The Association of County-level Structural Racism with Risk Factors for Negative Maternal Health and Birth Outcomes among Non-Hispanic Black People of Childbearing Age

Place-based measures of structural racism have shown adverse relationships with maternal health outcomes. Pre-existing conditions like diabetes, hypertension, and depression contribute to Black-White maternal health disparities. This study investigates the association between county-level structural racism (CSR) and these conditions among non-Hispanic Black women of reproductive age. We analyzed data from women of reproductive age in the 2011–2012 Behavioral Risk Factor Surveillance System (BRFSS). CSR was measured using a validated multi-indicator construct examined by quartile. Depression, diabetes, and hypertension were self-reported. Individual and county-level covariates were obtained from BRFSS and the 2010 US Census. We conducted multilevel logistic regression models. Women in the highest CSR quartile counties showed the highest depression prevalence and lowest hypertension prevalence. While initial analysis showed no significant associations between CSR and diabetes or hypertension, the fully adjusted model revealed women in the highest CSR quartile had significantly higher odds of diabetes [OR = 1.33(1.00-1.78)] and depression [AOR = 1.50(1.19–1.90)]. This study expands understanding of county-level structural racism’s relationship with chronic health conditions affecting Black women’s maternal health outcomes. Findings suggest that CSR is an important factor to consider in potential interventions to address maternal health disparities among NHB birthing parents. Structural racism at the individual level negatively impacts maternal health outcomes, however there are limited studies at the population level. This study shows how county-level structural racism impacts known risk factors of maternal health outcomes (diabetes, hypertension, depression).