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					           PSYCHOSOCIAL STRESS AND

           PERSISTENT RACIAL

           DISPARITIES IN ADVERSE

           BIRTH OUTCOMES




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

1) Review the nature of persistent racial
   disparities in adverse birth outcomes

2) Discuss the stress and pregnancy
   paradigm, highlighting physiological
   mechanisms

3) Present research findings from work on
   stress and birth outcomes
      Infant Mortality
deaths before age 1 per 1000 live births

  OVERALL                             6.8
  NONHISPANIC WHITE                   5.7
  HISPANIC                            5.4
  ASIAN/PACIFIC                       4.7
  ISLANDER

  NONHISPANIC BLACK                 13.5



                            Mathews, Menacker, & MacDorman, 2003
     Preterm Birth
      < 37 weeks gestation

OVERALL                                 12.1%
NONHISPANIC WHITE                       11.0%
HISPANIC                                11.6%
ASIAN/PACIFIC                           10.4%
ISLANDER

NONHISPANIC BLACK                        17.7%



                Martin, Hamilton, Sutton, Ventura, Menacker, & Munson, 2003
    Low Birthweight
           < 2500 grams

OVERALL                                   7.8%
NONHISPANIC WHITE                         6.9%
HISPANIC                                  6.5%
ASIAN/PACIFIC                             7.8%
ISLANDER

NONHISPANIC BLACK                        13.4%



                Martin, Hamilton, Sutton, Ventura, Menacker, & Munson, 2003
       Disparity not explained by established

                                                       Sociodemographic

                                                       Behavioral

                                                       Medical

                                                       risk factors


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, 1993
Psychosocial Stress
  Environmental demands that tax or
  exceed the adaptive capacity of an
  organism, resulting in physiological
  and psychological changes that may
  place the organism at risk for
  disease
                  Cohen, Kessler, & Gordon, 1995
African-American pregnant women report
more stress exposure and greater emotional
distress from that exposure than other
groups


               Feldman, Dunkel-Schetter, Woo & Hobel, 1997; Zambrana et al., 1999
     A Biopsychosocial Model


           Neuroendocrine
               system



               Immune
                               Birth
STRESS          system       outcomes



            Cardiovascular
               system
   Negative Self-Society Dialectic

The health of minority groups is intimately
connected to the HIGH STRESS STATES
created by a social system that condones,
reinforces, and perpetuates racial
discrimination.
                                     Myers, 1982
RACISM LINKED TO
       Decreased life satisfaction

Psychological distress    Depression
Lower self-esteem    High blood pressure
    Stroke       Cardiovascular disease
INFANT MORTALITY
                    PRETERM DELIVERY
             LOW BIRTHWEIGHT
               ALLOSTATIC LOAD
          Physiologic toll of repeated and/or chronic
                   stress system activation


         Allostasis                    Allostatic Load



Stress               Recovery




          Baseline                             Baseline


                                     McEwen & Stellar, 1993; Sterling & Eyer, 1988
RACISM AND ADVERSE
PREGNANCY OUTCOMES
 A Program of Research
Multi-Site Behavior in Pregnancy Study
                   1997-2002

 •   Prospective, repeated measures survey
 •   Psychosocial, medical, physiological variables
 •   480 ethnically/SES diverse pregnant women
 •   Recruited in clinics or referred by MDs
 •   Fluent English
 •   > 18 yrs
 •   < 18 wks gestation, non substance using
           STUDY 1
  Does stress mediate racial
differences in birth outcomes?




   Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2005
     STUDY SAMPLE

         N = 124
 African-American (n=51)
   Nonhispanic White (n=73)
 Born and raised in U.S.
 Live-born infant
 T1, T2, birth outcome data
          RACISM EXPOSURE

       • personal/vicarious experiences
       • childhood/adulthood
       • across different life domains

Have you ever felt that you (or someone close to you)
were (was) discriminated against or the target of
prejudice because of race in interpersonal, housing,
employment, educational, other situations?
             Mediation Models

DV = BW            Step 1       Step 2       Step 3

GA                 .65***       .67***       .65**
Medrisk            .05          .03          .04
Spont. Labor       -.01         -.00         .01
Parents’ Educ      .06          .03          .05
Race                            -.18*        -.13+
Racism-Life                                  -.13+
  Sobel test of mediation = -1.64, p < .10 (one-tailed)
              Mediation Models

