Using Index of Concentration at the Extremes as Indicators of Structural Racism to Evaluate the Association with Preterm Birth and Infant MortalityCalifornia, 2011-2012

Disparities in adverse birth outcomes for Black women continue. Research suggests that societal factors such as structural racism explain more variation in adverse birth outcomes than individual-level factors and societal poverty alone. The Index of Concentration at the Extremes (ICE) measures spatial social polarization by quantifying extremes of deprived and privileged social groups using a single metric and has been shown to partially explain racial disparities in black carbon exposures, mortality, fatal and non-fatal assaults, and adverse birth outcomes such as preterm birth and infant mortality. The objective of this analysis was to assess if local measures of racial and economic segregation as proxies for structural racism are associated and preterm birth and infant mortality experienced by Black women residing in California. California birth cohort files were merged with the American Community Survey by zip code (2011-2012). The ICE was used to quantify privileged and deprived groups (i.e., Black vs. White; high income vs. low income; Black low income vs. White high income) by zip code. ICE scores range from -1 (deprived) to 1 (privileged). ICE scores were categorized into five quintiles based on sample distributions of these measures: quintile 1 (least privileged)-quintile 5 (most privileged). Generalized linear mixed models were used to test the likelihood that ICE measures were associated with preterm birth or with infant mortality experienced by Black women residing in California. Black women were most likely to reside in zip codes with greater extreme income concentrations, and moderate extreme race and race + income concentrations. Bivariate analysis revealed that greater extreme income, race, and race + income concentrations increased the odds of preterm birth and infant mortality. For example, women residing in least privileged zip codes (quintile 1) were significantly more likely to experience preterm birth (race + income ICE OR=1.31, 95% CI=1.72-1.46) and infant mortality (race + income ICE OR=1.70, 95% CI=1.17-2.47) compared to women living in the most privileged zip codes (quintile 5). Adjusting for maternal characteristics, income, race, and race + income concentrations remained negatively associated with preterm birth. However, only race and race + income concentrations remained associated with infant mortality. Findings support that ICE is a promising measure of structural racism that can be used to address racial disparities in preterm birth and infant mortality experienced by Black women in California.