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Reducing Racial/Ethnic and Socioeconomic Disparities in Preterm and Low Birthweight Births
Policy Date: 11/8/2006
Policy Number: 20062
The purpose of this position paper is to guide further debate and decision-making by the American Public Health Association regarding public policy statements and practices to address the critical issue of racial/ethnic and socioeconomic disparities in preterm birth and low birthweight. This position paper provides the scientific basis and justification for the importance of addressing the issue of racial/ethnic and socioeconomic disparities in these birth outcomes, and outlines a broad course of action to reduce the excess risk of preterm and low birthweight births in minority and low-income populations. In particular, this paper emphasizes the importance of creating interventions at both the individual and societal or macro level (communities, health care systems, and government agencies) to address the problem of birth outcome disparities. This position paper will enable APHA to become a policy leader in addressing racial/ethnic and socio-economic differentials in preterm birth and low birthweight. The objectives of this position paper are for APHA to be well positioned to:
· Directly promote public policies and interventions and/or indirectly inform and support policy-making entities to address racial/ethnic and socioeconomic disparities in preterm birth and low birthweight, both at the level of the individual and the level of society;
· Increase public awareness about the problem of the disparities in preterm and low birthweight births, as well as the public's role in addressing the problem and/or support institutions that work towards these goals;
· Promote (and also support like efforts by individuals, organizations, and communities to advocate for) sufficient public (federal and state) and private funding for individual-level and community-level interventions, as well as population-based strategies;
· Promote (and also support like efforts by individuals, organizations, and communities) sufficient public (federal and state) and private funding for research to consider multiple factors, such as cultural, environmental, social, psychological, and biological determinants of disparities in preterm and low birthweight births, as well as to evaluate clinical and political interventions that may be designed as a result of that research; and
· Advocate for a committed, national effort to end social and racial inequalities which are fundamental causes of persistent birth outcome disparities.
II. The Problem- Scientific Basis
A) Overview of the Problem of Preterm Delivery and Low Birthweight
Preterm delivery and low birthweight are serious birth outcomes that can have negative consequences, not only for infants and their families, but for our communities and our nation as a whole. Preterm delivery, defined as a delivery before 37 weeks of gestation, is "currently the most important problem in maternal-child health in the United States."1,2 The rate of preterm births has increased 27 percent over the past 20 years from fewer than one in ten live births (9.4 percent) in 1981, to one in eight (12.4 percent) in 2004.3,4, 5 This rise in the preterm birth rate has been fairly steady, except for small declines in 1984 (from 9.6 to 9.4) and 1992 (from 10.8 to 10.7) (Martin et al, 2005) and with no change in the rate from 1993 to 1997 (at 11.0). Low birthweight (less than 2500 grams or 5 lbs., 8 oz.) is highly correlated with preterm birth. The international ranking of the United States for low weight births has worsened from 20th in 1980 to 40th in 2000 among countries reporting to the United Nations.6 The rate of low birthweight births has increased 16percent over the past two decades from 6.8 in 1981 to 8.1 in 2004 .4,5, Martin et al., 2005 There was a slight increase in the low birthweight rate in the 1980s (from 6.8 in 1981 to 7.0 in 1989), with larger changes occurring in the 1990s (from 7.0 in 1990 to 7.6 in 1999) and during the new millennium (from 7.6 in 2000 to 8.1 in 2004). 4
Babies who are born preterm and/or at low birthweight are at increased risk for death in the first year of life. 3,7 The loss of a baby can be a devastating experience for a family. Infant mortality (i.e. death of an infant less than one year of age) is an even greater tragedy when the death was due to a preventable preterm and/or low birthweight birth. Babies born very early or at a very low birthweight are at greater risk of dying before their first birthday. Nearly half of those infants born at less than 28 weeks of gestation or at less than 1,000 grams will not survive their first year of life.8
Many preterm and low birthweight infants that survive the perinatal period are rendered highly vulnerable to a host of childhood morbidities spanning a variety of functional domains, such as cerebral palsy, chronic lung disease, and attention deficit/hyperactivity disorder.9
