Background While evidence shows considerable geographic variations in county-level racial inequities in infant mortality, the role of structural racism across urban–rural lines remains unexplored. The objective of this study was to examine the associations between county-level structural racism (racial inequity in educational attainment, median household income and jail incarceration) and infant mortality and heterogeneity between urban and rural areas. Methods Using linked live birth/infant death data provided by the National Center for Health Statistics, we calculated overall and race-specific 2013–2017 5-year infant mortality rates (IMRs) per 1000 live births in every county. Racially stratified and area-stratified negative binomial regression models estimated IMR ratios and 95% CIs associated with structural racism indicators, adjusting for county-level confounders. Adjusted linear regression models estimated associations between structural racism indicators and the absolute and relative racial inequity in IMR. Results In urban counties, structural racism indicators were associated with 7%–8% higher black IMR, and an overall structural racism score was associated with 9% greater black IMR; however, these findings became insignificant when adjusting for the region. In white population, structural racism indicators and the overall structural racism score were associated with a 6% decrease in urban white IMR. Both absolute and relative racial inequity in IMR were exacerbated in urban counties with greater levels of structural racism. Conclusions Our findings highlight the complex relationship between structural racism and population health across urban–rural lines and suggest its contribution to the maintenance of health inequities in urban settings.

Injuries from Less-lethal Weapons during the George Floyd Protests In this analysis involving patients treated in Minnesota during protests after George Floyd’s death, 89 patients were identified w...

Racial and ethnic inequities in health are a national crisis requiring engagement across a range of factors, including the health care workforce. Racial inequities in maternal and infant health are...

Police brutality is a social determinant of health that can directly impact health status. Social determinants of health can also impact health indirectly by shaping how people access health care. In this study, we describe the relationship between perceived police brutality and an indicator of access to care, unmet need. We also examine medical mistrust as a potential mechanism through which perceived police brutality affects unmet need. Using data from the 2018 Survey of the Health of Urban Residents (N = 4,345), direct effects of perceived police brutality on unmet need and indirect effects through medical mistrust were obtained using the Karlson-Holm-Breen method of effect decomposition. Experiencing police brutality was associated with greater odds of unmet need. Controlling for covariates, 18 percent of the total effect of perceived police brutality on unmet need was explained by medical mistrust. Experiences outside of the health care system matter for access to care. Given the association between police brutality and unmet need for medical care, addressing unmet need among marginalized populations requires public health leaders to engage in conversations about reform of police departments. The coronavirus pandemic makes this even more critical as both COVID-19 and police brutality disproportionately impact Black, Indigenous, Latinx and other communities of color.

Background: Structural racism is a complex system of inequities working in tandem to cause poor health for communities of color, especially for Black people. However, the multidimensional nature of structural racism is not captured by existing measures used by population health scholars to study health inequities. Multidimensional measures can be made using complex analytical techniques. Whether or not the multidimensional measure of structural racism provides more insight than the existing unidimensional measures is unknown. Methods: We derived measures of Black-White residential segregation, inequities in education, employment, income, and homeownership, evaluated for 2,338 Public Use Microdata Areas (PUMAs) in the United States (US), and consolidated them into a multidimensional measure of structural racism using a latent class model. We compared the median COVID-19 vaccination rates observed across 54 New York City (NYC) PUMAs by levels (high/low) of structural racism and the multidimensional class using the Kruskal-Wallis test. This study was conducted in March 2021. Findings: Our latent class model identified three structural racism classes in the US, all of which can be found in NYC. We observed intricate interactions between the five dimensions of structural racism of interest that cannot be simply classified as “high” (i.e., high on all dimensions of structural racism), “medium,” or “low.” Compared to Class A PUMAs with the median rate of two-dose completion of 6·9%, significantly lower rates were observed for Class B PUMAs (5·5%, p = 0·04) and Class C PUMAs (5·2%, p = 0·01). When the vaccination rates were evaluated based on each dimension of structural racism, significant differences were observed between PUMAs with high and low Black-White income inequity only (7·2% vs. 5·3%, p = 0·001). Interpretation: Our analysis suggests that measuring structural racism as a multidimensional determinant of health provides additional insight into the mechanisms underlying population health inequity vis-à-vis using multiple unidimensional measures without capturing their joint effects. Funding: This project is funded by the Robert J. Jones Urban Research and Outreach-Engagement Center, University of Minnesota. Additional support is provided by the Minnesota Population Center, which is funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Grant P2C HD041023).

