BACKGROUND:The association between economic insecurity and mental health among low-income pregnant people is understudied. We examined the relationship between economic insecurity and perinatal stress, anxiety, and depressive symptoms among a low-income, racially/ethnically diverse study population, and differentiated associations by nativity status. METHODS:We used cross-sectional data from the EMBRACE Study that enrolled Medi-Cal (California's Medicaid program) eligible pregnant people in the Central Valley region of California. Economic insecurity was assessed through measures of food insecurity, low financial well-being, inability to pay an emergency expense, inability to pay bills, fear of eviction, and history of homelessness. We examined the association of these measures with perceived stress (Perceived Stress Scale), generalized anxiety symptoms (Generalized Anxiety Disorder-7), and depressive symptoms (Patient Health Questionnaire-9), adjusting for age, relationship status, and education level. We also examined effect measure modification by nativity among the Latinx population. We report the estimated differences and 95% confidence intervals for each exposure and outcome. RESULTS:In our sample of 674 participants, we observed associations between economic insecurity and mental health. Among the 24 models, 15 showed medium to large effects (>0.35 standard deviation differences) and only three showed negligible effect sizes. Across all outcomes, we observed a stronger relationship between economic insecurity and mental health for U.S.-born Latinx people compared with their foreign-born (93% Mexico-born) counterparts. CONCLUSION:We found low-income pregnant people experience significant economic insecurities that may impact mental health adversely. Programs that increase economic supports during pregnancy may serve as important maternal mental health interventions, especially among racial/ethnic minoritized groups.

Background: African-born women have a lower risk of preterm birth and small for gestational age (SGA) birth compared with United States-born Black women, however variation by country of origin is overlooked. Additionally, the extent that nativity disparities in adverse perinatal outcomes to Black women are explained by individual-level factors remains unclear. Methods: We conducted a population-based study of nonanomalous singleton live births to United States- and African-born Black women in California from 2011 to 2020 (n = 194,320). We used age-adjusted Poisson regression models to estimate the risk of preterm birth and SGA and reported risk ratios (RR) and 95% confidence intervals (CI). Decomposition using Monte Carlo integration of the g-formula computed the percentage of disparities in adverse outcomes between United States- and African-born women explained by individual-level factors. Results: Eritrean women (RR = 0.4; 95% CI = 0.3, 0.5) had the largest differences in risk of preterm birth and Cameroonian women (RR = 0.5; 95% CI = 0.3, 0.6) in SGA birth, compared with United States-born Black women. Ghanaian women had smaller differences in risk of preterm birth (RR = 0.8; 95% CI = 0.7, 1.0) and SGA (RR = 0.9; 95% CI = 0.8, 1.1) compared with United States-born women. Overall, we estimate that absolute differences in socio-demographic and clinical factors contributed to 32% of nativity-based disparities in the risk of preterm birth and 26% of disparities in SGA. Conclusions: We observed heterogeneity in risk of adverse perinatal outcomes for African- compared with United States-born Black women, suggesting that nativity disparities in adverse perinatal outcomes were not fully explained by differences in individual-level factors.

To characterize co-occurring social determinants of health for clients experiencing perinatal anxiety and depression (perinatal mood and anxiety disorders) or serious mental illness (SMI) in a diverse population receiving prenatal care in a safety -net health system, we conducted a latent class analysis, using data from a social determinants screener in pregnancy for the health system ' s clients during 2017 - 20. The sample included clients with positive screens for depression or anxiety or SMI diagnoses. Prenatal clients with a positive screen for perinatal mood and anxiety disorders or SMI comprised 13 - 30 percent of classes, characterized by more than two co-occurring social determinants (for example, co-occurring socioeconomic and interpersonal factors). The study findings highlight the salience of social determinants among prenatal patients experiencing perinatal mood and anxiety disorder and SMI and suggest the necessity of consistent screening for both social determinants and perinatal mental health. Policies to address social determinants within and beyond health care settings are critical.