Adolescents born prior to 35 weeks of completed gestation have been shown to have a higher degree of abnormal brain development and cognitive and behavioral problems than adolescents born full-term.10 These poorer birth outcomes have also been associated with serious health conditions in adulthood, such as cardiovascular disease, Type II diabetes, and hypertension.11,12,13 More than just a concern for a single individual in a particular generational cohort, a mother's own birth outcomes have been linked to those of her infant, suggesting that low birthweight and preterm delivery can be perpetuated across generations. 14,15,16
Additionally, the financial costs associated with treating preterm labor and delivery are quite high. According to the Nationwide Inpatient Sample for 2003, a database sponsored by the Agency for Healthcare Research and Quality of nearly 8 million all-payer inpatient hospital stays from a sample of 994 U.S. community hospitals, hospital charges for inpatient stays with any diagnoses of prematurity/low birthweight averaged $44,000, in comparison to hospital charges averaging $1,700 for newborn stays without complications. 17,18 Total hospital charges for preterm infants in the United States were estimated to be $18.1 billion in 2003. 17 Between 2002 and 2003, hospital charges for infants with a diagnosis of prematurity/low birthweight increased 16 percent.17
B) Persistent Racial/Ethnic and Socioeconomic Disparities
Significant and persistent disparities in preterm birth and low birthweight exist: some minority populations (in particular, African Americans and Native Americans) and poor women are at far greater risk for these poor birth outcomes.19, 20 In order to achieve the Healthy People 2010 objectives of eliminating health disparities and reducing the rate of preterm births to 7.6 percent and low birthweight to 5 percent, much work needs to be done to further characterize the causal pathways that lead to higher rates of preterm delivery and low birthweight births in minority and poor women. 21
A comparison of African American and Native American to non-Hispanic white births depicts a troubling difference in the rates of preterm birth. The percentage of non-Hispanic African American infants that were preterm in 2004 was 17.9 percent, versus 11.5 percent of non-Hispanic white infants.5 Trend data indicate that the African American rate of preterm delivery is consistently 1.5 to 2.4 times higher than that of their non-Hispanic white counterparts.22 The preterm birth rate of American Indian/Alaska Native women, 13.7 percent in 2004, is also higher than the national average and is second only to the African American rate.5 Other vulnerable groups include Puerto Rican women, whose preterm delivery rate was 13.8 in 2003. 4
Low birthweight, which is correlated with preterm birth, follows a somewhat different pattern of disparities. Non-Hispanic blacks or African Americans remain at highest risk: the percentage of low birthweight births for non-Hispanic blacks or African Americans nearly doubles that of non-Hispanic whites (13.6 vs.7.0 percent, 2003). 23 Other populations at risk for low birthweight in comparison to non-Hispanic whites include Puerto Ricans (9.7 percent), Filipinos (8.6 percent), Hawaiians (8.1 percent), Japanese (7.6 percent), American Indians or Alaska Natives (7.2 percent) (2002 data). 23
Infants of women with low socioeconomic status of any race or ethnic group are more likely to be preterm, low birthweight, and to die before one month of age.24, 25 Although race and class are closely aligned in this country, socioeconomic differentials do not fully explain racial differentials in poor birth outcomes, as higher rates of preterm birth and low birthweight are still evident in African Americans even after socioeconomic factors have been controlled.26-28 Further, increases in assisted reproductive technology (ART), which has contributed to increasing numbers of preterm and low birthweight births, also are unlikely to account for the disparities between African American and non-Hispanic white birth outcomes, given that only 0.1 percent of African American women have undergone ART as compared to 0.4 percent of non-Hispanic white women). 29
Clearly, socioeconomic determinants cannot
"explain away" racial and ethnic disparities in poor birth outcomes. Other individual determinants of poor birth outcomes must be considered, including factors that might provide a protective effect against low birthweight and preterm births. For example, some immigrant groups have been found to be less likely to have a low birthweight infant in comparison to their U.S. born counterparts, controlling for socio-economic factors. 31,32 Though the effect is not consistent across all immigrant groups, the "healthy immigrant" effect appears consistent within the overall immigrant Latina population. 31-33 The "healthy immigrant effect" deserves further study. 31
While individual-level determinants of preterm delivery and low birthweight, such as poor diet, chronic health issues such as diabetes and hypertension, substance use, and extremes of age and weight, can help to explain disparities, approximately half of preterm births have no identifiable risk factor.30, 34 Identifying the causes of racial/ethnic and socioeconomic status disparities in birth outcomes has proven quite challenging.35 For example, well-established medical, behavioral, and sociodemographic risk factors have been unable to fully account for persistent racial disparities, prompting a re-examination of conventional explanatory models. 36,37
