Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes

Anders Larrabee Sonderlund; Natasha J Williams; Mia Charifson; Robin Ortiz; Shawnita Sealy-Jefferson; Elaine De Leon; Antoinette Schoenthaler

doi:10.1016/j.ssmph.2023.101529

Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes

SSM Popul Health. 2023 Oct 4:24:101529. doi: 10.1016/j.ssmph.2023.101529. eCollection 2023 Dec.

Authors

Anders Larrabee Sonderlund^{1

2}, Natasha J Williams¹, Mia Charifson^{3

4}, Robin Ortiz^{1

5}, Shawnita Sealy-Jefferson⁶, Elaine De Leon³, Antoinette Schoenthaler¹

Affiliations

¹ Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA.
² Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark.
³ Department of Population Health, NYU Grossman School of Medicine, USA.
⁴ Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, USA.
⁵ Department of Pediatrics, NYU Grossman School of Medicine, USA.
⁶ College of Public Health, Ohio State University, USA.

Abstract

Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.

Keywords: Birth outcomes; Incarceration; Pregnant; Reproductive health; Structural racism.