Objective: National studies report that birth center care is associated with reduced racial and ethnic disparities and reduced experiences of mistreatment. In the US, there are very few BIPOC-owned birth centers. This study examines the impact of culturally-centered care delivered at Roots, a Black-owned birth center, on the experience of client autonomy and respect. Methods: To investigate if there was an association between experiences of autonomy and respect for Roots versus the national Giving Voice to Mothers (GVtM) participants, we applied Wilcoxon rank-sum tests for the overall sample and stratified by race. Results: Among BIPOC clients in the national GVtM sample and the Roots sample, MADM and MORi scores were statistically higher for clients receiving culturally-centered care at Roots (MADM p < 0.001, MORi p = 0.011). No statistical significance was found in scores between BIPOC and white clients at Roots Birth Center, however there was a tighter range among BIPOC individuals receiving care at Roots showing less variance in their experience of care. Conclusions for Practice: Our study confirms previous findings suggesting that giving birth at a community birth center is protective against experiences of discrimination when compared to care in the dominant, hospital-based system. Culturally-centered care might enhance the experience of perinatal care even further, by decreasing variance in BIPOC experience of autonomy and respect. Policies on maternal health care reimbursement should add focus on making community birth sustainable, especially for BIPOC provider-owners offering culturally-centered care.

<h3>Importance</h3><p>Police contact may have negative psychological effects on pregnant people, and psychological stress has been linked to preterm birth (ie, birth at &lt;37 weeks’ gestation). Existing knowledge of racial disparities in policing patterns and their associations with health suggest redesigning public safety policies could contribute to racial health equity.</p><h3>Objective</h3><p>To examine the association between community-level police contact and the risk of preterm birth among White pregnant people, US-born Black pregnant people, and Black pregnant people who were born outside the US.</p><h3>Design, Setting, and Participants</h3><p>This cross-sectional study used medical record data of 745 White individuals, 121 US-born Black individuals, and 193 Black individuals born outside the US who were Minneapolis residents and gave birth to a live singleton at a large health system between January 1 and December 31, 2016. Data were analyzed from March 2019 to October 2020.</p><h3>Exposures</h3><p>Police contact was measured at the level of the census tract where the pregnant people lived. Police incidents per capita (ie, the number of police incidents divided by the census tract population estimate) were dichotomized into high if the value was in the fourth quartile and low for the remaining three quartiles.</p><h3>Main Outcomes and Measures</h3><p>Preterm birth status was based on the<i>International Statistical Classification of Diseases and Related Health Problems, 10th revision, Clinical Modification </i>(<i>ICD-10-CM</i>) code. Preterm infants were those with<i>ICD-10-CM</i>codes P07.2 and P07.3 documented in their charts.</p><h3>Results</h3><p>Of 1059 pregnant people (745 [70.3%] White, 121 [11.4%] US-born Black, 193 [18.2%] Black born outside the US) in the sample, 336 White individuals (45.1%) and 62 Black individuals who were born outside the US (32.1%) gave birth between the ages of 30 and 34 years, while US-born Black individuals gave birth at younger ages, with 49 (40.5%) aged 25 years or younger. The incidence of preterm birth was 6.7% for White individuals (50 pregnant people), 14.0% for US-born Black individuals (17 pregnant people), and 5.7% for Black individuals born outside the US (11 pregnant people). In areas with high police contact vs low police contact, the odds of preterm birth were 90% higher for White individuals (odds ratio [OR], 1.9; 95% CI, 1.9-2.0), 100% higher for US-born Black individuals (OR, 2.0; 95% CI, 1.8-2.2), and 10% higher for Black individuals born outside the US (OR, 1.1; 95% CI, 1.0-1.2). Secondary geospatial analysis further revealed that the proportion of Black residents in Minneapolis census tracts was correlated with the number of police incidents reported between 2012 and 2016 (<i>P</i> = .001).</p><h3>Conclusions and Relevance</h3><p>In this study, police contact was associated with preterm birth for both Black and White pregnant people. Predominantly Black neighborhoods had greater police contact than predominantly White neighborhoods, indicating that Black pregnant people were more likely to be exposed to police than White pregnant people. These findings suggest that racialized police patterns borne from a history of racism in the United States may contribute to racial disparity in preterm birth.</p>