Among many researchers, attention has been shifting from individual-level causes of poor birth outcomes, such as negative health behaviors, to the cause of those causes- the social, political, economic, and cultural forces at the macro level that shape disease risk in populations and provide the context within which individuals function.38-41 Psychological stress, racism, and neighborhood environments are just some of the contextual factors that researchers have been investigating.42-45 Thus, both micro level and macro level factors need to be addressed.
III. A Call for Change
It is clear that disparities exist; women of racial and ethnic minority populations (especially African American and Native American women), as well as women of lower socioeconomic status, are at higher risk of delivering premature and low birthweight infants who may experience a range of health and developmental challenges. Appropriate interventions are needed to address these disparities. Educating the public and health care providers, broadening access to quality health care services, promoting healthier physical and social environments, supporting innovative research, and advocating for efforts to address racial and social inequalities can be effective tools in reducing disparities in preterm births and low birthweight.
Health care providers and the general public must be educated about the significance of preterm delivery and low birthweight as public health issues. The importance of social and economic inequities in life circumstances as underlying determinants of disparities in these adverse birth outcomes also must be acknowledged. Health care professionals must consciously adapt a culturally appropriate framework for working with different patient populations.
The Centers for Disease Control and Prevention is currently promoting preconception and interconception care (i.e., care between pregnancies where the earlier pregnancy had an adverse outcome)79 as critical to improving the health of the nation. Preconception care and care between pregnancies, which address health risks prior to and between pregnancies, and in early pregnancy, includes both prevention and health management.46 It is especially important for women who are at high risk for preterm and low birthweight births to have equitable access to both preconception or interconception care as well as care during the entire period of pregnancy (prenatal care); this care must address their unique needs in a competent manner. 35, 46-49 A REACH 2010 project in Genesee County, Michigan employs the use of maternal and infant health advocates to support African American women during pregnancy and up to the infant's first birthday to address racial disparities in infant mortality, including accompanying the woman to the doctor's appointment and providing transportation if necessary.50 Support services for behavioral change can lower preconception risks including effective interventions to curtail the use of tobacco, alcohol and illicit drugs and prevent sexually transmitted diseases.35,47,51 Women who are underweight and overweight need ways of improving their nutritional status prior to pregnancy, including knowledge of and access to nutritious and affordable food. Women who are under stress or being abused (physically, sexually or emotionally) need access to the psychosocial and community resources necessary to improve their situation.
Promoting healthier physical and social environments is also vital to our efforts to reduce disparities in low birthweight and preterm delivery. Impoverished communities and communities of color, which often are one and the same, are disproportionately exposed to environmental hazards such as lead, air pollutants, agrochemicals, and hazardous waste sites.52-54 Such exposures have been linked to reduced fertility, pregnancy loss, compromised fetal development, and preterm birth.55 Environmental cleanup and protection efforts and policies that advance environmental justice must be sensitive to the needs of affected communities and meaningfully involve them in those change efforts.56,57
Besides environmental contaminants, the social characteristics of a community also hold important implications for pregnancy outcomes. Neighborhoods that are crime-ridden, physically decayed, disorganized, socially unsupportive, and negatively perceived by the residents have been shown to negatively influence infant birthweight.58-61 These neighborhoods, often racially segregated and characterized by high levels of socioeconomic disadvantage, are likely to provide limited access to high quality medical and municipal services, grocery stores and recreational facilities, and are frequent targets of negative health messages from tobacco and alcohol companies.62-65 The physical and social environments within which individuals function need to be safe, clean, affordable, socially supportive, and adequately resourced in order to maximize every woman's potential to deliver a full-term and healthy infant.
