children, vigilance in anticipating future racism events, as well as the pervasiveness and chronicity of racism exposure, all of which could be sources of ongoing stress with potentially serious implications for birth outcomes. Measures of racism addressing these issues should be developed and formally tested.

This report is based largely on the experience of a project in San Francisco, CA, between 1987 and 1990. A joint university and health dept. effort improved the capacity of the San Francisco Dept. of Public Health (SFDPH) to monitor key information related to maternal and child health, especially for vulnerable groups. The project produced several reports on the status of perinatal health and children's health and well-being in San Francisco. Thise reports demonstrated the potential of information to help community advocacy groups, service providers, and program planners identify priorities for policy decisions and resource allocation., University of Tennessee, Knoxville. Libraries