Investigating the Black Birth Experience: A Race-Stratified Analysis of Preterm Birth Risk and Exposure to Metropolitan Statistical Area-Level Police-Related Deaths, US 2018-2019.

Police-related violence may be a source of chronic stress underlying entrenched racial inequities in reproductive health in the USA. Using publicly available data on police-related fatalities, we estimated total and victim race-specific rates of police-related fatalities (deaths per 100,000 population) in 2018-2019 for Metropolitan Statistical Areas (MSA) and counties within MSAs in the USA. Rates were linked to data on live births by maternal MSA and county of residence. We fit adjusted log-Poisson models with generalized estimating equations and cluster-robust standard errors to estimate the relative risk of preterm birth associated with the middle and highest tertiles of police-related fatalities compared to the lowest tertile. We included a test for heterogeneity by maternal race/ethnicity and additionally fit race/ethnicity-stratified models for associations with victim race/ethnicity-specific police-related fatality rates. Fully adjusted models indicated significant adverse associations between police-related fatality rates and relative risk of preterm birth for the total population, non-Hispanic Black, and non-Hispanic White groups separately. Results confirm the role of fatal police violence as a social determinant of population health outcomes and inequities, including preterm birth.

Neighbourhood-level policing as a racialised gendered stressor: multilevel analysis of police stops and preterm birth in Seattle, Washington.

BACKGROUND: Most studies capturing the health effects of police violence focus on directly impacted individuals, but a burgeoning field of study is capturing the indirect, community-level health effects of policing. Few empirical studies have examined neighbourhood-level policing, a contextual and racialised gendered stressor, in relation to preterm birth risk among Black and other racially minoritised people. METHODS: We spatially linked individual birth records (2017-2019) in Seattle, Washington (n=25 909) with geocoded data on police stops for three exposure windows: year before pregnancy, first and second trimester. We fit race-stratified multilevel modified Poisson regression models predicting preterm birth (<37 gestational weeks) across tertiles of neighbourhood stop rates controlling for individual and neighbourhood-level covariates. For the second trimester exposure window, birth was operationalised as a time-to-event outcome using multilevel Cox proportional hazard models. RESULTS: Neighbourhood stop rates of Black residents was higher compared with White residents, and Black and Asian pregnant people were exposed to the highest median neighbourhood-level stop rates. Black birthing people living in neighbourhoods with more frequent police stops had increased risk of preterm birth across all exposure windows including the year before pregnancy (adjusted risk ratio (aRR): 1.38, 95% CI 1.02 to 1.85), first trimester (aRR:1.74, 95% CI 1.17 to 2.57) and second trimester (aHR: 1.66, 95% CI 1.14 to 2.42). We found null or inverse associations among Asian, Hispanic and White people. CONCLUSION: Our study adds to the growing evidence documenting associations of higher risk of preterm birth with neighbourhood police stops among Black birthing people. These findings suggest that routine police practices are one aspect of structural racism contributing to racialised perinatal health inequities.

Evaluating Firearm Violence After New Jersey's Cash Bail Reform.

Importance: Reducing the pretrial detention population has been a cornerstone of movements to end mass incarceration. Across many US cities, there are ongoing public debates on policies that would end pretrial detention due to the inability to afford bail, with some raising concerns that doing so would increase community violence. Objective: To evaluate changes in firearm violence after New Jersey's 2017 bail reform policy that eliminated financial barriers to avoiding pretrial detention. Design, Setting, and Participants: This case-control study used synthetic control methods to examine changes in firearm mortality and combined fatal and nonfatal shootings in New Jersey (2014-2019). New Jersey was chosen because it was one of the first states to systematically implement cash bail reform. Outcomes in New Jersey were compared with a weighted combination of 36 states that did not implement any kind of reform to pretrial detention during the study period. Data were analyzed from April 2023 to March 2024. Exposure: Implementation of New Jersey's cash bail reform law in 2017. Main Outcomes and Measures: Quarterly rates of fatal and nonfatal firearm assault injuries and firearm self-harm injuries per 100 000 people. Results: Although New Jersey's pretrial detention population dramatically decreased under bail reform, the study did not find evidence of increases in overall firearm mortality (average treatment effect on the treated, -0.26 deaths per 100 000) or gun violence (average treatment effect on the treated, -0.24 deaths per 100 000), or within racialized groups during the postpolicy period. Conclusions and Relevance: Incarceration and gun violence are major public health problems impacting racially and economically marginalized groups. Cash bail reform may be an important tool for reducing pretrial detention and advancing health equity without exacerbating community violence.