Additional research is needed to further identify the interactive effects of environmental, social, psychological, and physiological risk factors that contribute to racial/ethnic and socioeconomic disparities in preterm and low birthweight births. These risk factors may negatively impact health and increase risk for poor birth outcomes long before a woman ever becomes pregnant. For example, studies conducted in Great Britain half a century ago 67-69 demonstrate that the socioeconomic context of a woman's childhood is significantly associated with her pregnancy outcomes in adulthood. More contemporary work suggests that childhood socioeconomic factors are important contributors to adult health outcomes more generally. 70-72 Therefore, the research agenda should include a life course approach to studying the problem of low birthweight and preterm delivery. 40,73
A stress paradigm is particularly promising for guiding work in this regard. Stressors, environmental demands that strain or overwhelm one's ability to adapt, trigger psychological and biological processes that may contribute to disease risk.66 Over time, cumulative exposure to stressors, and the psychological and physiological changes they produce, cause wear and tear on the body. This increasing inefficiency of the body's response to stressors, also known as allostatic load, can compromise functioning in key biological systems.74 Allostatic load is hypothesized to be one way in which the life challenges that social inequality produces may contribute to racial/ethnic and socioeconomic differentials in adverse birth outcomes.75 There are innovative research efforts that examine the multiple factors which contribute to low birthweight and gestational age-related outcomes.43,44,60,76 The research into allostatic load and the biological processes by which cumulative stress may result in a poor birth outcome, however, is still in the early stages.75 Innovative research efforts to develop and test multidimensional, multi-level models of low birthweight and preterm delivery must be supported and encouraged.
Finally, the American Public Health Association and other health care organizations should advocate that future efforts to reduce preterm birth and low birthweight include a focus on the broad, multifactorial causes of disparities in these newborn outcomes; this would include examining the social, political, economic, and cultural forces at the macro level that shape disease risk in populations and provide the context within which individuals function. The March of Dimes launched its five-year, $75 million Prematurity Campaign in 2003 to increase public understanding of the seriousness of prematurity and its reducible risk factors, to assist health care providers to improve the prevention and management of preterm labor, and to expand federal research funding by $50 million to prevent and stop preterm labor. However, education, research, intervention and advocacy efforts aimed at reducing social and racial inequities need to be a national priority if disparities in prematurity and low birthweight rates are to decline.77.78
IV. Goals for APHA
Eliminating racial/ethnic and socioeconomic disparities in health is a priority of the American Public Health Association and one of the two major goals of Healthy People 2010, the nation's public agenda. Therefore, to reduce racial/ethnic and socioeconomic disparities in preterm delivery and low birthweight, the American Public Health Association will work with its members, health care providers, advocates, policy-makers, government agencies, health insurance providers, other appropriate organizations, and/or communities to:
1.Promote education of the general public, including pregnant women, regarding the problem of preterm and low birthweight births including;
· the disproportionate burden on certain racial and ethnic groups including African Americans and Native Americans.
· the disproportionate burden on low-income families.
· population-based strategies for eliminating racial and socioeconomic disparities to reduce the rate of preterm delivery and low birthweight.
2. Foster greater dissemination of evidence-based and culturally competent interventions for women during both the interconceptual and perinatal periods including:
· setting and reinforcing standards of care;
· educating providers; and
· advocating for on-going funding to sustain both standards and provider education.