From historical slave patrols and the enforcement of Black Codes and Jim Crow laws to the more recent War on Drugs and "stop and frisk," police violence is one of the oldest forms of structural racism in the US. 1 Policing tactics have relied heavily on the use of force to sub-jugate Black and Hispanic and Latinx communities and uphold white supremacy by enforcing race, class, and other visible and invisible boundaries. 1 To maintain these boundaries, police officers are trained to use strategies that include violence and harm, forcing their subjects to acquiesce. While not a new phenomenon, police violence among racial and ethnic minority groups has been catapulted to a subject of considerable attention within the national public discourse, capturing the interest of individuals, communities, and policy makers across the US over the past year. Following the murders of Breonna Taylor and George Floyd, there has been a sustained public outcry against police training and tactics, brutality, and the allocation of police funding in cities across the US. However, structural racism is embedded in policing like other US systems. Thus, instances of police brutality and violence toward Black and Hispanic and Latinx youth are not isolated instances at all. In the year since George Floyd's death on May 25, 2020, at least 229 more Black people have lost their lives at the hands of police. 2 Indeed, the system of policing in the US must be understood as a chronic and continuous injury to the body, mind, soul, and overall well-being of Black and Hispanica and Latinx bodies. 3 Policing has clear associations with health and well-being, for even the youngest members of society. And though, in the past year, many health care professionals have proclaimed "Black Lives Matter," we have been reticent to discuss the role of policing in health and health care. Connection Between Police and Health In this issue of JAMA Pediatrics, Jindal et al 4 analyze the current literature on policing and youth health. This systematic review used a convergent segregated approach, which includes separately examining both qualitative and quantitative studies but integrating all the findings to create a wholis-tic picture of the state of the science. Jindal et al found an association between police presence and the health of Black youth. Specifically, this review highlights the toll on mental and emotional health (eg, sadness, anger, fear, externalizing behaviors, and feelings of safety), risky behaviors (eg, intentions to have sex and number of sexual partners), and substance use (eg, smoking) associated with police presence. The small number of studies (N = 3) examining physical health outcomes and policing constrained this systematic review. While there is less research demonstrating the impact of police presence on physical health, it is critical to understand the evidence that exists. These studies associate police exposure with overall health and sleep. For example, adolescents with direct or vicarious exposures to police stops report worse health than their peers, especially among Black and Hispanic and Latinx youth. Procedural injustice, or the perception that appropriate procedures were not applied fairly or consistently, exacerbated this association between both direct and vicarious contact and self-reported health. 5 Further, adolescents stopped by the police may report more intrusive stops (eg, frisking , harsh language, and threat of force), which may be associated with higher levels of sleep deprivation and lower sleep quality. These associations were attenuated by social stigma and posttraumatic stress. 6 In this same issue, Farkas et al 7 examined physical health by using California state-level emergency department and hospitalization administrative data (ie, International Classification of Diseases, Tenth Revision coding) to characterize law enforcement-induced injuries by demographic characteristic of youth. The authors reference a new pediatric framework that includes well-child questions about police interactions after finding that beginning at ages 10 to 14 years, Black youth had higher rates of sustaining injuries from law enforcement as compared with their White peers, ranging from rate ratios of 3.5 (95% CI, 3.3-3.7) for Black male youth aged 15 to 19 years to 6.7 (95% CI, 4.8-9.5) for Black female youth aged 10 to 14 years. Though limited by state-level data and the reliance on administrative coding, this study further elucidates the disproportionate experience of police violence on Black youth, especially for Black girls, who have higher relative rates of policing injuries as compared with White girls. Further inquiry is needed to understand the incidence of police violence for gender nonconforming youth, and other demographic features , such as sexual orientation, socioeconomic status, or community characteristics. Both Jindal et al and Farkas et al offer compelling evidence of the impact of police violence among racial and ethnic minority groups on the health and well-being of Black and Hispanic and Latinx youth when they are exposed to police. While policing has come under considerable scrutiny and criticism recently, health care professionals and leaders have been less vocal about their role in public safety. This, despite recent findings that demonstrate experiencing police brutality affects relationships with the medical system. Individuals with negative police encounters have higher levels of medical mistrust compared with those without these encounters. 3 Fur

Purpose: Bias has been shown to influence the experience and mental health of healthcare professional trainees and faculty in academic medicine. The authors investigated the character and impact of self-reported bias experiences sustained in the academic medical arena that were submitted anonymously online to the website SystemicDisease.com. Method: This qualitative study analyzed 22 narratives submitted online to SystemicDisease.com between September 2015 and March 2017. Both deductive and inductive content analysis was performed, using a combination of a priori axial and open coding. Results: The most commonly reported biases occurred on the basis of race and/or gender. Multiple submitters indicated this bias had influenced or threatened their intended career trajectory. Healthcare professional trainees also expressed altruistic concerns toward other underrepresented individuals as well as toward patients from disadvantaged backgrounds. Conclusion: Racial and gender bias constitute a considerable barrier for trainees and professionals in academic medicine. Institutional awareness of these impacts can inform interventions designed to foster a more inclusive professional climate.