BACKGROUND:Improving perinatal mental health and care experiences and preventing adverse maternal and infant outcomes are essential prenatal care components, yet existing services often miss the mark, particularly for low-income populations. An enhanced group prenatal care program, "Glow! Group Prenatal Care and Support," was developed in California's Central Valley in response to poor perinatal mental health, disrespectful care experiences, and high rates of adverse birth outcomes among families with low incomes. METHODS:Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) is a pragmatic, two-arm, randomized, comparative-effectiveness study designed to assess depression (primary outcome), the experience of care (secondary outcome), and preterm birth (exploratory outcome) among Medi-Cal (California's Medicaid program)-eligible pregnant and birthing people, comparing those assigned to Glow! Group Prenatal Care and Support (Glow/GC) with those assigned to enhanced, individual prenatal care through the California Department of Public Health's Comprehensive Perinatal Services Program (CPSP/IC). Participating clinical practices offer the two comparators, alternating between comparators every 6 weeks, with the starting comparator randomized at the practice level. Participant-reported outcomes are assessed through interviewer-administered surveys at study entry, during the participant's third trimester, and at 3 months postpartum; preterm birth and other clinical outcomes are abstracted from labor and delivery records. Patient care experiences are further assessed in qualitative interviews. The protocol complies with the Standard Protocol Items for Randomized Trials. CONCLUSIONS:This comparative-effectiveness study will be used to determine which of two forms of enhanced prenatal care is more effective, informing future decisions regarding their use. TRIAL REGISTRATION:ClinicalTrials.gov: NCT04154423.

Importance:Preterm birth (PTB) (gestational age <37 weeks) is a major cause of infant mortality and morbidity in the US and is marked by racial and ethnic and socioeconomic inequities. Further research is needed to elucidate the association of risk and protective factors with trends in PTB rates and with related inequities. Objective:To describe the association of PTB rates with inequities as well as related risk and protective factors over the past decade in a US population-based cohort. Design, Setting, and Participants:This retrospective cohort study of singleton live births in California from January 1, 2011, to December 31, 2022, was conducted using vital statistics records and hospital records. The cohort included births with a gestational age of 22 to 44 weeks. Main Outcomes and Measures:Preterm birth rates by racial and ethnic group and by public and nonpublic insurance (considered as a proxy for socioeconomic status) were studied across years. Log-linear regression (relative risks with 95% CIs) was used to evaluate risk and protective factors within groups. Associations of PTB rates with risk and protective factors were assessed. Results:This study included 5 431 018 singleton live births to individuals who identified as American Indian or Alaska Native (0.3%), Asian (14.2%), Black (4.9%), Hispanic (47.8%), or White (27.0%). A total of 43.1% of births were to individuals with public health insurance. From 2011 to 2022, the overall PTB rate increased from 6.8% to 7.5% (change [SE], 10.6% [0.6%]; z score of 18.5; P < .001). Differences in PTB rates and associated changes were observed for racial and ethnic groups and insurance groups. For example, 2022 PTB rates ranged from 5.8% among White individuals with nonpublic insurance to 11.3% among Black individuals with public health insurance. From 2011 to 2022, PTB rates decreased from 9.1% to 8.8% (change [SE], -3.5% [4.2]; z score of -0.8; P = .42) among Black individuals with nonpublic insurance, whereas they increased from 6.4% to 9.5% (change [SE], 49.8% [16.0%]; z score of 3.1; P = .002) among American Indian or Alaska Native individuals with nonpublic insurance. Increases in some risk factors (eg, preexisting diabetes, sexually transmitted infections, mental health conditions) were observed in most groups, and decreases in some protective factors (eg, participation in the California Women, Infants, and Children program) (P for trend < .001 from 2011 to 2021) were observed mostly in low-income groups. Conclusions and Relevance:In this cohort study of singleton live births in California, PTB rates increased in many groups. Persistent racial and ethnic and socioeconomic inequities were also observed. Changes in risk and protective factors provided clues to patterns of PTB. These data point to an urgent need to address factors associated with PTB at both the individual and population levels.