3. Promote pre/interconception care including setting and reinforcing standards of care and advocating for ongoing funding to sustain standards. Support the inclusion of education of female patients during their reproductive years regarding the signs and symptoms of preterm labor as a standard of pre/interconception care.
4. Support funding for pre/interconception care to be included in standard government and private insurance coverage programs, with government funding to cover women who are uninsured as described below.
5. Encourage the federal government to expand health care coverage for uninsured women throughout their lifespan, with a particular emphasis on their reproductive years to insure that every woman receives a basic level of coverage and has a medical home.
6. Promote increased public and private funding for research on environmental, social, economic and cultural determinants of preterm and low birthweight births, including the development and evaluation of interventions to reduce disparities with an emphasis on population-level interventions.
7. Encourage the development of federally funded pilot projects to foster partnering between health care delivery systems or organizations (including local and state health departments) and community coalitions to address disparities in birth outcomes by developing community-level, population-based interventions. Financial and other incentives may be used to forge these partnerships and evaluation must be a required component of every project.
8. Increase advocacy efforts to address the fundamental inequities in social and economic life circumstances of women and to make the reduction of disparities in birth outcomes a national priority.
1. MacDorman MF, Martin JA, Mathews TJ, Hoyert, DL. Explaining the 2001-2002 Infant Mortality Increase: Data from the Linked Birth/Infant Death Data Set. Vital Statistics Reports, vol. 53, no. 12. Hyattsville, MD: National Center for Health Statistics; 2005.
2. Wadhwa PD, Culhane JF, Rauh V, Barve SS et al. Stress, infection, and preterm birth: a biobehavioural perspective. Paediat Perinat Epidemiol. 2001; 15: 17-29.
3. Centers for Disease Control and Prevention. National Center for Health Statistics. Infant, neonatal, and postneonatal deaths, percent of total deaths, and mortality rates for the 15 leading causes of infant death by race and sex: United States, 2000. Available at: www.cdc.gov/nchs/data/dvs/LCWK7_2000.pdf Accessed February 10, 2003.
4. Martin, J.A., Hamilton, B.E., Sutton, P.D., Ventura, S.J., Menacker, F., & Munson, M.L. (2005). Births: Final Data for 2003. National Vital Statistics Reports, vol. 54, no. 2. Hyattsville, MD: National Center for Health Statistics. 2005.
5. Hamilton BE, Ventura SJ, Martin JA, Sutton PD. Preliminary births for 2004. Health E-stats. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths04/ prelimbirths04health.htm. Accessed November 29, 2005.
6. UNICEF. Statistics, End of Decade Databases, Child Mortality: Infant Mortality Rate,
1960 to 2000. Available at: www.childinfo.org/cmr/revis/db1.htm. Accessed February 13, 2003.
7. Mathews TJ, Menacker F, MacDorman MF. Infant mortality statistics from the 2002 period linked birth/infant death data set. National Vital Statistics Reports, vol. 53, no. 10. Hyattsville, MD: National Center for Health Statistics; 2004.
8. Mathews TJ, MacDorman MF. Infant mortality statistics from the 2003 period linked birth/infant death data set. Natl Vital Stat Rep. 2006;54:1-29.
9. Botting N, Powls A, Cooke RW, Marlow N. Cognitive and educational outcomes of very-low-birthweight children in early adolescence. Dev Med Child Neurol 1998;40(10):652-660.
10. Stewart AL, Rifkin L, Amess PN, et al. Brain structure and neurocognitive and behavioural function in adolescents who were born very preterm. Lancet 1999; 353: 1653-1657.
11. Barker D. Mothers, babies, and disease in later life. London: BMJ Publishing Group; 1993.
12. Law CM, deSwiet M, Osmond C, et al. Initiation of hypertension in utero and its amplification throughout life. BMJ 1993;306:24-27.
13. Rich-Edwards JW, Stampfer MJ, Manson JE, et al. Birth weight and risk of cardiovascular disease in a cohort of women followed up since 1976. BMJ 1997;315:396-400.
