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Racial Disparities in Adverse Pregnancy Outcomes and Psychosocial Stress

Grobman, William, A., MD, MBA; Parker, Corette, B., DrPH; Willinger, Marian, PhD; Wing, Deborah, A., MD; Silver, Robert, M., MD; Wapner, Ronald, J., MD; Simhan, Hyagriv, N., MD; Parry, Samuel, MD; Mercer, Brian, M., MD; Haas, David, M., MD; Peaceman, Alan, M., MD; Hunter, Shannon, MS; Wadhwa, Pathik, MD; Elovitz, Michal, A., MD; Foroud, Tatiana, MD; Saade, George, MD; Reddy, Uma, M., MD

doi: 10.1097/AOG.0000000000002441
Contents: Original Research
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OBJECTIVE: To assess the relationships between self-reported psychosocial stress and preterm birth, hypertensive disease of pregnancy, and small-for-gestational-age (SGA) birth and to assess the extent to which these relationships account for racial and ethnic disparities in these adverse outcomes.

METHODS: Self-reported measures of psychosocial stress (perceived stress, depression, racism, anxiety, resilience, and social support) were collected during pregnancy among a racially and ethnically diverse cohort of women enrolled in a prospective observational study of nulliparous women with singleton pregnancies, from eight clinical sites across the United States, between October 2010 and May 2014. The associations of preterm birth, hypertensive disease of pregnancy, and SGA birth with the self-reported measures of psychosocial stress as well as with race and ethnicity were evaluated.

RESULTS: The study included 9,470 women (60.4% non-Hispanic white, 13.8% non-Hispanic black, 16.7% Hispanic, 4.0% Asian, and 5.0% other). Non-Hispanic black women were significantly more likely to experience any preterm birth, hypertensive disease of pregnancy, and SGA birth than were non-Hispanic white women (12.2% vs 8.0%, 16.7% vs 13.4%, and 17.2% vs 8.6%, respectively; P<.05 for all). After adjusting for potentially confounding factors, including the six different psychosocial factors singly and in combination, non-Hispanic black women continued to be at greater risk of any preterm birth and SGA birth compared with non-Hispanic white women.

CONCLUSION: Among a large and geographically diverse cohort of nulliparous women with singleton gestations, non-Hispanic black women are most likely to experience preterm birth, hypertensive disease of pregnancy, and SGA birth. These disparities were not materially altered for preterm birth or SGA birth by adjustment for demographic differences and did not appear to be explained by differences in self-reported psychosocial factors.

Despite adjustment for differences in self-reported psychosocial stress, non-Hispanic black women are at significantly higher risk of preterm or small-for-gestational-age births than non-Hispanic white women.

Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina; the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; and the Departments of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, the University of California at Irvine, Irvine, California, the University of Utah Health Sciences Center, Salt Lake City, Utah, Columbia University, New York, New York, the University of Pittsburgh, Pittsburgh, Pennsylvania, the University of Pennsylvania, Philadelphia, Pennsylvania, MetroHealth Medical Center–Case Western Reserve University, Cleveland, Ohio, Indiana University, Indianapolis, Indiana, and the University of Texas Medical Branch, Galveston, Texas.

Corresponding author: William A. Grobman, MD, MBA, 250 East Superior Street, Suite 05-2175, Chicago, IL 60611; email:

Supported by grant funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) to Research Triangle Institute (U10 HD063036); Case Western Reserve University (U10 HD063072); Columbia University (U10 HD063047); Indiana University (U10 HD063037); Magee-Women's Hospital (U10 HD063041); Northwestern University (U10 HD063020); University of California at Irvine (U10 HD063046); University of Pennsylvania (U10 HD063048); and University of Utah (U10 HD063053).

Financial Disclosure The authors did not report any potential conflicts of interest.

*For a list of institutions and researchers in the nuMoM2b Network, see Appendix 1, available online at

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.