Background: Racial inequities in maternal and child health outcomes persist: Black women and birthing people experience higher rates of adverse outcomes than their white counterparts.Similar inequities are seen in coronavirus disease (COVID-19) mortality rates.In response, we sought to explore the intersections of racism and the COVID-19 pandemic impact on the daily lives and perinatal care experiences of Black birthing people.Methods: We used an intrinsic case study approach grounded in an intersectional lens to collect stories from Black pregnant and postpartum people residing in Fresno County (July-September 2020).All interviews were conducted on Zoom without video and were audio recorded and transcribed.Thematic analysis was used to group codes into larger themes.Results: Of the 34 participants included in this analysis, 76.5% identified as Black only, and 23.5% identified as multiracial including Black.Their mean age was 27.2 years [SD, 5.8].Nearly half (47%) reported being married or living with their partner; all were eligible for Medi-Cal insurance.Interview times ranged from 23 to 96 min.Five themes emerged: (1) Tensions about Heightened Exposure of Black Lives Matter Movement during the pandemic; (2) Fear for Black Son's Safety; (3) Lack of Communication from Health Care Professionals; (4) Disrespect from Health Care Professionals; and (5) Misunderstood or Judged by Health Care Professionals.Participants stressed that the Black Lives Matter Movement is necessary and highlighted that society views their Black sons as a threat.They also reported experiencing unfair treatment and harassment while seeking perinatal care.Conclusions: Black women and birthing people shared that exposure to racism has heightened during the COVID-19 pandemic, increasing their levels of stress and anxiety.Understanding how racism impacts Black birthing people's lives and care experiences is critical to reforming the police force and revising enhanced prenatal care models to better address their needs.

BACKGROUND:Black women in the United States (US) have the highest risk of preterm birth (PTB) and small for gestational age (SGA) births, compared to women of other racial groups. Among Black women, there are disparities by nativity whereby foreign-born women have a lower risk of PTB and SGA compared to US-born women. Differential exposure to racism may confer nativity-based differences in adverse perinatal outcomes between US- and foreign-born Black women. This remains unexplored among US- and African-born women in California. OBJECTIVES:Evaluate the relationship between structural racism, nativity, PTB and SGA among US- and African-born Black women in California. METHODS:We conducted a population-based study of singleton births to US- and African-born Black women in California from 2011 to 2017 (n = 131,424). We examined the risk of PTB and SGA by nativity and neighbourhoods with differing levels of structural racism, as measured by the Index of Concentration at the Extremes. We fit crude and age-adjusted Poisson regression models, estimated using generalized estimating equations, with risk ratios (RR) and 95% confidence intervals (CI) as the effect measure. RESULTS:The proportions of PTB and SGA were 9.7% and 14.5%, respectively, for US-born women, while 5.6% and 8.3% for African-born women. US-born women (n = 24,782; 20.8%) were more likely to live in neighbourhoods with high structural racism compared to African-born women (n = 1474; 11.6%). Structural racism was associated with an elevated risk of PTB (RR 1.19, 95% CI 1.12, 1.26) and SGA (RR 1.19, 95% CI 1.13, 1.25) for all Black women, however, there was heterogeneity by nativity, with US-born women experiencing a higher magnitude of effect than African-born women. CONCLUSIONS:Among Black women in California, exposure to structural racism and the impacts of structural racism on the risk of PTB and SGA varied by nativity.

IntroductionTraditional perinatal care alone cannot address the social and structural determinants that drive disparities in adverse birth outcomes. Despite the wide acceptance of partnerships between healthcare systems and social service agencies to address this challenge, there needs to be more research on the implementation factors that facilitate (or hinder) cross-sector partnerships, particularly from the perspective of community-based organizations. This study aimed to integrate the views of healthcare staff and community-based partner organizations to describe the implementation of a cross-sector partnership designed to address social and structural determinants in pregnancy. MethodsWe used a mixed methods design (in-depth interviews and social network analysis) to integrate the perspectives of healthcare clinicians and staff with those of community-based partner organizations to identify implementation factors related to cross-sector partnerships. ResultsWe identified seven implementation factors related to three overarching themes: relationship-centered care, barriers and facilitators of cross-sector partnerships, and strengths of a network approach to cross-sector collaboration. Findings emphasized establishing relationships between healthcare staff, patients, and community-based partner organizations. ConclusionThis study provides practical insights for healthcare organizations, policymakers, and community organizations that aim to improve access to social services among historically marginalized perinatal populations.