14. Coutinho, R., David, R.J., & Collins, J.W. Jr. (1997). Relationship of parental birth weight to infant birth weight among African-American and White women in Illinois: A transgenerational study. American Journal of Epidemiology, 146, 804-809.
15 Porter, TF, Fraser, AM, Hunter, CY, Ward, RH, & Varna, MW (1997). Risk of preterm birth across generations. Obstetrics and Gynecology, 90, 63-67.
16 Wang, X., Zucherman, B., Coffman, G.A., & Corwin, M.J. (1995). Familial aggregation of low birth weight among whites and blacks in the United States. New England Journal of Medicine, 333, 1744-1749.
17. Hospital charges for prematurity - 2003 Data. 1-2. 2005. Unpublished data from analyses conducted by the March of Dimes Perinatal Data Center, October, 2005.
Ref Type: Unpublished Work.
18. Healthcare cost and utilization project (HCUP) Overview of the Nationwide Inpatient Sample (NIS). Agency for Healthcare Quality and Research (AHRQ) . 2006. 6-16-2006.
Ref Type: Electronic Citation.
19. March of Dimes Racial and Ethnic Disparities in Prematurity: Data and Trends. 2004. Available at: http://www.marchofdimes.com/files/Racial_EthnicPremDataTrends071404.pdf. Retrieved September 15, 2005.
20. Centers for Disease Control. "Racial/ethnic disparities in neonatal mortality" United States, 1989-2001. MMWR 2004;53:655-658.
21. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Available at: http://www.healthypeople.gov/document/html/volume2/16mich.htm#_Toc494699660. Retrieved February 9, 2005.
22. Centers for Disease Control and Prevention, Division of Reproductive Health. State-specific changes in singleton preterm births among black and white women, United States 1990 to 1997. MMWR 2000; 49:837-40.
23. Health, United States, 2005 With chartbook on trends in the health of Americans. DHHS Pub No. 2005-1232, i-535. 2005. Hyattsville, MD., National Center for Health Statistics. Ref Type: Report.
24. Pamuk E, Makuc D, Heck K, et al. Socioeconomic Status and Health Chartbook: Health, United States, 1998. Hyattsville MD: National Center for Health Statistics; 1998.
25. Starfield, B., Shapiro, S., Weiss, J., Liang, K-Y, Ra, K, Paige, D., & Wang, X. (1991). Race, family income, and low birthweight. American Journal of Epidemiology, 134, 1167-1174.
26. Foster HW, Wu L, Bracken MB, et al. Intergenerational effects of high
socioeconomic status on low birthweight and preterm birth in African Americans. J Natl Med Assoc. 2000; 92(5): 213-221.
27. Krieger N. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical sciences, and current controversies: An ecosocial perspective. Am J Public Health 2003; 93:194-199.
28. Nazroo, JY. The structuring of ethnic inequalities in health: economic position, racial discrimination, and health. Am J Public Health 2003;93:277-284.
29. National Survey of Family Growth, 2002. National Center for Health Statistics. Series 23, No. 25, 2005. Available at:
http://www.cdc.gov/nchs/data/series/sr_23/sr23_025.pdf. Retrieved January 30, 2006.
30. Galtier-Dereure F, Boegner C, Bringer J. Obesity and Pregnancy: Complications and cost. Am J Clin Nut. 2000; 71: 1242S-1248S.
31. Acevedo-Garcia D, Soobader MJ, Berkman LF. The differential effect of foreign-born status on low birth weight by race/ethnicity and education. Pediatrics 2005;115:e20-e30.
32. Fuentes-Afflick E, Hessol NA, Perez-Stable EJ. Maternal birthplace, ethnicity, and low birthweight in California. Arch Pediatr Adolesc Med 1998;152:1105-1112.
33. Kelaher M, Jessop DJ. Differences in low-birthweight among documented and undocumented foreign-born and US-born Latinas. Soc Sci Med 2002;55:2171-2175.
