Background: Infant mortality rates for black mothers are up to three times higher than for white mothers. Even after adjusting for age, income, and other socioeconomic factors, infant mortality rate (IMR) disparities persist. Racial bias and segregation have been found to impact IMR in other studies, most of which rely on self-reported measures of exposure to bias or racism. With 15 years of survey responses, the implicit association test provides a more objective measure of implicit bias levels in the mother's community. This enables a new method to test whether exposure to bias impacts pregnancies.

Objective: This study creates a model to isolate the impact of implicit bias on IMRs. This study will also independently gauge the potential effect of segregation, and will then assess the combined impact of the two. Lastly, this study will determine whether public health programs moderate that effect.

Methods: A longitudinal dataset is constructed for all Florida counties, combining demographics, socioeconomic factors, population mental health indicators, bias, and segregation. IMR by age and race are drawn from County Health Ranking and Florida HealthCharts. Measures of racial bias are computed using Project Implicit's database of racial implicit association test results, with remaining characteristics sourced from the American Community Survey, Centers for Disease Control, Area Resource Files, and the Behavioral Risk Factor Surveillance System. Lastly, public health spending on pregnancy-related programs (Maternal Health and Improved Pregnancy Outcomes, Women, Infants, and Children, and Healthy Start) is factored in as well.

Results: Higher implicit bias among whites is associated with higher black IMR, but only in counties with lower segregation, and only among older black mothers. Although public health programs were effective at reducing IMR among black mothers of all ages, the influence was unaffected by either bias or segregation.

Conclusions: Implicit bias has a negative impact on black pregnancy outcomes, unique from other race-related factors such as income and employment.

Implications: By demonstrating the impact of implicit bias measures, this study introduces a new perspective to add to the weight of evidence of the deleterious health effects of bias and racism.

Background: Racial and ethnic disparities in adverse birth outcomes have persistently been wide and may be explained by individual and area-level factors.

Objectives: Our primary objective was to determine if county-level black-white segregation modified the association between maternal race and ethnicity and adverse birth outcomes using birth records from the National Center for Health Statistics (2012).

Methods: Based on maternal residence at birth, county-level black-white racial residential segregation was calculated along five dimensions of segregation: evenness, exposure, concentration, centralization, and clustering. For preterm birth analyses, 2,036,564 singleton live births (between 20 and 44 weeks of gestation with a birth weight of at least 500 grams) across 376 counties met selection criteria and were included. For term low birth weight analyses, 1,701,777 singleton live births (between 37 and 44 weeks of gestation with a birth weight of at least 500 grams) across 294 counties were included. We conducted a two-stage analysis: (1) county-specific logistic regression to determine whether maternal race and ethnicity were associated with preterm birth and term low birth weight; and (2) Bayesian meta-analyses to determine if segregation moderated these associations.

Results: We found greater black-white (posterior mean odds ratio (OR) multiplier: 1.069; 95% credible interval (CrI): 1.004, 1.135) and Hispanic-white (posterior mean OR multiplier: 1.120; 95% CrI: 1.033, 1.214) disparities in preterm birth in racially isolated counties (exposure) relative to non-isolated counties. We found reduced Hispanic-white disparities in term low birth weight in racially concentrated (posterior mean OR multiplier: 0.901; 95% CrI: 0.817, 0.997) and centralized (posterior mean OR multiplier: 0.874; 95% CrI: 0.789, 0.976) counties relative to non-segregated counties.

Conclusions: Segregation appears to modify the association between maternal race and ethnicity and adverse birth outcomes. The theoretical perspective of place stratification may explain why exposure was associated with greater disparities in preterm birth. The spatial assimilation perspective may explain protective health effects of concentration and centralization.

Public health implications: Policy interventions that reduce black-white racial isolation, or buffer the poor social and economic correlates of segregation, may help to reduce disparities in preterm birth and term low birth weight.

