Tyan Parker Dominguez, PhD, MPH, MSW School of Social Work University of Southern California

Tyan Parker Dominguez, PhD, MPH, MSWTyan Parker Dominguez, PhD, MPH, MSWSchool of Social WorkSchool of Social Work

University of Southern CaliforniaUniversity of Southern California

BIOPSYCHOSOCIAL CONTRIBUTORS BIOPSYCHOSOCIAL CONTRIBUTORS

TO RACIAL DISPARITIES IN TO RACIAL DISPARITIES IN

ADVERSE BIRTH OUTCOMESADVERSE BIRTH OUTCOMES

1) Discuss stress paradigm and links to 1) Discuss stress paradigm and links to adverse health outcomesadverse health outcomes

2) Describe ethnic differences in 2) Describe ethnic differences in lifetime exposure and impact on lifetime exposure and impact on outcomes in pregnancy outcomes in pregnancy

3) Identify physiological mechanisms3) Identify physiological mechanisms

OBJECTIVESOBJECTIVES

African-Americans have the highest infant mortality rate and the highest rates of low birthweight and preterm delivery of all

racial and ethnic groups in this country

Persistent Racial Disparity

• In childhood:In childhood:Cerebral palsy, epilepsy, chronic lung disease, Cerebral palsy, epilepsy, chronic lung disease, deafness, blindness, ADHD, cognitive deficits, deafness, blindness, ADHD, cognitive deficits, learning disabilitieslearning disabilities

• In adulthood:In adulthood:Cardiovascular disease, diabetes, hypertensionCardiovascular disease, diabetes, hypertension(Barker thesis)(Barker thesis)

RELATED SEQUELAERELATED SEQUELAE

INFANTINFANT

• BirthweightBirthweight• Gestational age Gestational age • Fetal GrowthFetal Growth

• Gestational ageGestational age

MOTHERMOTHER

• BirthweightBirthweight

• Gestational ageGestational age

Intergenerational Perpetuation of RiskIntergenerational Perpetuation of Risk

Disparity not explained by establishedDisparity not explained by established

SociodemographicSociodemographic

BehavioralBehavioral

MedicalMedical

risk factorsrisk factors

Berkowitz & Papiernik, 1993; Collins & David, 1990; David & Collins, 1991; Frisbie, Biegler, de Turk, Forbes, & Pullum, 1997; Berkowitz & Papiernik, 1993; Collins & David, 1990; David & Collins, 1991; Frisbie, Biegler, de Turk, Forbes, & Pullum, 1997; Kleinman & Kessel, 1987; Shiono, Klebanoff, Graubard, Berendes, & Rhoads, 1986; Wise, 1993Kleinman & Kessel, 1987; Shiono, Klebanoff, Graubard, Berendes, & Rhoads, 1986; Wise, 1993

P s y c h o s o c i a l S t r e s sP s y c h o s o c i a l S t r e s s

Environmental demands that tax or Environmental demands that tax or

exceed the adaptive capacity of an exceed the adaptive capacity of an

organism, resulting in physiological organism, resulting in physiological

and psychological changes that may and psychological changes that may

place the organism at risk for place the organism at risk for

diseasediseaseCohen, Kessler, & Gordon, 1995Cohen, Kessler, & Gordon, 1995

BirthweightBirthweight

Gestational lengthGestational length

Stressful life eventsStressful life events

Events distressEvents distress

Perceived stressPerceived stress

State anxietyState anxiety

Pregnancy anxietyPregnancy anxiety

THE EVIDENCETHE EVIDENCE

African-Americans face greater and more African-Americans face greater and more

severe stressors earlier in life, encounter them severe stressors earlier in life, encounter them

more frequently, and perceive these events as more frequently, and perceive these events as

more stressful than do other groupsmore stressful than do other groups

Askenasy, Dohrenwend, & Dohrenwend, 1977; Askenasy, Dohrenwend, & Dohrenwend, 1977; Dohrenwend, 1973; Feldman, Dunkel-Schetter, Woo & Dohrenwend, 1973; Feldman, Dunkel-Schetter, Woo &

Hobel, 1997; Myers, 1982; Zambrana et al., 1999 Hobel, 1997; Myers, 1982; Zambrana et al., 1999

A Biopsychosocial ModelA Biopsychosocial Model

Neuroendocrine Neuroendocrine systemsystem

Immune Immune systemsystem

Cardiovascular Cardiovascular systemsystem

STRESSSTRESSBirth Birth

outcomesoutcomes

NeuroendocrineNeuroendocrineSystemSystem

Placental CRH controls placental clockPlacental CRH controls placental clock

Maternal stress maternal CRH, ACTH, Maternal stress maternal CRH, ACTH,

cortisol releasedcortisol released

Triggers additional CRH expression in placentaTriggers additional CRH expression in placenta