DV = BW            Step 1        Step 2       Step 3

GA                 .65***        .67***       .64**
Medrisk            .05           .03          .03
Spont. Labor       -.01          -.00         .02
Parents’ Educ      .06           .03          .05
Race                             -.18*        -.13+
Racism-ChV                                    -.16*

  Sobel test of mediation = -1.97, p < .05 (one-tailed)
    KEY FINDING
     Racism exposure, particularly
  vicarious childhood experiences,
predicts BW and attenuates race effects
  on BW, controlling for confounders
           STUDY 2
  Are there physiological
  factors that link racism
    to birth outcomes?


Parker Dominguez, Hilmert, Dunkel Schetter, Glynn, Sandman, & Hobel, 2005
      Neuroendocrine Variables

  -              CRH
mother                             +
                ACTH
  +
                                            +
           CORTISOL
placenta




           Assayed from blood at
   10-12 weeks, 18-20 weeks, 24-26 weeks,
   30-32 weeks, and 34-36 weeks gestation
          ETHNIC COMPARISON

  NE levels rise across pregnancy course in both
  ethnic groups
                       HOWEVER


Evidence of possible NE dysregulation in African Americans:
      - high ACTH, low CRH and Cortisol
      - smaller level of change in CRH and Cortisol
Racism, NE Function and BW


   Vicarious Childhood Exposure


                   +
CRH 34-36 weeks         Birthweight
               Mediation Models

DV = BW              Step 1         Step 2         Step 3
GA                   .53***         .50***         .51**
Medrisk              .17            .15            .10
Spont. Labor         .00            .02            .02
Parents’ Educ        .06            .10            .08
Race                 -.30**         -.22*          -.22+
Racism-ChV                          -.22*          -.16+
CRH 32-36wks                                        .20*
     Sobel_ChV = -1.91, p < .05; Sobel_NE = -1.71, p < .05
 KEY FINDINGS
1. Evidence of NE dysregulation in AfrAms
2. Racism associated with AfrAm NE
   pattern
3. Late term CRH predicts BW and
   mediates ChV racism effects on BW
            STUDY 3
  Are there differences across
 multiple racial/ethnic groups in
exposure to and impact of racism?



       Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
MS-BIPS SAMPLE consisted of

      70    Latinas
      177   Nonhispanic Whites
      25    Asian/Pacific Islanders
      51    African-Americans

                      with racism data
            RACISM EXPERIENCES

                       LIFETIME

Variable     AfrAm      API           Latina           White           p-value
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


           Unadj: APIs & AfrAms / Latinas & Whites
                     Adj: Latinas / Whites

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

   AfrAms and Latinas
   were significantly less
   distressed than APIs
   and Whites
RESPONSE

   •AfrAms significantly
   more likely to keep racism
   experiences to themselves
   •AfrAms significantly
   more likely to accept
   unfair treatment as a fact
   of life
 Associations with Racism

    Variable                   r                   b
       PSS              0.27**               0.23**
      STAI              0.30**               0.30**
   Preg Anx             0.24**               0.22**
    CES-D               0.18**               0.15*
  Resources           -0.14*               -0.14*
* p<0.05, ** p<0.01

                  Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
  Associations with Racism


  Variable               r                      b
     BW            -0.13*               -0.08
      GA           -0.12*               -0.10
*p<0.05




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


 African Americans X APIs

     b = .22, p < .05

      Racism and BW

 APIs: b = .07, p > .10
AfrAms: b = -.36, p < .05
 KEY FINDINGS
• Ethnic differences in racism exposure,
   distress, and coping
• Racism impacts psychosocial fx of all
  groups
• Evidence race may moderate racism
  effects on birth outcomes
Looking ahead…..




               Improved racism measures
                     Multi-level studies
                    Lifespan Approach
                           CBPR
                   Interdisciplinary teams
        Acknowledgements
Christine Dunkel Schetter
    Department of Psychology, UCLA
Laura Glynn
    Department of Psychiatry, UC-Irvine
Calvin J. Hobel
    Department of Maternal/Fetal Med, Cedars-Sinai
Curt Sandman
    Department of Psychiatry, UC-Irvine

				
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posted:9/6/2011
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