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Dynamic changes in place-based measures of structural racism and preterm birth in the USA
  1. Abhery Das1,
  2. Joan A Casey2,3,
  3. Alison Gemmill4,
  4. Ralph Catalano5,
  5. Hedwig Lee6,
  6. Allison Stolte7,8,
  7. Brenda Bustos7,8,
  8. Tim A Bruckner7,8
  1. 1Health Policy and Administration, University of Illinois Chicago, Chicago, Illinois, USA
  2. 2Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
  3. 3Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA
  4. 4Department of Family, Population and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  5. 5Public Health, University of California Berkeley, Berkeley, California, USA
  6. 6Department of Sociology, Duke University, Durham, North Carolina, USA
  7. 7Health, Society and Behavior, University of California Irvine, Irvine, California, USA
  8. 8Center for Population, Inequality, and Policy, University of California Irvine, Irvine, California, USA
  1. Correspondence to Abhery Das, Health Policy and Administration, University of Illinois Chicago, Chicago, Illinois, USA; abhery{at}


Background Structurally racist systems, ideologies and processes generate and reinforce inequities among minoritised racial/ethnic groups. Prior cross-sectional literature finds that place-based structural racism, such as the Index of Concentration at the Extremes (ICE), correlates with higher infant morbidity and mortality. We move beyond cross-sectional approaches and examine whether a decline in place-based structural racism over time coincides with a reduced risk of preterm birth across the USA.

Methods We used as the outcome count of preterm births overall and among non-Hispanic (NH) black and NH white populations across three epochs (1998–2002, 2006–2010, 2014–2018) in 1160 US counties. For our measure of structural racism, we used ICE race/income county measures from the US Census Bureau. County-level fixed effects Poisson models include a population offset (number of live births) and adjust for epoch indicators, per cent poverty and mean maternal age within counties.

Results An SD increase in ICE (0.11) over time corresponds with a 0.6% reduced risk of preterm birth overall (incidence rate ratio (IRR): 0.994, 95% CI 0.990, 0.998), a 0.6% decrease in preterm risk among NH black births (IRR: 0.994, 95% CI 0.989, 0.999) and a 0.4% decrease among NH white births (IRR: 0.996, 95% CI 0.992, 0.999).

Conclusions Movement away from county-level concentrated NH black poverty preceded reductions in preterm risk, especially among NH black populations. Our longitudinal design strengthens inference that place-based reductions in structural racism may improve perinatal health. These improvements, however, do not appear sufficient to redress large disparities.


Data availability statement

Data are available upon reasonable request. Aggregated datasets and statistical code are available from the corresponding author upon request.

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Data availability statement

Data are available upon reasonable request. Aggregated datasets and statistical code are available from the corresponding author upon request.

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  • Contributors AD conducted the data collection/analysis with AS. AD and TB drafted the manuscript. TB, AS, JAC, AG, HL, RC and BB reviewed the analysis and manuscript. TB provided funding and served as the guarantor.

  • Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development (Grant R01HD103736).

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  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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