34. Ronnenberg AG, Wang X, Xing H, Chen C, Chen D, Guang W, Guang A, Wang L, Ryan L, and Xu X. Low preconception body mass index is associated with birth outcomes in a prospective cohort of Chinese women. J Nutr 2003; 133: 3449-3455.
35. Goldenberg R. The management of preterm labor. Obstet Gynecol 2002; 100:1020-37.
36. Berg CJ, Wilcox LS, d'Almada PJ. The prevalence of socioeconomic and behavioral characteristics and their impact on very low birth weight in black and white infants in Georgia. Matern Child Health J 2001; 5: 75-84.
37. English PB, Eskenazi B, Christianson RE. Black-white differences in serum cotinine levels among pregnant women and subsequent effects on infant birthweight. Am J Public Health 1994;84:1439-1443.
38. Hogan VK, Ferre CD. The social context of pregnancy for African American women: Implications for the study and prevention of adverse perinatal outcomes. Matern Child Health J 2001; 5:67-69.
39. Rowley DL. Closing the gap, opening the process: Why study social contributors to preterm delivery among Black women. Matern Child Health J 2001;5:71-74.
40. Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: A life-course perspective. Matern Child Health J 2003;7: 13-30.
41. Williams DR. Racial/ethnic variations in women's health: The social embeddedness of health. Am J Public Health 2002; 92: 588-597.
42. Collins JW Jr., David RJ, Symons R et al. Low income African-American mothers' perception of exposure to racial discrimination and infant birth weight. Epidemiol. 2000;11:337-339.
43. Dole N, Savitz DA, Hertz-Picciotto I et al. Maternal stress and preterm birth. Am J Epidemiol 2003;157: 14-24.
44. Parker Dominguez T, Dunkel-Schetter C, Mancuso R, et al. Stress in African American pregnancies: testing the roles of various stress concepts in prediction of birth outcomes. Ann Behav Med 2005;29:12-21.
45. Roberts EM. Neighborhood social environmental and the distribution of low birthweight in Chicago. Am J Public Health 1997;87:597-603.
46. Centers for Disease Control and Prevention, Preconception Health and Care. CDC At a Glance. Atlanta, GA: CDC; 2006.
47. Lockwood C. Predicting premature birth: no easy task. N Eng J Med 2002;346:282-284.
48. Cifuentes J, Bronstein J, Phibbs CS, Phibbs RH, Schmitt SK, Carlo WA. Mortality in low birthweight infants according to level of neonatal care at hospital of birth. Pediatr 2002;109:745-751.
49. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health. Washington, DC: National Academy Press; 2003.
50. Centers for Disease Control and Prevention. Racial and Ethnic Approaches to Community
Health. Genesee County Health Department, Michigan. Available at:
http://www.cdc.gov/reach2010/community_examples/genesee_county_ health_department.htm. Retrieved June 4, 2006.
51. Women and Smoking: A Report of the Surgeon General. Washington, D.C.: U.S. Department of Health and Human Services; 2001. PHS Publication 675.
52. Faber DR, Krieg EJ. Unequal exposure to ecological hazards: Environmental injustices in the Commonwealth of Massachusetts. Environ Health Perspect 2002;110(suppl): 277-288.
53. Lopez R. Segregation and black/white differences in exposure to air toxics in 1990. Environ Health Perspect 2002;110(suppl): 289-295.
54. Morello-Frosch R, Pastor M Jr, Porras C, Sadd, J. Environmental justice and regional inequality in southern California: Implications for future research. Environ Health Perspect 2002;110(suppl):149-154.
55. Silbergeld EK, Patrick TE. Environmental exposures, toxicologic mechanisms, and adverse pregnancy outcomes. Am J Obstet Gynecol 2005;192: S11-S21.
56. Clark JM, Bing-Canar J, Renninger D et al. Methyl parathion in residential properties: Relocation and decontamination methodology. Environ Health Perspect 2002;110:1061-1070.
