Resilience as a potential modifier of racial inequities in preterm birth

Preterm birth (PTB) is a major risk factor for infant mortality and morbidity. While rates of PTB have fluctuated in the United States in recent years, racial and ethnic inequities have persisted. In particular, non-Hispanic Black individuals are 55% more likely (9.3% vs 14.4%) to have PTB than non-Hispanic White individuals [1]. These racial and ethnic inequities are seen even when controlling for known risk factors, such as education and partnership status [2]. We use the term inequity as opposed to disparity because we believe injustice, not innate biology, is responsible for racial differences in PTB [3]. From this health equity standpoint, it is vital to investigate contributing and mitigating factors in order to form evidence-based strategies to reduce and eventually eliminate the racial inequity in PTB [4]. Race is not a biological cause of PTB, it is likely a marker for other exposures that may lead to PTB. For example, structural racism causes lower socioeconomic position among Black compared to White populations, which in turn leads to differential environmental and psychosocial exposures. In addition, both structural and interpersonal racism lead to chronic stress which in turn may contribute to PTB [5], [6], [7].

Resilience is the ability to manage stressors and trauma and can be conceptualized as the result of characteristics or resources that foster positive coping abilities despite demands [8], [9], [10]. While often applied in psychology and the social sciences, more recently a growing body of literature on resilience has emerged in health and medicine, where it has shown promise to be a potentially modifiable target for intervention [9]. Resilience may also differ by ethnicity, nativity, race [11]. However, Grobman et al. found that adding psychosocial measures, including resilience, to their model did not change the association between race and PTB, showing that resilience is not a confounder and is unlikely to be on the causal pathway between race and PTB [12]. Montoya-Williams and colleagues found that among individuals with the highest level of resilience, racial inequities in low birth weight persisted [13]. The March of Dimes 2021 Consensus Statement on the Black-White inequity in PTB included a review of the literature on PTB inequities and resilience, revealing inconsistencies in the literature. They concluded that there was insufficient evidence to draw a conclusion on the association between PTB inequities and resilience [14].

Another way in which resilience could affect pregnancy outcomes is as an effect measure modifier. Specifically, it is possible that among individuals with higher resilience, associations between independent variables and outcomes during pregnancy may differ from individuals with lower resilience. For example, Kishore and colleagues studied how resilience impacts the relationship between adverse childhood outcome scores and behavioral and mental health outcomes. Although there was an association between adverse childhood outcome scores and mental health in pregnancy, this association was not present among those with high resilience [15]. To our knowledge, there have not been studies of resilience as an effect measure modifier in epidemiologic studies using PTB as the outcome.

In the current study, we aimed to investigate racial inequities in PTB through the lens of the potential protective effect of resilience, which has been shown to produce favorable outcomes in those facing stressors and trauma. We estimated the association of race (serving as a proxy for exposure to racism and other stressors) with PTB within strata of resilience to assess resilience as a potential modifier of the race-PTB association, rather than as a confounder or mediator. Given demonstrated racial inequities exist in both psychosocial stress in pregnancy [16] and pregnancy outcomes, and that stress and pregnancy anxiety are risk factors for PTB [17], [18], we hypothesized that among patients with high resilience, racial inequities in PTB would be less pronounced. If this were the case, working to bolster resilience during pregnancy might improve outcomes.

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