THE HPA AXISTHE HPA AXIS

Elevated levels of CRH significantly related to…Elevated levels of CRH significantly related to…

• PRETERM LABOR PRETERM LABOR (Korebritis et al, 1998; Wadhwa et al, (Korebritis et al, 1998; Wadhwa et al, 1998)1998)

• PRETERM DELIVERY PRETERM DELIVERY (Hobel et al, 1999; McLean et al, (Hobel et al, 1999; McLean et al, 1995; Wadhwa et al, 2004)1995; Wadhwa et al, 2004)

• FETAL GROWTH RESTRICTION FETAL GROWTH RESTRICTION (Wadhwa et al, (Wadhwa et al, 2004)2004)

independent of medical riskindependent of medical risk

ImmuneImmuneSystemSystem

Paternal antigens immunosuppressionPaternal antigens immunosuppression

Stress immunosuppressionStress immunosuppression

Infection major risk factor for PTDInfection major risk factor for PTD

BV most common; AfrAms highest prevalenceBV most common; AfrAms highest prevalence

Proinflammatory cytokines promote placental CRH Proinflammatory cytokines promote placental CRH

expressionexpression

INFECTIONINFECTION

High maternal stress significantly associated with…High maternal stress significantly associated with…

• DEPRESSED LYMPHOCYTE ACTIVITY DEPRESSED LYMPHOCYTE ACTIVITY (Herrera et al, 1998)(Herrera et al, 1998)

• BACTERIAL VAGINOSIS BACTERIAL VAGINOSIS (Culhane et al, 2001)(Culhane et al, 2001)

independent of confoundersindependent of confounders

CardiovascularCardiovascularSystemSystem

Stress cardiovascular disordersStress cardiovascular disorders

Preg-induced hypertension and preeclampsia Preg-induced hypertension and preeclampsia

Major risk factors for PTDMajor risk factors for PTD Significantly elevated CRH levels Significantly elevated CRH levels (Jeske et al, 1990; (Jeske et al, 1990;

Perkins et al, 1995; Warren et al, 1995)Perkins et al, 1995; Warren et al, 1995)

HYPERTENSIVE DISORDERSHYPERTENSIVE DISORDERS

• Elevated CRH related to abnormal Elevated CRH related to abnormal UTEROPLACENTAL BLOOD FLOW UTEROPLACENTAL BLOOD FLOW (Giles et al, (Giles et al, 1996)1996)

• DBP REACTIVITY to stressor task predicted DBP REACTIVITY to stressor task predicted gestational length and infant birthweight gestational length and infant birthweight (McCubbin (McCubbin et al, 1996)et al, 1996)

• Maternal anxiety associated with PULSATILITY Maternal anxiety associated with PULSATILITY INDEX INDEX (Sjostrom et al, 1997; Teixeria et al, 1999)(Sjostrom et al, 1997; Teixeria et al, 1999)

The health of minority groups is intimately The health of minority groups is intimately

connected to the connected to the HIGH STRESS HIGH STRESS STATESSTATES

created by a social system that condones, created by a social system that condones,

reinforces, and perpetuates racial reinforces, and perpetuates racial

discrimination.discrimination. Myers, 1982

Negative Self-Society DialecticNegative Self-Society Dialectic

RACISM LINKED TORACISM LINKED TODecreased life satisfactionDecreased life satisfaction

PRETERM PRETERM DELIVERYDELIVERYLOW LOW

BIRTHWEIGHTBIRTHWEIGHT

INFANT INFANT MORTALITYMORTALITY

Cardiovascular diseaseCardiovascular diseaseStrokeStroke

High blood pressureHigh blood pressure

Psychological distressPsychological distress DepressionDepression

Lower self-esteemLower self-esteem

Few groups, if any, have experienced Few groups, if any, have experienced

for so long the kind and degree of for so long the kind and degree of

discrimination that US-born Blacks discrimination that US-born Blacks

have faced.have faced.

- Singh & Yu, 1996- Singh & Yu, 1996

. . . a likely fundamental cause of the. . . a likely fundamental cause of the

nations’s enduring racial/ethnic nations’s enduring racial/ethnic

disparities in health disparities in health

- James, 2003- James, 2003

RACISMRACISM

ALLOSTATIC LOADALLOSTATIC LOADPhysiologic toll of repeated and/or chronic Physiologic toll of repeated and/or chronic

stress system activationstress system activation

StressStress

BaselineBaseline

RecoveryRecovery

AllostasisAllostasis Allostatic LoadAllostatic Load

BaselineBaseline

McEwen & Stellar, 1993; Sterling & Eyer, 1988McEwen & Stellar, 1993; Sterling & Eyer, 1988

