The portion of newborns delivered before term is considerably higher in the United States than in other developed countries. We compare the array of risk exposures and protective factors common to women across national settings, using national, regional, and international databases, review articles, and research reports. We find that U.S. women have higher rates of obesity, heart disease, and poor health status than women in other countries. This is in part because more U.S. women are exposed to the stresses of racism and income disparity than women in other national settings, and stress loads are known to disrupt physiological functions. Pregnant women in the United States are not at higher risk for preterm birth because of older maternal age or engagement in high-risk behaviors. However, to a greater extent than in other national settings, they are younger and their pregnancies are unintended. Higher rates of multiple gestation pregnancies, possibly related to assisted reproduction, are also a factor in higher preterm birth rates. Reproductive policies that support intentional childbearing and social welfare policies that reduce the stress of income insecurity can be modeled from those in place in other national settings to address at least some of the elevated U.S. preterm birth rate.

A distinct health gradient was observed in which NHB infants (n = 1,250,222) had the highest risk of first week (aOR 2.29, CI 2.21-2.37), neonatal (aOR 2.23, CI 2.17-2.30), postneonatal (aOR 1.74, CI 1.68-1.81), and infant mortality (aOR 2.05, CI 2.00-2.10) compared to NHW infants (n = 4,578,150). Hispanic black infants (n = 84,377) also experienced higher risk of first-week (aOR 1.28 (1.12-1.47), neonatal (aOR .27, CI 1.13-1.44), postneonatal (aOR 1.34, CI 1.15-1.56), and infant mortality (aOR 1.30, CI 1.18-1.43) compared to both NHW and Hispanic white infants (n = 1,989,109). Conclusions for Practice: Risk of infant mortality varies among Hispanic infants by race, with poorer outcomes experienced by Hispanic black infants. Compared to non-Hispanic infants of the same race, Hispanic black infants experience a smaller health disadvantage and Hispanic white infants have better or similar infant health outcomes. Our findings suggest implications of racial heterogeneity on infant health outcomes, and provide insight into the role of race as a social construct.

Pediatric Emergency Department (ED) utilization in the U.S. saw large declines during the COVID19 pandemic. What is relatively unexplored is whether the extent of declines differed by race and insurance status. An observational study was conducted using electronic medical record (EMR) data from the largest pediatric ED in Alabama for 2020 and 2019. The four subgroups of interest were African-American (AA), Non-Hispanic White (NHW), privately insured (PRIVATE), and publicly insured or self-insured (PUBLIC-SELF). Percentage changes in the 7-day moving average between dates in 2020 and 2019 were computed for total and high-severity ED visits by subgroup. Trends in percentage changes were plotted. T-tests were used to compare mean changes between subgroups. Large percentage declines in total ED visits and somewhat smaller percentage declines in high-severity visits were observed from March 2020. Declines were consistently larger for AA than NHW and for PUBLIC-SELF than PRIVATE. T-test results indicated mean date-specific percentage declines were significantly larger for AA than NHW for total visits (-38.92% [95% CI: -41.1, -36.8] versus -29.11% [95% CI: -30.8, -27.4]; p<0.001) and high-severity visits (-24.31% [95% CI: -26.2, -22.4] versus -19.49% [95% CI:-21.2, -17.8]; p<0.001), and larger for PUBLIC-SELF than PRIVATE for total visits (-36.32% [95% CI:-38.4, -34.3] versus 27.63% [95% CI:-29.2, -26.0]; p<0.001) and high-severity visits (-21.72% [95% CI: -23.5, -19.9] versus -20.01% [95% CI: -21.7, -18.3]; p = 0.04). In conclusion, significant differences by race and insurance status were observed in the decline in ED visits during the COVID19 pandemic, including high-severity visits. Minority-race and publicly insured or self-insured children often depend on the ED for health needs, lacking a usual source of care. Thus, these findings have worrisome implications regarding unmet healthcare needs and future exacerbations in health disparities.

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Background: There is growing evidence that the early months of the COVID19 pandemic saw substantial declines in pediatric Emergency Department (ED) utilization in the U.S. However, less is known about whether utilization changed differentially for children who are socio-economically disadvantaged. We examined how changes pediatric ED visits during the early months of the COVID19 pandemic differed by two markers of socio-economic disadvantage, minoritized race and being publicly insured. Methods: This retrospective observational study used electronic medical records from a large pediatric ED in a Deep South state for January-June 2020. Three time-periods -- pre-COVID19 (TP0), COVID19 with restrictions like stay-at-home (TP1), and COVID19 with restrictions relaxed (TP2) in 2020 were compared with the corresponding time-periods in 2019. Changes in overall visits, visits for minoritized race (MR) versus non-Hispanic white (NHW) children, and Medicaid-enrolled versus privately-insured children were considered, and changes in acuity-mix of ED visits and share of visits resulting in inpatient admits were inspected. Results: Compared to 2019, total ED visits declined in TP1 and TP2 of 2020 (54.3%, 48.9%). Declines were larger for MR children (57.3%, 57.8%) compared to NHW children (50.5%, 39.3%), and Medicaid enrollees (56.5%, 52.0%) compared to the privately insured (48.3%, 39.0%). Particularly, MR children saw steeper percentage declines in high-acuity visits and visits resulting in inpatient admissions compared to NHW children. The mix of pediatric patients by race and insurance-status, as well as the share of high-acuity visits and visits with inpatient admissions differed between TP1 and TP2 of 2019 and 2020 (p<0.05 for all cases). In contrast, there was little evidence of difference between TP0 of 2019 and 2020. Conclusion: The role of socioeconomic disadvantage and the potential impacts on pediatric ED visits during COVID19 in the Deep South of the United States changes is understudied. We find evidence of steeper declines in visits among MR and Medicaid-enrolled children, including for high-acuity conditions, than their NHW and privately-insured counterparts. Since disadvantaged children sometimes lack access to a usual source of care, this raises concerns about unmet health needs, and worsening health disparities, in a region that already has poor health indicators.