Who are the "police" in "police violence"? Fatal violence by U.S. law enforcement agencies across levels of government.

BACKGROUND: Police violence is increasingly recognized as an urgent public health problem. Basic questions about police violence, however, remain unanswered, including which types of law enforcement agency are responsible for fatal police violence deaths. METHODS: We estimated the proportion of police violence deaths in the U.S. (2013-2022) that were attributable to local, county, state, federal, or tribal police agencies, using mapping police violence data. We examined proportions overall, by decedent race/ethnicity, and by state. RESULTS: Nationally, 60% of decedents were killed by municipal, 29% by county, 8% by state, and 3% by federal, police, with < 1% killed by tribal or other officers. These proportions varied by race/ethnicity, with 56% of Native American decedents killed by municipal police compared to 70-75% among other racially minoritized people. While municipal police were responsible for most deaths in most states, in the Southeast, county police predominated. In some Northeastern states (and Alaska), state police were responsible for > 40% of deaths. CONCLUSIONS: We identify wide geographic & racial/ethnic variation in the agencies responsible for fatal police violence. Findings suggest that the budgetary and infrastructural shifts required to prevent fatal police violence need to occur at multiple levels of government.

Structural Racism-Related State Laws and Healthcare Access Among Black, Latine, and White U.S. Adults.

Racialized healthcare inequities in the USA remain glaring, yet root causes are understudied. To address this gap, we created a state-level structural racism legal index (SRLI) using the Structural Racism-Related State Law Database and analyzed its association with racialized inequities in four outcomes (lacking health insurance coverage, lacking a personal doctor, avoiding care due to cost, lacking a routine check-up) from the 2013 Behavioral Risk Factor Surveillance System (N = 454,834). To obtain predicted probabilities by SRLI quartiles (Q1 = less structural racism, Q4 = more structural racism) and racialized group, we fit survey-weighted multilevel logistic models adjusted for individual- and state-level covariates. We found substantial healthcare access inequities across racialized groups within SRLI quartiles and less pronounced, but still meaningful, inequities within racialized groups across SRLI quartiles. For example, the predicted probabilities of lacking health insurance coverage across SRLI quartiles ranged from 13 to 20% among Black adults, 31 to 41% among Latine adults, and 8 to 11% among White adults. Across racialized groups in Q4 states, predicted probabilities ranged from 11% among White adults to 41% among Latine adults. Similar patterns were observed for lacking a personal doctor and avoiding care due to cost. Findings underscore the need to address structural racism in laws and policies to mitigate these inequities.

Organized abandonment under racial capitalism: Measuring accountable actors of structural racism for public health research and action.

Understanding the shifting nature of structural racism historically and across institutions is vital for effective action towards racial health equity. While public health research on structural racism is rapidly increasing, most studies are missing the interdependence of policies and institutional practices over time that shape power imbalances and lead to entrenched health inequities. Here, we discuss Ruth Wilson Gilmore's concept of organized abandonment - the intentional disinvestment in communities which, in turn, creates opportunities for extraction, revenue generation, and carceral enforcement to fill the cracks of a compromised social infrastructure - to encourage action-oriented public health research that is grounded in history and an understanding of racial capitalism. We present a case example using publicly-available data on redlining, gentrification and policing in Seattle, Washington. We mapped the intersections of redlining and gentrification and estimated their neighborhood-level association with police activity using Bayesian spatial Poisson regression models. We found that histories of racist housing policies like redlining and processes of gentrification are interdependent and shape contemporary neighborhood racial and economic segregation and police activity. Compared to structurally advantaged neighborhoods, police stops were higher in neighborhoods that were 1) historically disinvested (i.e. redlined) and remain low-income and structurally disadvantaged and 2) formerly industrial and business districts that were not redlined and are now gentrified. Notably, we found that policing practices were significantly more intensive in neighborhoods that were both high redlined and gentrified. Together, these findings illustrate how the place-based racialized processes of dispossession, displacement and policing are deeply intertwined to maintain racial capitalism. Our findings also highlight the importance of examining multiple racialized processes simultaneously to fill critical gaps in the existing literature that are necessary for sustainable solutions to address structural racism.