• WeatheringWeathering (Geronimus, 1992)(Geronimus, 1992)

• as African-American women aged, their risk of as African-American women aged, their risk of delivering a low birthweight infant delivering a low birthweight infant significantly increased significantly increased

• Socioeconomic status moderated the effectSocioeconomic status moderated the effect

• Relationship not evident in White women Relationship not evident in White women

• accelerated decline in health statusaccelerated decline in health status in response in response to the cumulative effects of social inequalityto the cumulative effects of social inequality

Physiological Impact of InequalityPhysiological Impact of Inequality

• AfrAms show heightened & AfrAms show heightened & prolonged cardiovascular reactivity prolonged cardiovascular reactivity to racist stimulito racist stimuli (Armstead et al, 1989; Guyll et al, 2001)(Armstead et al, 1989; Guyll et al, 2001)

• Hypertension = cardiovascular dysregulation Hypertension = cardiovascular dysregulation caused by hyperreactivity to stresscaused by hyperreactivity to stress (Manuck, (Manuck, Kasprowicz, & Muldoon, 1990Kasprowicz, & Muldoon, 1990)

• AfrAms highest rates of general hypertension, AfrAms highest rates of general hypertension, hypertensive disorders in pregnancyhypertensive disorders in pregnancy

Physiological Impact of RacismPhysiological Impact of Racism

• AfrAms report PTSD-like symptomsAfrAms report PTSD-like symptoms (Thompson, 1996)(Thompson, 1996)

• PTSD associated w/ HPA axis dysregulationPTSD associated w/ HPA axis dysregulation

• Evident in AfrAm adolescent girls and Evident in AfrAm adolescent girls and pregnant womenpregnant women

Physiological Impact of RacismPhysiological Impact of Racism

Are there ethnic differences in perceived Are there ethnic differences in perceived lifetime exposure to racism events?lifetime exposure to racism events?

Are there ethnic differences in the impact Are there ethnic differences in the impact of racism on psychosocial functioning?of racism on psychosocial functioning?

Are there ethnic differences in the impact Are there ethnic differences in the impact of racism on birth outcomes?of racism on birth outcomes?

A MULTIETHNIC COMPARISONA MULTIETHNIC COMPARISON

Prospective, repeated measures surveyProspective, repeated measures survey

Psychosocial, medical, physiological variablesPsychosocial, medical, physiological variables

480 Ethnically/socioeconomically diverse 480 Ethnically/socioeconomically diverse

pregnant womenpregnant women

Recruited in clinics or referred by private Recruited in clinics or referred by private

MDsMDs

Fluent EnglishFluent English

>> 18 yrs, 18 yrs, < < 18 wks gestation, non-smokers18 wks gestation, non-smokers

MS-BIPS DESIGNMS-BIPS DESIGN

70 70 LatinasLatinas

177 177 Nonhispanic WhitesNonhispanic Whites

25 25 Asian/Pacific IslandersAsian/Pacific Islanders

5151 African-AmericansAfrican-Americans

with racism datawith racism data

SAMPLE consisted ofSAMPLE consisted of

Variable AfrAm API Latina White p-value

Income 2.3(1.7) 3.6(1.8) 2.0(1.4) 4.0(1.6) 0.000

College 19.6% 60.0% 17.1% 66.1% 0.000

Work 45.1% 60.0% 70.0% 77.0% 0.000

Cohab 66.7% 100.0% 88.6% 94.8% 0.000

US born 100.0% 48.0% 75.7% 93.1% 0.000

SOCIODEMOGRAPHICSSOCIODEMOGRAPHICS

Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004

Are there ethnic differences Are there ethnic differences

in perceived lifetime exposure in perceived lifetime exposure

to racism?to racism?

Have you ever felt that you (or someone Have you ever felt that you (or someone

close) were discriminated against or the close) were discriminated against or the

target of prejudice b/c of race in target of prejudice b/c of race in

interpersonal, housing, employment, interpersonal, housing, employment,

educational, other situations?educational, other situations?

