Introduction: Racial inequities in birth outcomes persist in the United States. Doula care may help to decrease inequities and improve some perinatal health indicators, but access remains a challenge. Recent doula-related state legislative action seeks to improve access, but the prioritization of equity is unknown. We reviewed recent trends in doula-related legislation and evaluated the extent to which new legislation addresses racial health equity. Methods: We conducted a landscape analysis of the LegiScan database to systematically evaluate state legislation mentioning the word “doula” between 2015 and 2020. We identified and applied nine criteria to assess the equity focus of the identified doula-related legislative proposals. Our final sample consisted of 73 bills across 24 states. Results: We observed a three-fold increase in doula-related state legislation introduced over the study period, with 15 bills proposed before 2019 and 58 proposed in 2019–2020. Proposed policies varied widely in content and scope, with 53.4% focusing on Medicaid reimbursement for doula care. In total, 12 bills in 7 states became law. Seven of these laws (58.3%) contained measures for Medicaid reimbursement for doula services, but none guaranteed a living wage based on the cost of living or through consultation with doulas. Only two states (28.6%; Virginia and Oregon) that passed Medicaid reimbursement for doulas also addressed other racial equity components. Conclusions: There has been an increase in proposed doula-related legislation between 2015 and 2020, but racial health equity is not a focus among the laws that passed. States should consider using racial equity assessments to evaluate proposed doula-related legislation.

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...

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>

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.

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.

Racial disparities in health have existed in the United States for centuries. 1 In 1899, WEB Du Bois noted the prevalence of poor health among black people, describing it as an important indicator of societal racial inequality. 2 Black Americans continue to have substantially worse health and shorter life expectancies than their white counterparts. 1,3 Particularly in health services research, evidence of black-white disparities in health and health care costs have been acknowledged for decades. However, much of this work has been divorced from the social context of deeply seated racial oppression (read: racism) that has created it. This dangerously incomplete view of disparities often fails to evoke racism as the fundamental cause of these injustices. 4 By separating health disparities from racism, we fail to recognize disparities as inequi-ties-that is avoidable injustices. Instead, we focus on individual differences rather than the systems and structures that uphold and replicate them. Disciplinary self-critique, a tenet of public health critical race praxis (PHCRP), helps a discipline shine a light on itself from within in order to understand how its norms may inadvertently buttress inequities either within the discipline or in society at large. 5 PHCRP also defines the term "outsiders within" as people who are members of a field but often marginalized within it because of their social identity. We, the authors of this commentary , represent the outsiders within. We understand and appreciate the discipline of health services research, its strengths and visions. We care deeply about how health services research can and should address health inequities and propel our discipline toward more equitable realization of its mission to produce new knowledge about the structure, processes, and effects of health services for individuals and populations. This commentary will interrogate the ways we as health services researchers pose our research questions, create methodological approaches, and interpret our findings. We, the authors, hope that this commentary will serve as a disciplinary self-critique that will expose how our disciplinary practices are steeped in white supremacy. This commentary asserts that without acknowledging shortcomings within our discipline, we cannot identify solutions to the most vexing health equity issues in our field. 1 | R ACIS M , WHITE SUPREMAC Y, AND HE ALTH S ERVI CE S RE S E ARCH Structural racism lies underneath, all around, and across society. It refers to the normalization and legitimization of an array of dynamics historical , cultural, institutional, and interpersonal-that routinely advantage whites while producing cumulative and chronic adverse outcomes for black people. 6 Structural racism encompasses (a) history, which lies underneath the surface, providing the foundation for white supremacy in this country; (b) culture, which exists all around our everyday lives, providing the normalization and replica-tion of racism; and (c) interconnected institutions and policies, they key relationships and rules across society providing the legitimacy and reinforcements to maintain and perpetuate racism. 6 To produce antiracist research and to achieve health equity, we must acknowledge the influence of white supremacist ideologies within our discipline. However, our traditional notions of white supremacy keep us focused on hate groups and vulgar language rather than a culture and ideology born from the premise of black inferiority and false notions of race as biological that have permeated the ways in which we conduct our research. As a result, a white racial frame-the overarching worldview that encompasses important racial ideas, terms, images, emotion and interpretation, and lens by which white supremacy is perpetuated-then legitimizes structural racism by providing a narrative , belief system and worldview that upholds and sustains it. 7 Our long-held belief systems drive the research questions we ask, the methods we employ, and the interpretation of our research findings. By interrogating it head on, we have everything to gain in the fight for racial health equity and the production of antiracist research. A disciplinary self-critique of our: 1. Research questions. Predominant notions about race shape the way we as health services researchers frame our research questions. For example, research questions are often phrased as "what causes Black people to have so many disadvantages compared to whites; and, what forces are at work?" This question or variations of it are widely used and accepted among health services researchers and at first look appear innocuous This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Background: To fight racism and its potential influence on health, health care professionals must recognize, name, understand and talk about racism. These conversations are difficult, particularly when stakes feel high-in the workplace and in interracial groups. We convened a multidisciplinary, multi-racial group of professionals in two phases of this exploratory project to develop and pilot an intervention to promote effective dialogues on racism for first year medical students at the University of Minnesota Medical School. Methods: Informed by a Public Health Critical Race Praxis (PHCRP) methodology in Phase I, initial content was developed by a group of seven women primarily from racial and ethnic minority groups. In a later phase, they joined with five White (primarily male) colleagues to discuss racism and race. Participants met monthly for 12 months from Jan 2016-Dec 2016. All participants were recruited by study PI. An inductive approach was used to analyze meeting notes and post intervention reflections to describe lessons learned from the process of employing a PHCRP methodology to develop the aforementioned curriculum with a multidisciplinary and multi-racial group of professionals dedicated to advancing conversations on racial equity. Results: Participants from Phase I described the early meetings as “powerful,” allowing them to “bring their full selves” to a project that convened individuals who are often marginalized in their professional environments. In Phase II, which included White colleagues, the dynamics shifted: “…the voices from Phase I became quieter…”; “I had to put on my armor and fight in those later meetings…” Conclusions: The process of employing PHCRP in the development of an intervention about racism led to new insights on what it means to discuss racism among those marginalized and those with privilege. Conversations in each phase yielded new insights and strategies to advance a conversation about racism in health care.

Objectives: Although a range of factors shapes health and well-being, institutionalized racism (societal allocation of privilege based on race) plays an important role in generating inequities by race. The goal of this analysis was to review the contemporary peer-reviewed public health literature from 2002-2015 to determine whether the concept of institutionalized racism was named (ie, explicitly mentioned) and whether it was a core concept in the article. Methods: We used a systematic literature review methodology to find articles from the top 50 highest-impact journals in each of 6 categories (249 journals in total) that most closely represented the public health field, were published during 2002-2015, were US focused, were indexed in PubMed/MEDLINE and/or Ovid/MEDLINE, and mentioned terms relating to institutionalized racism in their titles or abstracts. We analyzed the content of these articles for the use of related terms and concepts. Results: We found only 25 articles that named institutionalized racism in the title or abstract among all articles published in the public health literature during 2002-2015 in the 50 highest-impact journals and 6 categories representing the public health field in the United States. Institutionalized racism was a core concept in 16 of the 25 articles. Conclusions: Although institutionalized racism is recognized as a fundamental cause of health inequities, it was not often explicitly named in the titles or abstracts of articles published in the public health literature during 2002-2015. Our results highlight the need to explicitly name institutionalized racism in articles in the public health literature and to make it a central concept in inequities research. More public health research on institutionalized racism could help efforts to overcome its substantial, longstanding effects on health and well-being.

Title from cover. An international journal on population differences in disease patterns.