Pregnant Black people at greater risk, Kaiser Permanente study finds
Neighborhood segregation stemming from institutional racism against Black Americans may be related to depression and anxiety in pregnancy, according to new Kaiser Permanente research. The study was published in JAMA Health Forum.
Researchers at the Kaiser Permanente Division of Research analyzed clustering of one racial or ethnic group in an area, categorized as high, medium, or low residential segregation. They explored whether living in a highly segregated neighborhood was linked to higher rates of depression and anxiety among pregnant patients across different racial and ethnic groups who receive care through Kaiser Permanente Northern California (KPNC).
They found that for Black individuals, living in a highly segregated neighborhood was associated with higher odds of depression and anxiety in pregnancy. However, for Asian, Hispanic, and White pregnant patients, high residential segregation was associated with lower odds of depression and anxiety.
“Our study explores one avenue of structural racism — residential segregation — and provides evidence of how these factors are associated with negative health outcomes among Black populations,” said co-lead author Kendria Kelly-Taylor, PhD, a DOR research fellow. “These findings support the growing body of literature demonstrating racial residential segregation is associated with health inequities between Black and White Americans.”
The effects of residential segregation may differ by racial and ethnic group, the authors said. Racial residential segregation is a byproduct of practices, policies, and laws that limited economic investment from housing and zoning restrictions based on race, thus creating and reinforcing racial inequalities by limiting economic and educational opportunity, they said. The authors also acknowledged that racial and ethnic groups may reside among themselves for more positive reasons, such as seeking community and support from others with similar backgrounds.
Though this study did not explore the reasons for the different effects of residential segregation on mental health in pregnancy, the study findings offer an important signal that neighborhood economic conditions have an impact on well-being.
“What we identified is one piece of a much more complicated story,” Kelly-Taylor said. “We looked at a factor of structural racism that has shaped and affected communities over the years. This research study, and many more, are beginning to answer the question of how we can conduct research of structural factors and their impact to achieve health equity.”
Additional factors that future research could consider include subgroups of each race or ethnicity, nativity (US-born or non-US born), immigrant status, and length of residence in a neighborhood, she said.
“This kind of analysis is so important to developing public policies to benefit the population of pregnant individuals, and preventing depression and anxiety during pregnancy,” said senior author Lyndsay Avalos, PhD, MPH, a DOR research scientist. “These big-picture social factors need to be explored to develop policies and interventions to ensure the health and well-being of mothers and families.”
The researchers examined records for 201,115 KPNC patients who were pregnant between 2014 and 2019 and self-identified as Asian, Black, Hispanic or White. Participants’ addresses were linked to census tract-level population estimates. Researchers used a commonly used measure of segregation to categorize neighborhoods and make separate comparisons for each racial or ethnic group of low segregation vs. medium segregation, and low vs. high segregation.
They found depression and anxiety diagnoses highest in Black pregnant individuals (18.3% and 18.4% respectively); followed by White (16.0%, 18.2%), Hispanic (13.0%, 14.4%), and Asian (5.7%, 6.4%) individuals.
Asian and Black individuals were more likely to live in highly segregated neighborhoods. High racial residential segregation was associated with 25% higher odds of prenatal depression and 14% higher odds of prenatal anxiety among Black individuals.
By contrast, high racial residential segregation was associated with lower odds of prenatal depression and anxiety among Asian, and Hispanic individuals, and lower odds of depression among White individuals.
The study also highlighted that Black individuals living in highly segregated neighborhoods had a lower proportion of people with a college degree and a higher proportion of people on Medicaid health insurance. “The negative economic effects of long-standing practices of institutional racism such as racial residential segregation could negate [any] protective cultural and social factors attributed to living among one’s race, especially for Black pregnant individuals,” the authors wrote.
High racial residential segregation for White individuals appeared to provide protection against depression during pregnancy. These neighborhoods also had less economic deprivation.
The authors said they focused on mental health diagnoses in pregnancy because it is a particularly vulnerable period of life. “Pregnancy is a vulnerable period in which health conditions experienced during this time can have long-lasting influences on both the mother’s and child’s well-being,” Kelly-Taylor said. “And these effects can have multigenerational health consequences.”
The study team plans to continue examining how structural mechanisms affect mental health in pregnancy, said co-lead author Sylvia Badon, PhD, a DOR research scientist. “We plan to dive further into some of the mechanisms of these relationships and how they differ between racial and ethnic groups, considering the interplay between socioeconomic conditions and social and cultural ties that may blunt the negative mental health impact of living in an area with less economic opportunity,” Badon said.
The study was funded by a Kaiser Permanente Community Health Policy and Disparities Research grant and by the National Institute of Child Health and Human Development.
Additional co-authors were Wendy T. Dyer, MS, Alex Asera, MPH, Huyun Dong, MPH, Tess Baker, Nerissa Nance, Charles Quesenberry, PhD, and Kelly Young-Wolff, PhD, MPH, of the Division of Research; Mibhali Bhalala, MD, and Kathryn Erickson-Ridout, MD, PhD, of The Permanente Medical Group; and Kiarri N. Kershaw, PhD, of Northwestern University Feinberg School of Medicine.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.
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