Pernicious racial disparities in birth outcomes in the United States have their roots in structural racism—the systematic allocation of opportunities and resources based on race. These inequities, caused by systemic factors which contribute to lower quality of care, negatively impact the lives of Blacks/African Americans. The development of new maternity care models hold potential to reduce disparities and costs by focusing on the root cause of racism. Roots Community Birth Center is an African American-owned, midwife-led freestanding birth center in North Minneapolis. Roots provides a culturally-centered model of care during pregnancy, childbirth, and the postpartum period. The culturally-centered care model utilized by Roots Community Birth Center offers culturally-centered care that is community based, accepts Medicaid beneficiaries, and provides prenatal and postpartum visits that are customized to the needs of the birthing individual. Like other institutions, this birth center faces the financial challenges associated with maternity care payment models and inadequate Medicaid reimbursement, challenges that directly interfere with the center's culturally-centered care model which advocates for longer prenatal visits and close follow-up postpartum. The birth center model of care has proven effective; over the last four years Roots has had 284 families with zero preterm births. The culturally-centered care model used by Roots is not currently well-supported by maternity care payment models that were designed in large part to reflect typical care provided by obstetricians and hospitals.

Achieving racial equity in childbirth care is critical to the health and well-being of our nation. Black infants are more than twice as likely as White infants to die before reaching their first birthday, and Black individuals who experience reproduction are 3-4 times more likely to experience a complication or death related to childbirth. 1 These inequities are one clear manifestation of structural racism-a form of racism that lacks an identifiable perpetrator but is instead the codification and legalization of society's unequal allocation of resources and opportunity based on an established racial hierarchy. 2,3 Clinical care during pregnancy and childbirth is an important determinant of perinatal-infant outcomes; however , for Black birthing people, care in the medical context does not consistently meet their clinical needs. 4 In addition, racial discrimination and experiences of interpersonal racism such as implicit racial bias and microaggressions during clinical encounters create disproportionate barriers to high-quality , respectful, patient-centered care experienced by Black people. 5-8 Perinatal care, as currently designed and delivered in most settings in the United States, has proven woefully inadequate for addressing structural and interpersonal racism in the day-today experiences of Black birthing people and in their encounters with the health care system. 8-11 Health care services that are grounded in relationships that acknowledge dynamics of power and that foster mutual respect may help shift pernicious patterns of racial inequity in perinatal care and childbirth. The patient-clinician relationship is central to achieving high-quality perinatal care. Indeed, relationships provide the context for many important functions and activities in health care. 12 Relationship-centered care-a theoretical concept introduced in 2006 by Beach and colleagues, can be defined as care in which all participants appreciate the importance of their relationships with one another. 12 To date, few scholars have explored this concept, and despite a considerable body of relationship-centered care literature devoted to prenatal and perinatal care, there is very little written about what constitutes relationship-centered care specifically for Black birthing people. 13 Racial identity and experiences of racism influence the care Black birthing people desire-this suggests that meaningful care for this population needs to incorporate not only a relationship-centered care approach, but also anti-racism-based theoretical approaches that focus specifically on the experiences of Black parenthood. 10,14 This call to action describes Beach and colleague's four principles of relationship-centered care through a critical race lens in the context of pregnancy and childbirth care. Taken together, the two concepts-relationship-centered care and critical race theory-have the potential to powerfully reduce racism's impact on childbirth outcomes for Black birth-ing individuals, infants, and families.

Stolen Breaths In the wake of George Floyd’s public execution, uprisings have ignited in cities throughout the United States. The words “I can’t breathe” hang heavy in the air. Black people cannot ...