57. Corburn J. Environmental justice, local knowledge, and risk: The discourse of a community-based cumulative exposure assessment. Environ Manage 2002; 29:451-466.
58. Buka SL, Brennan RT, Rich-Edwards JW et al. Neighborhood support and the birth weight of urban infants. Am J Epidemiol 2003; 157: 1-8.
59. Collins JW Jr , David RJ. Urban violence and African-American pregnancy outcomes: An ecologic study. Ethn Dis 1997; 7:184-190.
60. Collins JW Jr, David RJ, Symons R et al. African-American mothers- perceptions of their residential environment, stressful life events, and very low birthweight. Epidemiol 1998; 9:286-289.
61. Morenoff JD. Neighborhood mechanisms and spatial dynamics of birth weight. AJS; 108:976-1017.
62. Culhane JF, Elo IT. Neighborhood context and reproductive health. Am J Obstet Gynecol 2005;192:S22-S29.
63. MacIntyre S, Ellaway A, Cummins S. Place effects on health: How can we conceptualize, operationalize, and measure them? Soc Sci Med 2002; 55:125-139.
64. Moore DJ, Williams JD, Qualls WJ. Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States. Ethn Dis 1996; 6: 83-98.
65. Robert SA. Socioeconomic position and health: The independent contribution of community socioeconomic context. Annu Rev Soc 1999; 25: 489-516.
66. Cohen S, Kessler RC, Gordon, LU. Strategies for measuring stress in studies of psychiatric and physical disorders. In: Cohen S, Kessler RC, Gordon LU eds. Measuring stress: A guide for health and social scientists. New York, NY: Oxford University Press; 1995:3-28.
67. Baird, D. (1964). The epidemiology of prematurity. American Journal of Obstetrics and Gynecology 65, 909-924.
68. Drillien, CM (1957). The social and economic factors affecting the incidence of premature birth. Part I: Premature births without complications of pregnancy. Journal of Obstetrics & Gynaecology of the British Empire 64, 161-184.
69. Illsley, R (1955). Social class selection and class differences in relation to stillbirths and infant deaths. British Medical Journal, II 1523-1524.
70. Lundberg, O. (1993). The impact of childhood living conditions on illness and mortality in
adulthood. Social Science and Medicine 36, 1047-1052.
71. Nystrom Peck, A.M. (1992). Childhood environment, intergenerational mobility, and adult
health- Evidence from Swedish data. Journal of Epidemiology and Community Health 46, 71-74.
72. Rahkonen, O., Lahelma, E., & Huuhka, M. (1997). Past or present? Childhood living conditions and current socioeconomic status as determinants of adult health. Social Science and Medicine 44, 327-336.
73. Rich-Edwards, J.W. & Grizzard, T.A.. (2005). Psychosocial stress and neuroendocrine mechanisms in preterm delivery. American Journal of Obstetrics and Gyncecology 192, S30-35.
74. McEwen BS. Stress adaptation and disease: Allostasis and allostatic load. Ann N Y Acad Sci 1998; 840:33-44.
75. Rich-Edwards JW, Grizzard TA. Psychological stress and neuroendocrine mechanisms in preterm delivery. Am J Obstet Gynecol 2005; 192(suppl): s30-s35.
76. Rini CK, Dunkel-Schetter C, Wadhwa PD, Sandman CA. Psychological adaptation and birth outcomes: The role of personal resources, stress, and sociocultural context in pregnancy. Health Psychol 1999;18: 333-345.
77. Misra DP, Guyer B, Allston A. Integrated Perinatal Health Framework: A multiple determinants model with a life span approach. Am J Prev Med 2003;25(1): 65-75.
78. Bennett T, Kotelchuck M. Mothers and Infants. In: Kotch J, ed. Maternal and Child Health: Programs, problems and policy in public health. Gaithersburg, MD: Aspen Publishers, 1997: 85-114.
79. Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG, CDC/ATSDR Preconception Care Work Group, Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep 2006 Apr 21;55(RR-6):1-23.
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