Background: The COVID-19 pandemic has been associated with increased social and economic stressors among pregnant individuals. While community and social services have been available to mitigate stressors in pregnancy (e.g. food insecurity and financial hardship) and reduce the risk of adverse maternal outcomes, it is unclear how the pandemic impacted access to these resources, particularly in communities of color with lower incomes. Objective: To examine the experiences accessing community and social service resources during the COVID-19 pandemic among pregnant people of color with low incomes. Design: Participants for this COVID-related qualitative study were recruited from two sources—a prospective comparative effectiveness study of two models of enhanced prenatal care and the California Black Infant Health Program between August and November of 2020. Methods: We conducted 62 interviews with Medicaid-eligible participants in California’s Central Valley. During their interviews, study participants were asked to share their pregnancy-related experiences, including how they felt the pandemic had affected those experiences. Results: We identified two broad themes: challenges with accessing community and social service resources during the pandemic and opportunities for improving access to these resources. Sub-themes related to challenges experienced included difficulty with remote access, convoluted enrollment processes for community and social services, and problems specific to accessing COVID-19 resources (e.g. testing). Sub-themes related to opportunities to improve access included leveraging instrumental support from perinatal staff and informational (e.g. practical) support from other community programs and pregnant peers. Participant recommendations included leveraging opportunities to improve client experiences through increased transparency and better patient–provider communication. Conclusion: This study highlights some important trends that emerged with the rollout of remote service delivery for social services among a vulnerable population. Many participants were able to leverage support through other programs and perinatal staff. These individuals identified additional opportunities to improve client experiences that can inform the future implementation of support services for pregnant people.

Recent evidence on perceived stress during the COVID-19 pandemic shows that birthing people experienced stress from pandemic-related stressors. While psychosocial stress is a significant predictor of adverse birth outcomes, social support can reduce stress levels during pregnancy. This study examined social support moderation of relationships between COVID-19-related stressors and perceived stress during pregnancy. The analysis included data from publicly insured pregnant participants who were enrolled in a randomized control trial of two enhanced prenatal care models in Fresno, California, and completed a third-trimester questionnaire between April and August 2020 (n = 77). Multivariate linear regression was used to estimate the associations between perceived stress and COVID-19-related stressors and social support moderation. COVID-19-related stressors related to childcare and tension at home remained significantly associated with perceived stress adjusting for sociodemographic characteristics and other COVID-19-related stressors. Social support moderated the relationship between perceived stress and loss of childcare (beta = 2.4, 95 percent CI = 0.5-4.3, p = .014). Overall, social support moderated the association between COVID-19 stressors and perceived stress. While social support is commonly conceptualized as protective, the finding of greater stress around childcare among individuals reporting greater social support suggests complexity for leveraging these support networks during the pandemic.

To create and test a preterm birth (PTB) risk and resiliency score that includes variables associated with social determinants of health (SDoH). The sample included a training and testing population of liveborn infants in California (2016 to 2018, n = 1,225,479). Data were obtained from linked birth certificates, hospital records, CalEnviroscreen, and Health Professional Shortage Areas. SDoH variables included race/ethnicity, payer, educatio, language, housing status, comorbidities, residing in a health care shortage area, and census tract indicators (e.g., percent of the population living below two-times the federal poverty level). Forty-three demographic and clinical factors were included in a final logistic model for preterm birth. Risk and resiliency scores were created by adding beta-coefficients developed in the model. Resiliency factors had negative values, while risk factors had positive values. Rates of PTB and other adverse outcomes (preeclampsia, placental abruption, placenta previa, antepartum hemorrhage, early term birth, small for gestational age infant, neonatal death, and infant preterm birth-related morbidities) were calculated as a risk and resiliency score in the training and testing samples. In the testing population, fewer than 5% of people with a risk and resiliency score ≤0.0 had a preterm birth, while 9.4% of people with a score between >0.0 to < 1.0; 23.0% of people with a score of 1.0 to < 2.0; 35.9% of people with a score of 2.0 to < 3.0; 56.0% of people with a score of 3.0 to < 4.0 and 64.0% of people with a score ≥4.0 had a PTB. Risk and resiliency scores for PTB were similarly predictive of other adverse birth outcomes. Maternal factors, including SDoH, can be combined to create a cumulative risk and resiliency score to identify women at the lowest and highest risk for PTB. These findings were robust across race/ethnicity by socioeconomic status groupings, suggesting that such scoring could be useful in developing personalized, precision-focused research or care approaches across groups.

