Remapping racial and ethnic inequities in severe maternal morbidity: The legacy of redlining in California

Abstract

Background: Historical mortgage redlining, a racially discriminatory policy designed to uphold structural racism, may have played a role in producing the persistently elevated rate of severe maternal morbidity (SMM) among racialised birthing people.Objective: This study examined associations between Home-Owner Loan Corporation (HOLC) redlining grades and SMM in a racially and ethnically diverse birth cohort in California. Methods:We leveraged a population-based cohort of all live hospital births at ≥20 weeks of gestation between 1997 and 2017 in California. SMM was defined as having one of 21 procedures and diagnoses, per an index developed by Centers for Disease Control and Prevention. We characterised census tract-level redlining using HOLC's security maps for eight California cities. We assessed bivariate associations between HOLC grades and participant characteristics. Race and ethnicity-stratified mixed effects logistic regression models assessed the risk of SMM associated with HOLC grades within non-Hispanic Black, Asian/Pacific Islander, American Indian/ Alaskan Native and Hispanic groups, adjusting for sociodemographic information, pregnancy-related factors, co-morbidities and neighbourhood deprivation index. Results:The study sample included 2,020,194 births, with 24,579 cases of SMM (1.2%). Living in a census tract that was graded as "Hazardous," compared to census tracts graded "Best" and "Still Desirable," was associated with 1.15 (95% confidence interval [CI] 1.03, 1.29) and 1.17 (95% CI 1.09, 1.25) times the risk of SMM among Black and Hispanic birthing people, respectively, independent of sociodemographic

Associations of Historical Redlining With BMI and Waist Circumference in Coronary Artery Risk Development in Young Adults

“… 74 , 75 This study's findings do not align with increasing research that identified associations between redlining and adverse health outcomes. 15 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 Instead, this study found that White adults may have better health in historically redlined areas. Black adults face structural and interpersonal racist barriers that are not present for White adults.…”

“…19 Although racial discrimination in housing, including redlining, became illegal in the U.S. with the Fair Housing Act of 1968, this historical practice lingers. Research has explored the legacy of redlining on health 20 and has identified associations between hazardous and declining HOLC map ratings and lower preterm birth, 21 , 22 severe maternal morbidity, 23 increased overall mortality, 24 self-rated poor health, 15 poor cardiovascular health, 25 , 26 and higher risk of certain cancers. 27 , 28 , 29 Few studies have examined the historical redlining maps in relation to obesity outcomes.…”

Historic redlining and health outcomes: A systematic review

“…We found that communities affected by redlining experience increased cardiovascular disease rates, increased preterm birth rates, increased cancer rates, Redlining is associated with adverse health outcomes for those living in redlined communities and those disparities impact certain population subgroups more than others. Three articles included in this review found stronger effects in Black individuals (Gao et al, 2022;Mentias et al, 2023;Mujahid et al, 2021), one found stronger effects specifically in Black women (Plascak et al, 2022), and one found stronger effects in Hispanic individuals (Gao et al, 2022). America's extensive history of systemic racism has made many tragedies worse for Black individuals, such as the impact of the Great Recession (Famighetti & Hamilton, 2019), opioid overdoses (Larochelle et al, 2021), and climate change (Kramar et al, 2018).…”

“…Of the 36 included articles, 31 (86%) found a significant association between worse redlining scores (i.e., HOLC grade C or D) and adverse health outcomes. More specifically, living in a redlined neighborhood, compared to neighborhoods with better redlining scores (i.e., HOLC grade A or B), was associated with more severe asthma (Friedman et al., 2022; Nardone, Casey et al., 2020; Schuyler & Wenzel, 2022), increased preterm birth rates (Hollenbach et al., 2021; Krieger, Van Wye et al., 2020; Nardone, Casey et al., 2020), increased late‐stage cancer diagnoses (Krieger, Wright et al., 2020), poorer breast cancer outcomes (Bikomeye et al., 2023), increased prevalence of cardiovascular disease or events (Al‐Kindi et al., 2023; Deo et al., 2023; Jadow et al., 2023; Motairek et al., 2022; White et al., 2021; Wing et al., 2022), increased COVID‐19 infection and death rates (Li & Yuan, 2022), poorer diabetes outcomes (Linde et al., 2022; White et al., 2021), increased gunshot wounds rates (Benns et al., 2020; Jacoby et al., 2018; Mehranbod et al., 2022; Spitzer et al., 2023), increased heat‐related illness rates (Li et al., 2021), increased infant mortality (Huang & Sehgal, 2022; Lynch et al., 2021), increased kidney failure rates (Nguyen et al., 2023), more childhood obesity (Kowalski et al., 2023), increased pedestrian fatalities (Taylor et al., 2023), increase in fatal encounters with police (Mitchell & Chihaya, 2022), worse postoperative outcomes (Diaz et al., 2021), increased maternal mortality (Gao et al., 2022), overall worse self‐rated physical health (Lynch et al., 2021; McClure et al., 2019), poorer mental health (Lynch et al., 2021), and increased prevalence of visual impairment and blindness (Hicks et al., 2023).…”

“…Of the 31 studies reporting significant associations, two described differential negative effects of redlining within specific population subgroups. The groups that had stronger associations between redlining and negative health outcomes were: non‐White individuals (compared to White individuals; Deo et al., 2023) and Black and Hispanic individuals (compared to Asian/Pacific Islanders and American Indians/Alaskan Natives; Gao et al., 2022). Additionally, two studies found that areas that had worse redlining scores (such as grade C or D) but have current day economic and/or racial privilege had a stronger association between redlining and poor health outcomes (Krieger, Wright et al., 2020; Li & Yuan, 2022).…”