Background. Kalamazoo County Michigan has a long history of racial disparities in maternal-infant health, with black infants dying at nearly four times the rate of white infants (RR3.6, 2015-2017). An interdisciplinary collaborative, Cradle-Kalamazoo, identified fragmented medical/social care as a primary contributor.

Objectives: Our population health goal was to reduce disparities in prenatal care access and birth outcomes by implementing risk-stratified care-coordination of home visitation and community health worker (HV-CHW) programs.

Methods. A social media campaign and stakeholder meetings created awareness and the disproportionate risk carried by (1)people-of-color, (2)low-income families and (3)women with prior-poor-birth-outcomes. A medical-public health partnership led to a Care-Coordination-Registry and weekly case review meetings among all county HV-CHW programs. Program-specific data sharing procedures were developed, piloted and standardized. IRB-approved and HIPAA-compliant case sharing protocols were instituted.

Results. In the first 18 months (2017 to mid-2018), 48 case review meetings were held and 254 HV-CHW cases were reviewed: 216 were handed off or shared with another program, and 38 were presented for team problem-solving. Additionally, 4303 prenatal referrals (spanning 2016 to mid-2018) for 2612 women were deposited into the registry. Despite a 26% reduction in referrals from 2016 to 2017 due to clinic-based changes from universal referrals to consented-only referrals, enrollment levels stayed the same: 27.2% of eligible referrals in 2016 and 27.6% in 2017. Enrollment among two of our focus populations increased: Women-of-color enrollment increased from 56.6% to 62.4%, and enrollment of women with prior-poor-birth-outcome increased from 9.9% to 13.0%. Enrollment of Medicaid-population stayed the same high level, above 95%. Among enrollees, racial disparities in prenatal care utilization decreased by 25% (from 11.1% difference to 8.3% difference). Most importantly, among enrolled people-of-color, 5 infant deaths were expected (based upon existing prevalence rates), but zero infant deaths actually occurred.

Conclusions. Cradle-Kalamazoo successfully implemented risk-stratified care-coordination of fragmented maternal health programming, increasing enrollment of focus populations, and reducing racial disparities in prenatal care access and infant mortality.

Public Health Implications. Community-driven solutions that streamline systems of care can have immediate and significant impact reducing racial disparities in access and outcomes.

The Preterm Birth Initiative-California (PTBi-CA) unites researchers, clinicians, and various community stakeholders in order to adopt a place-based and cell-to-society approach to decrease preterm birth rates. Our study objective was to identify priority policy issues for PTBi-CA by exploring key opportunities for research and contributions to professionals, decision-makers, and public education. The methodology employed by the group of researchers included a systematic review, focus groups, surveys, and a round table discussion to identify priority policy areas. The systematic review included peer-reviewed and organizational consensus reports (grey literature) addressing one or more of the process of conception periods and aimed at health care policy and/or the social determinants of maternal and child health. Those findings were used to inform a survey to the broader network of the initiative and for focus groups that reflected the diversity of the PTBi-CA stakeholder community, including public health practitioners, direct health services providers, health services researchers, local collective impact initiative participants, persons with lived experience, and Community Advisory Board members. Content coding and descriptive analyses identified the most frequently identified priorities for PTBi-CA contributions. The clearest message from the literature review, focus groups, and survey data is the priority participants place on addressing the sequelae of institutionally-entrenched racism on both health care experiences and neighborhood conditions, such as inadequate housing and access to resources. These findings were then presented to a broad policy roundtable that further clarified specific policy priorities for both clinical and neighborhood-related issues. From these, another survey was given to interested stakeholders that clarified what was captured during the roundtable. From there, researchers emerged with four recommendations for policy priorities: develop culturally respectful and responsive maternal and child health services, assess and develop strategies for engaging women in preconception care, develop and disseminate briefs on Medicaid, healthcare racism, and immigration, and support and assess the impacts of engagement of persons with personal experience of preterm birth in policy advocacy. Participants from the focus groups were debriefed on the outcome of their input. The process demonstrates that community can ground systematic literature reviews to create relevant and science-driven policy agendas .