Objective Examine the risk of adverse perinatal outcomes among the United States (US)-born and foreign-born Black women in California. Study design The study comprised all singleton live births to Black women in California between 2011 and 2017. We defined maternal nativity as US-born or foreign-born. Using Poisson regression, we computed risk ratios (RR) and 95% confidence intervals (CI) for three adverse perinatal outcomes: preterm birth, small for gestational age deliveries, and infant mortality. Results Rates of adverse perinatal outcomes were significantly higher among US-born Black women. In adjusted models, US-born Black women experienced an increased risk of preterm birth (RR 1.51, 95% CI 1.39, 1.65) and small for gestational age deliveries (RR 1.52, 95% CI 1.41, 1.64), compared to foreign-born Black women. Conclusions Future studies should consider experiences of racism across the life course when exploring heterogeneity in the risk of adverse perinatal outcomes by nativity among Black women in the US.

To describe racial/ethnic discrimination experienced across situational domains and within medical care settings among low-income pregnant women. This analysis includes baseline data collected as part of the Engaging Mothers and Babies - Reimagining Antenatal Care for Everyone (EMBRACE) Study being conducted in Fresno, California. 101 Medi-Cal eligible participants were enrolled from 11/2019 through 3/2020 . Racial/ethnic discrimination was measured at baseline using the modified Experiences of Discrimination (EOD) scale and the Discrimination in Medical Care (DMC) scale. Response options were recoded to “yes” or “no” to ever having experienced racial or ethnic discrimination in 9 situational domains (e.g., ‘at school’) for the EOD scale, and 7 experiences (e.g., ‘you receive poorer service than others’) for the DMC scale. Descriptive statistics were calculated to describe these experiences of racial/ethnic discrimination. The mean age of the participants was 26.5. Most of these women identify as Latinx (n 66, 65%), are married/partnered (n 71, 70%), and are English speaking (n 85, 84%). Half of the women reported experiencing racial/ethnic discrimination in one or more situational domains (n 48, 48%) across their lifetime. The most frequent domains were stores or restaurants (n 28, 28%), and public settings (n 35, 35%) (Figure 1). In the medical care setting, half of the participants reported experiencing racial/ethnic discrimination during one or more interactions with a physician or nurse (n 48, 48%) across their lifetimes. The most frequent affirmative responses were to the statements that “A doctor or nurse is not listening to what you are saying” (n 37, 37%) and “A doctor or nurse acts as if he/she thinks you are not smart” (n 26, 26%) (Figure 2). Experiences of racial/ethnic discrimination varied in this sample of low-income pregnant women. The fact that nearly half of the participants reported experiences of discrimination is very problematic; concrete steps should be taken to eliminate this widespread and serious threat to the quality of prenatal care.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: This study aims to compare preterm birth (PTB) risk and maternal factors associated with PTB among non-Hispanic White, Black, and mixed-race Black/White women in the United States. Methods: In this study, we used U.S. birth certificate data from the 2017 National Vital Statistics System. We included live singleton births to women who self-identified as non-Hispanic White, Black, or mixed-race Black/White. PTB was defined as less than 37 weeks of gestation. We used logistic regression models to estimate the PTB odds ratios for Black and Black/White relative to White women, adjusted for maternal factors. We used logistic regression to estimate as-sociations between PTB and maternal factors in race-stratified models. Results: The sample included a total of 2,297,076 births in 2017 to White (n =1,792,257), Black (n = 476,969), and Black/ White (n = 27,850) women. The prevalence of PTB varied for Black (11.2%), Black/White (8.2%), and White (6.8%) women. The odds of PTB compared with White differed for Black (odds ratio, 1.51; 95% confidence interval, 1.49-1.53) and Black/ White (odds ratio, 1.13; 95% confidence interval, 1.08-1.18) women after adjusting for maternal factors. The odds of PTB associated with maternal sociodemographic, prepregnancy, and gestational factors differed by maternal race. Conclusions: Evaluation of PTB risk among White, Black, and Black/White women revealed distinct associations between PTB and maternal factors for Black/White women. This study highlights the need for research assessing the relationships between social risk factors such as colorism and racism and the outcome of PTB, and it provides evidence that may inform more targeted PTB prevention among Black/White and Black women. (c) 2021 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights reserved.

