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

1. PSYCHOSOCIAL STRESS AND PERSISTENT RACIAL DISPARITIES IN ADVERSE BIRTH OUTCOMES Tyan Parker Dominguez, PhD, MPH, MSW School of Social Work University of Southern California

2. OBJECTIVES • Review the nature of persistent racial disparities in adverse birth outcomes • Discuss the stress and pregnancy paradigm, highlighting physiological mechanisms • Present research findings from work on stress and birth outcomes

3. Infant Mortalitydeaths before age 1 per 1000 live births Mathews, Menacker, & MacDorman, 2003

4. Preterm Birth< 37 weeks gestation Martin, Hamilton, Sutton, Ventura, Menacker, & Munson, 2003

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

6. 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

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

8. 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

9. A Biopsychosocial Model Neuroendocrine system Birth outcomes Immune system STRESS Cardiovascular system

10. 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

11. RACISM LINKED TO Decreased life satisfaction Psychological distress Depression Lower self-esteem High blood pressure Stroke Cardiovascular disease INFANT MORTALITY PRETERM DELIVERY LOW BIRTHWEIGHT

12. 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

13. RACISM AND ADVERSE PREGNANCY OUTCOMES A Program of Research

14. 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

15. STUDY 1 Does stress mediate racial differences in birth outcomes? Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2005

16. 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

17. 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?

18. Mediation Models Sobel test of mediation = -1.64, p < .10 (one-tailed)

19. Mediation Models Sobel test of mediation = -1.97, p < .05 (one-tailed)

20. K E Y F I N D I N G Racism exposure, particularly vicarious childhood experiences, predicts BW and attenuates race effects on BW, controlling for confounders

21. STUDY 2 Are there physiological factors that link racism to birth outcomes? Parker Dominguez, Hilmert, Dunkel Schetter, Glynn, Sandman, & Hobel, 2005

22. Neuroendocrine Variables - mother + C R H A C T H C O R T I S O L Assayed from blood at 10-12 weeks, 18-20 weeks, 24-26 weeks, 30-32 weeks, and 34-36 weeks gestation + placenta +

23. 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

24. Racism, NE Function and BW Vicarious Childhood Exposure + CRH 34-36 weeks Birthweight

25. Mediation Models Sobel_ChV = -1.91, p < .05; Sobel_NE = -1.71, p < .05

26. K E Y F I N D I N G S • Evidence of NE dysregulation in AfrAms • Racism associated with AfrAm NE pattern • Late term CRH predicts BW and mediates ChV racism effects on BW

27. 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

28. MS-BIPS SAMPLE consisted of 70 Latinas 177 Nonhispanic Whites 25 Asian/Pacific Islanders • African-Americans with racism data

29. RACISM EXPERIENCES LIFETIME Variable AfrAm API Latina White p-value Unadj: APIs & AfrAms / Latinas & Whites Adj: Latinas / Whites Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004

30. DISTRESS AfrAms and Latinas were significantly less distressed than APIs and Whites

31. RESPONSE • AfrAms significantly more likely to keep racism experiences to themselves • AfrAms significantly more likely to accept unfair treatment as a fact of life

32. Associations with Racism * p<0.05, ** p<0.01 Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004

33. Associations with Racism *p<0.05 Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004

34. Interaction Effects African Americans X APIs b = .22, p < .05 APIs: b = .07, p > .10 AfrAms: b = -.36, p < .05 Racism and BW

35. K E Y F I N D I N G S • Ethnic differences in racism exposure, • distress, and coping • Racism impacts psychosocial fx of all groups • Evidence race may moderate racism effects on birth outcomes

36. Looking ahead….. Improved racism measures Multi-level studies Lifespan Approach CBPR Interdisciplinary teams

37. 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