People bring the social contexts of their lives into the medical encounter. As a social determinant of health, police brutality influences physical and mental health. However, negative experiences with institutions such as law enforcement might decrease trust in other institutions, including medical institutions. Mistrust might limit engagement with the healthcare system and affect population health. This study investigates the relationship between police brutality and medical mistrust and assesses whether it varies by race. Data were obtained from a 2018 cross-sectional survey of adults living in urban areas in the USA (N = 4389). Medical mistrust was regressed on police brutality (experiences and appraisal of negative encounters with the police), controlling for socio-demographics, health status, and healthcare access. Means of mistrust were predicted by racial group after including interactions between police brutality and race. Respondents who had negative encounters with the police, even if they perceived these encounters to be necessary, had higher levels of medical mistrust compared to those with no negative police encounters. Police brutality increased mistrust for all racial groups. Conditions outside the medical system such as experiencing police brutality impact relationships with the medical system. Given that clinicians are in a unique position of having access to firsthand information about the struggles and injustices that shape their patients’ health, advocating for systemic change on behalf of their patients might build trust.

Perinatal health outcomes in the United States continue to worsen, with the greatest burden of inequity falling on Black birthing communities. Despite transdisciplinary literature citing structural racism as a root cause of inequity, interventions continue to be mostly physician-centered models of perinatal and reproductive healthcare (PRH). These models prioritize individual, biomedical risk identification and stratification as solutions to achieving equity, without adequately addressing the social and structural determinants of health. The objective of this review is to: (1) examine the association between the impact of structural and obstetric racism and patient-centered access to PRH, (2) define and apply reproductive justice (RJ) as a framework to combat structural and obstetric racism in PRH, and (3) describe and demonstrate how to use an RJ lens to critically analyze physician-led and community-informed PRH models. We conclude with recommendations for building a PRH workforce whose capacity is aligned with racial equity. Institutional alignment with a RJ praxis creates opportunities for advancing PRH workforce diversification and development and improving PRH experiences and outcomes for our patients, communities, and workforce.

Research Objective: In the United States, Black infants are twice as likely than their white counterparts to experience preterm birth (PTB)-an inequity that has existed for decades. Forms of structural racism such as residential segregation have recently been associated with PTB. Segregated communities are often disproportionately exposed to police contact. Little is understood about how simply living in a community that experiences disproportionate police contact may impact PTB. Our objective is to assess whether high exposure to police contact is associated with PTB. Study Design: Neighborhood police exposure was measured at the census tract level with police incident data extracted from the Minneapolis Police Incident Report (2012-2016). The 5-year cumulative count of police incidents of all offense types was calculated for each census tract. This cumulative count ranged from 10 to more than 9000 incidents during these 5 years which likely reflects heterogeneity in neighborhood vigilance or that census tracts with a larger number of residents were more likely to have more police incidents. To account for the latter, we categorized each census tract into neighborhoods with high (fourth quartile) vs low (first to third quartile) police exposure and included census tract population estimate as a covariate along with marital status, maternal age at the time of delivery, insurance status, diagnosis of diabetes (prepregnancy and gestational), and hypertension. All population estimates were from the 2016 American Community Survey 5-year estimates. We mapped 5-year cumulative police incident count and proportion of Black residents to visually assess relationships. We also test for correlation of the incident count and the proportion of Black residents. To examine the association between the neighborhood police exposure and PTB, we constructed multivariate multilevel generalized linear regression models, adjusting for correlated data of women who lived in the same census tract, and estimated robust standard errors with the sandwich estimator. Population Studied: The analytic sample included Black and White women who gave birth to live singletons from January 1 to December 31, 2016 and lived in one of the 116 census tracts that make up the City of Minneapolis plus the 15 bordering census tracts. Principal Findings: When the measure of neighborhood police exposure, census tract population estimate, and the woman's racial group were regressed on PTB, we observed an 83% increase in the odds of PTB among those who resided in the neighborhood with high police exposure relative to those in the low exposure neighborhood (OR = 1.83, CI: 1.01-3.32). When maternal and census tract median household income was controlled for, we observed a slightly larger magnitude of our association of interest (OR = 1.99, CI: 1.00-3.96). Conclusions: A high level of neighborhood police exposure increases the risk of PTB among women of all racial groups. However, since neighborhoods with greater proportion of Blacks residents are more likely to be policed, the higher incident of PTB among Black than White women may be attributed to racialized pattern of exposure rather than differential effect between the two groups. Implications for Policy or Practice: Police contact, specifically routine stops conducted by police departments as a crime deterrent measure, may impact health outcomes.