The causes of preterm birth are multi-dimensional and vary across the reproductive life course. Limited data exist about preterm birth (PTB, <37 weeks gestation) among youth (individuals ≤24 years) in California. This study aimed to examine the associations between various maternal characteristics and PTB among youth. Population-based retrospective cohort of California singleton live births to youth between 2011-2017. Race/ethnicity was self-reported. PTB was identified using linked birth certificate and hospital discharge records. Multivariable logistic regression was conducted to determine the association between maternal characteristics and PTB. The overall prevalence of PTB among youth was 27.0% (n=69,575 of 257,957). Among those who had a PTB, 63.9% were Hispanic, 16.0% White, 10.3% Black, and 3.9% Asian. PTB risk factors included being <15 years of age (OR: 1.8 95% CI: 1.5-2.1), smoking (OR: 1.3 95% CI: 1.2-1.3), receiving inadequate prenatal care (OR: 1.6 95% CI: 1.5–1.6), pre-pregnancy hypertension (OR: 2.7 95% CI: 2.5-2.9), and drug use (OR: 1.7 95% CI: 1.6–1.8). Higher levels of education (OR: 0.89 95% CI: 0.87-0.92), Medi-Cal insurance (OR: 0.97 95% CI: 0.95–0.99), WIC participation (OR: 0.76 95% CI: 0.75-0.78), and interpregnancy intervals ≤ 24 months (OR: 0.92 95%CI: 0.90–0.95) were associated with lower PTB risk among youth ≤ 24 years. Factors associated with PTB vary among youth. Education, public insurance, and longer interpregnancy intervals are protective against PTB among youth in California. Future research is needed to better understand this phenomenon.

Introduction: Our understanding of the association between coronavirus disease 19 (COVID-19) and preterm or early term birth among racially and ethnically diverse populations and people with chronic medical conditions is limited.Methods: We determined the association between COVID-19 and preterm (PTB) birth among live births documented by California Vital Statistics birth certificates between July 2020 and January 2021 (n=240,147). We used best obstetric estimate of gestational age to classify births as very preterm (VPTB, <32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks), as each confer independent risks to infant health and development. Separately, we calculated the joint effects of COVID-19 diagnosis, hypertension, diabetes, and obesity on PTB and VPTB.Findings: COVID-19 diagnoses on birth certificates increased for all racial/ethnic groups between July 2020 and January 2021 and were highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). There was no effect modification of the overall association by race/ethnicity or insurance status. COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity.Interpretation: In a large population-based study, COVID-19 diagnosis increased the risk of VPTB, PTB, and early term birth, particularly among people with medical comorbidities. Considering increased circulation of COVID-19 variants, preventative measures, including vaccination, should be prioritized for birthing persons.Funding: UCSF-Kaiser Department of Research Building Interdisciplinary Research Careers in Women's Health Program (BIRCWH) National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH) [K12 HD052163] and the California Preterm Birth Initiative, funded by Marc and Lynn Benioff.

BACKGROUND: Birthing people of color are more likely to deliver low birthweight and preterm infants, populations at significant risk of morbidity and mortality. Birthing people of color are also at higher risk for mental health conditions and emergency mental healthcare utilization postpartum. Although this group has been identified as high risk in these contexts, it is not known whether racial and ethnic disparities exist in mental healthcare utilization among birthing people who have delivered preterm. OBJECTIVE: We sought to determine if racial and ethnic disparities exist in postpartum mental healthcare-associated emergency department visits or hospitalizations for birthing people with preterm infants in a large and diverse population. STUDY DESIGN: This population-based historic cohort study used a sample of Californian live-born infants born between 2011 and 2017 with linked birth certificates and emergency department visit and hospital admission records from the California Statewide Health Planning and Development database. The sample was restricted to preterm infants (<37 weeks' gestation). Self-reported race and ethnicity groups included Hispanic, non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, and non-Hispanic others. Mental health diagnoses were identified from the International Classification of Diseases Ninth and Tenth revision codes recorded in emergency department and hospital discharge records. Logistic regression analysis was used to estimate the association between mental health-related emergency department visits and rehospitalizations by race or ethnicity compared with non-Hispanic White birthing people and controlling for the following characteristics and health condition covariates: age, parity, previous preterm birth, body mass index, smoking, alcohol use, hypertension, diabetes, previous mental health diagnosis, and prenatal care. RESULTS: Of 204,539 birthing people who delivered preterm infants in California, 1982 visited the emergency department and 836 were hospitalized in the first year after preterm birth for a mental health-related illness. Black birthing people were more likely to have a mental health-related emergency department visit and hospitalization (risk ratio, 1.8; 95% confidence interval, 1.5-2.0 and risk ratio, 1.9; 95% confidence interval, 1.5-2.3, respectively) within the first postpartum year than White birthing people. Hispanic and Asian birthing people were less likely to have mental health-related emergency department visits (adjusted risk ratio, 0.7; 95% confidence interval, 0.7-0.8 and adjusted risk ratio, 0.2; 95% confidence interval, 0.2-0.3, respectively) and hospitalizations (adjusted risk ratio, 0.6; 95% confidence interval, 0.5 -0.7 and adjusted risk ratio, 0.2; 95% confidence interval, 0.1-0.3, respectively). When controlling for birthing people with a previous mental health diagnosis and those without, the disparities remained the same. CONCLUSION: Racial and ethnic disparities exist in emergency mental healthcare escalation among birthing people who have delivered preterm infants. Our findings highlight a need for further investigation into disparate mental health conditions, exacerbations, access to care, and targeted hospital and legislative policies to prevent emergency mental healthcare escalation and reduce disparities.

