Towards Perinatal Health Equity: An Intersectional Framework for Assessing Birth Outcome Inequities among Sexually- and Ethnoracially-Minoritized Women Open Access

Abstract

Growing evidence indicates that sexually- and ethnoracially-minoritized women (SERMW) experience birth outcome inequities. Emerging research has demonstrated birth outcome inequities across sexual identity and ethnoracial categories separately, such as increased rates of preterm birth and low birthweight. However, this single-axis approach is limited. Preliminary evidence suggests that an intersectional approach to account for marginalization based on sexual and ethnoracial identities together reveals critical gaps in the understanding of social-structural determinants of birth outcomes, offering a more nuanced perspective on the severity of inequities across various populations. The proposed methodology of analyzing birth outcome inequities is rooted in intersectionality theory, which asserts that exposure to social inequities exacerbates health risks through complex interacting pathways. In addition, adverse childhood experiences (ACEs) and experiences of victimization have been linked to poorer reproductive health outcomes, such as unintended pregnancy, which are in turn linked with adverse birth outcomes.

Drawing upon several foundational socioecological models as groundwork, this study aims to propose an integrative socioecological model that accounts for multilevel factors that affect individual health and well-being. This study also aims to utilize an intersectional framework in proposing a novel explanatory pathway model between identity and birth outcomes with the mediation of ACEs and victimization, while accounting for several demographic, preconception health, and pregnancy-related factors such as maternal age, education level, self-rated health, body mass index, prenatal care, and unintended pregnancy. This work intends to expand upon current research on birth outcome inequities among SERMW by modeling the factors of interest in the context of nationally-representative cohort data from the National Longitudinal Study of Adolescent to Adult Health.

The proposed secondary data analysis will contribute to the growing body of evidence of birth outcome inequities among SERMW, in addition to providing a basis for qualitative research to explore nuances such as reproductive health experiences of SERMW as well as transgender and nonbinary populations. The study’s novelty lies in its proposal of assessing the intersection of sexual and ethnoracial identity in the context of birth outcomes and the identification of potential mediating effects of ACEs and victimization. Ultimately, this research aims to inform more culturally relevant, targeted, and tailored education, policy, clinical, and public health intervention strategies.

Table of Contents

Table of Contents

1. Introduction 1

1.1 Perinatal Health and Birth Outcomes 1

1.2 Perinatal and Birth Outcome Inequities 2

1.3 A Review of Birth Outcomes at the Intersection of Ethnoracial & Sexual Identity 3

1.3.1 Race and Ethnicity-Related Inequities 4

1.3.2 Sexual Identity-Related Inequities 5

1.3.3 Intersectionality in Disparities Research 6

1.4 Explanatory Factors of Adverse Birth Outcomes 9

1.4.1 Individual-Level Explanatory Factors: General Population 9

1.4.2 Interpersonal-Level Explanatory Factors: General Population 10

1.4.3 Explanatory Factors: Ethnoracically-Minoritized Populations 11

1.4.4 Explanatory Factors: Sexually-Minoritized Populations 12

1.5 Theoretical & Conceptual Framework 14

1.5.1 Foundational Theories 14

1.5.2 Proposed Conceptual Model 17

1.6 Proposed Current Study 18

1.6.1 Research Aims 18

1.6.2 Innovation of Study 18

2. Approach for Testing Proposed Framework 20

2.1 Dataset and Analytic Sample 20

2.2 Measures 21

2.2.1 Independent Variables 21

2.2.2 Outcomes 23

2.2.3 Mediators 24

2.2.4 Control Variables 24

2.2.4.1 Sociodemographic Variables 24

2.2.4.2 Preconception Health Variables 25

2.2.4.3 Pregnancy-Related Variables 26

2.3 Statistical Analysis Plan 26

3. Discussion 28

3.1 Expected Results 28

3.2 Advancing an Integrative Socioecological Model and Novel Explanatory Pathway 29

3.3 Limitations of Proposed Study and Future Directions 31

3.4 Public Health and Clinical Implications 33

4. Conclusions 38

5. Appendices 39

Appendix A 39

Appendix B 40

6. Disclosures 41

7. References 42

List of Figures

Figure 1. Bronfenbrenner’s Ecological Systems Theory 14

Figure 2. Conceptual Model for Health Equity 15

Figure 3. Sexual & Gender Minority Health Disparities Framework 15

Figure 4. Proposed Integrative Socioecological Model 17

Figure 5. Proposed Explanatory Pathway Model 18

About this Honors Thesis

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School	Emory College
Department	Human Health
Degree	B.A.
Submission	Honors Thesis
Language	English
Research Field	Health Sciences, Obstetrics and Gynecology GLBT Studies Health Sciences, Public Health
Keyword	Victimization Racial minorities Maternal health Intersectionality ACEs Public health Add Health Dataset Birth outcomes Sexual minority women Add Health Race and ethnicity Socioecological model Intersectional research Pregnancy Explanatory pathway Sexual and gender minorities Adverse childhood experiences Trauma Perinatal health National Longitudinal Study of Adolescent to Adult Health Clinical implications Obstetric health
Committee Chair / Thesis Advisor	Megan Sutter, Emory University
Committee Members	Andrea Fitzroy, Emory University Ju Hyun Park, Emory University

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