Objective: To use an interdisciplinary, mixed-methods conceptual framework to present sundown towns as a multilevel geospatial measure of structural racism.

Methods: a descriptive case study of sundown towns in Iowa, alongside multilevel regression geospatial modeling.

Findings: Analysis of the History and Social Justice Project Sundown Town Database revealed 48 locations in Iowa identified as possible, probable, or confirmed sundown towns. Examination of birth certificate data at the zip code-level from the Iowa Department of Public Health from 2016-2022 (n=213,516) revealed that birthing women racialized as Black and Indigenous faced an increased risk of adverse birth outcomes, including preterm births, low birthweight infants, and maternal mortality.

Conclusion: This study highlights the significance of sundown towns as indicators of structural racism and their association with adverse health outcomes, particularly among marginalized communities. These findings underscore the need for targeted interventions to address health disparities rooted in historical inequities.