Non-Hispanic Black women remain at increased risk for adverse birth outcomes, yet Black immigrant women are at lower risk than their US-born counterparts. This study examines whether neighborhood context contributes to the nativity advantage in preterm birth (PTB, < 37 weeks) among Black women in California. A sample of live singleton births to non-Hispanic US-born (n = 83,169), African-born (n = 7151), and Caribbean-born (n = 943) Black women was drawn from 2007 to 2010 California birth records and geocoded to urban census tracts. We used 2010 American Community Survey data to measure tract-level Black immigrant density, Black racial concentration, and a neighborhood deprivation index. Risk ratios (RR) and 95% confidence intervals (95%CI) were estimated using log-binomial regression to assess whether neighborhood context partially explained nativity differences in PTB risk. Compared to US-born Black women, African-born Black women had lower PTB risk (RR = 0.65, 95%CI: 0.60-0.71). The difference in PTB risk between US- and Caribbean-born women did not reach statistical significance (RR = 0.87, 95%CI: 0.71-1.05). The nativity advantage in PTB risk was robust to neighborhood social conditions and maternal factors for African-born women (RR = 0.59, 95%CI: 0.51-0.67). This study is one of few that considers area-level explanations of the nativity advantage among Black immigrants and makes a significant contribution by showing that the neighborhood context does not explain the nativity advantage in PTB among Black women in California. This could be due to many factors that should be examined in future research.

Perceived stress during pregnancy is associated with adverse maternal, infant, and childhood outcomes, and increases in stress since the advent of the COVID-19 pandemic have been widely reported. We sought to assess the relationship between perceived stress and COVID-19-related worry in pregnancy. Prior to the COVID-19 pandemic, we initiated a study of two enhanced prenatal care models among English- or Spanish-speaking low-income women in Fresno, CA. Recruitment was halted at the onset of the pandemic, providing an opportunity to assess COVID-19 worry and other COVID-related issues among the 101 women who had enrolled. This analysis focuses on the 79 women who completed a third trimester COVID questionnaire. We used linear regression analysis to test the hypothesis that COVID worry (measured using a scale we developed for the study, adapted in part from the Cambridge Worry Scale; scores range from 1 to 10) is associated with perceived stress (measured using the Perceived Stress Scale (PSS); scores range from 0 to 40). One bivariable and two multivariable models were run: one in which all other variables that we hypothesized could be related to PSS were included (Model 2), and a second in which we used backwards elimination (Model 3). Most of the sample (86.1%) self-identified as Latinx, Black, or bi/multiracial (with Black and/or Latinx as one of their race/ethnicities). 58.2% reported no more than a high school education. The mean COVID worry scale score was 5.4 (2.3); the mean PSS score was 12.2 (7.3). COVID-19 worry was associated with PSS in the bivariable analysis (β =1.14 (0.33), p=.001 and after adjustment for maternal factors (Model 2: β=0.92 (0.39), p=.02). In Model 3, COVID worry remained significantly associated with increased PSS (β =1.04 (0.32), p=.002), and being foreign-born was associated with lowered PSS (β =-3.51 (1.67), p=.04). COVID worry is associated with increased stress in this pregnant population. Whether this will lead to higher incidence of adverse birth outcomes remains to be determined.