INTERPERSONAL RACISMINTERPERSONAL RACISM


DSCR_C 3.2(3.2) 3.1(2.4) 1.4(1.9) 1.0(1.7) 0.000

DSCR_D 72.5% 88.0% 54.3% 40.7% 0.000

RACISM EXPERIENCESRACISM EXPERIENCES

LIFETIMELIFETIME

Unadj: APIs & AFrAms / Latinas & Whites

Adj: Latinas / Whites



PERS_C 1.5(1.7) 1.6(1.6) 0.7(0.9) 0.5(0.9) 0.000

PERS_D 58.7% 72.0% 44.3% 27.4% 0.000


PERSONALPERSONAL





VIC_C 1.9(2.0) 1.5(2.0) 0.8(1.3) 0.5(1.1) 0.000

VIC_D 63.0% 60.0% 37.1% 29.9% 0.000


VICARIOUSVICARIOUS





Child_C 1.5(1.8) 1.8(1.9) 0.9(1.4) 0.5(1.0) 0.000

Child_D 51.1% 80.0% 40.0% 25.6% 0.000


AS A CHILDAS A CHILD

Unadj: APIs & AfrAms / Latinas & Whites

Adj: AfrAms do not differ from Latinas



Adult_C 2.0(2.2) 1.3(1.8) 0.6(0.9) 0.5(1.0) 0.000

Adult_D 63.0% 60.0% 37.1% 29.9% 0.000


AS AN ADULTAS AN ADULT

Unadj: APIs &AFrAms / Latinas & Whites



DISTRESSDISTRESS

AfrAms and Latinas were significantly less distressed than APIs and Whites

RESPONSERESPONSE

•AfrAms significantly more likely to keep racism experiences to themselves

•AfrAms significantly more likely to accept unfair treatment as a fact of life


in the impact of racism on in the impact of racism on

psychosocial functioning psychosocial functioning

in pregnancy?in pregnancy?

Stressful Life EventsStressful Life Events

Perceived Stress (PSS)Perceived Stress (PSS)

State Anxiety (STAI)State Anxiety (STAI)

Pregnancy-related AnxietyPregnancy-related Anxiety

Depression (CES-D)Depression (CES-D)

Personal ResourcesPersonal Resources

PSYCHOSOCIAL FUNCTIONINGPSYCHOSOCIAL FUNCTIONING

ETHNIC DIFFERENCESETHNIC DIFFERENCES

UnadjustedUnadjusted

AfrAms & Latinas higher AfrAms & Latinas higher PSSPSS than Whites than Whites

AfrAms higher AfrAms higher CES-DCES-D than Whites than Whites

Latinas marginally higher Latinas marginally higher Preg AnxPreg Anx than than WhitesWhites

AdjustedAdjusted

Whites lower Whites lower Preg AnxPreg Anx than Latinas and APIs than Latinas and APIs


Associations with RacismAssociations with Racism

VariableVariable rr bb

PSSPSS 0.270.27**** 0.230.23****

STAISTAI 0.300.30**** 0.300.30****

Preg AnxPreg Anx 0.240.24**** 0.220.22****

CES-DCES-D 0.180.18**** 0.150.15**

ResourcesResources -0.14-0.14** -0.14-0.14*** p<0.05, ** p<0.01* p<0.05, ** p<0.01


No evidence that racism’s o evidence that racism’s

impact on psychosocial impact on psychosocial

functioning was moderated functioning was moderated

by race.by race.

INTERACTIONSINTERACTIONS


in the impact of racism on in the impact of racism on

birth outcomes?birth outcomes?

White 3484.40 (554.63)

Latina 3447.33 (600.21)

API 3226.88 (715.70)

AfrAm 3216.86 (508.72)

BIRTHWEIGHT DIFFERENCESBIRTHWEIGHT DIFFERENCES

Unadj: Whites / AfrAms

Adj: Whites / AfrAms & APIs


White 39.15 (1.60)

Latina 38.76 (2.00)

API 38.14 (2.77)

AfrAm 38.60 (1.96)

Gestational Age DifferencesGestational Age Differences

Unadj: Whites / APIs (marginal)

Adj: NS


Associations with RacismAssociations with Racism

VariableVariable rr bb

BWBW -0.13-0.13** -0.13-0.13**

GAGA -0.12-0.12** -0.12-0.12**

*p<0.05*p<0.05


No evidence that racism’s o evidence that racism’s

impact on birth outcomes impact on birth outcomes

was moderated by race.was moderated by race.

INTERACTIONSINTERACTIONS

Ethnic differences in racism exposure, distress, Ethnic differences in racism exposure, distress,

and copingand coping

Racism impacts psychosocial fx and birth Racism impacts psychosocial fx and birth

outcomesoutcomes

Physiological mediators important to elucidatePhysiological mediators important to elucidate

ConclusionsConclusions

Christine Dunkel SchetterChristine Dunkel Schetter

Department of Psychology, UCLADepartment of Psychology, UCLA

Curt SandmanCurt Sandman

Department of Psychiatry, UC-IrvineDepartment of Psychiatry, UC-Irvine

Laura GlynnLaura Glynn

Department of Psychiatry, UC-IrvineDepartment of Psychiatry, UC-Irvine

Calvin J. HobelCalvin J. Hobel

Department of Maternal/Fetal Med, Cedars-SinaiDepartment of Maternal/Fetal Med, Cedars-Sinai

AcknowledgementsAcknowledgements

Tyan Parker Dominguez, PhD, MPH, MSW School of Social Work University of Southern California

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