Legislating Inequity: Structural Racism In Groups Of State Laws And Associations With Premature Mortality Rates.

Most evaluations of health equity policy have focused on the effects of individual laws. However, multiple laws' combined effects better reflect the crosscutting nature of structurally racist legal regimes. To measure the combined effects of multiple laws, we used latent class analysis, a method for detecting unobserved "subgroups" in a population, to identify clusters of US states based on thirteen structural racism-related legal domains in 2013. We identified three classes of states: one with predominantly harmful laws ([Formula: see text]), another with predominantly protective laws ([Formula: see text]), and a third with a mix of both ([Formula: see text]). Premature mortality rates overall-defined as deaths before age seventy-five per 100,000 population-were highest in states with predominantly harmful laws, which included eighteen states with past Jim Crow laws. This study offers a new method for measuring structural racism on the basis of how groups of laws are associated with premature mortality rates.

School closures significantly reduced arrests of black and latinx urban youth.

BACKGROUND & METHODS: Youth of color are surveilled and arrested by police at higher rates than their White peers, contributing to racial inequities across the life course and in population health. Previous research points to schools as an increasingly relevant site for youth criminalization, but existing studies emphasize within-school mechanisms, with limited analysis of policing in surrounding school areas. To fill this gap, we study changes in police arrests of youth after initial COVID-19 school closures in 2020 across four US cities overall and in relation to public school locations. We analyze geocoded arrest records and use interrupted time series negative binomial regression models with city and month fixed effects to estimate change in weekly arrest rates among White, Black, and Latinx youth. We estimate arrest densities within school areas before and after school closures using spatial buffers of 300 feet. RESULTS: In the immediate weeks and months following COVID-19 pandemic school closures, youth arrest rates fell dramatically and with lasting impacts compared to other age groups. During the period of remote learning, weekly youth arrest rates declined by 54.0% compared to youth arrests rates in 2019, adjusting for city and seasonality (Incident Rate Ratio 0.46, 95% CI: 0.41, 0.52). We estimate Black youth weekly arrests fell from 43.6 to 16.8 per 100,000, vs. 4.6 to 2.2 per 100,000 among White youth. However, Black youth arrest rates during the remote learning period were still nearly 5 times that of White youth pre-pandemic. We also find that youth arrest rates declined during two school closure periods: at the start of the pandemic in 2020 and during Summer 2019. A spatial analysis shows Black and Latinx youth arrest densities in the surrounding 300 feet of K-12 schools were at least 15 and 8.5 times that of White youth, respectively, in both pre- and remote-learning periods. CONCLUSIONS: Black and Latinx youth face a higher likelihood of being arrested near a school than do White youth and older age groups, and racial inequities in arrests remains after school closures. Our findings show school closures significantly reduced arrests of urban youth of color, and policies addressing youth criminalization and structural racism should consider the joint spatial context of schools and policing. Although school closures may have resulted in learning loss and harms to youth wellbeing, closures interrupted comparatively high levels of arrest for Black and Latinx youth.

Neighborhood Proactive Policing and Racial Inequities in Preterm Birth in New Orleans, 2018‒2019.

Objectives. To measure neighborhood exposure to proactive policing as a manifestation of structural racism and its association with preterm birth. Methods. We linked all birth records in New Orleans, Louisiana (n = 9102), with annual census tract rates of proactive police stops using data from the New Orleans Police Department (2018-2019). We fit multilevel Poisson models predicting preterm birth across quintiles of stop rates, controlling for several individual- and tract-level covariates. Results. Nearly 20% of Black versus 8% of White birthing people lived in neighborhoods with the highest rates of proactive police stops. Fully adjusted models among Black birthing people suggest the prevalence of preterm birth in the neighborhoods with the highest proactive policing rates was 1.41 times that of neighborhoods with the lowest rates (95% confidence interval = 1.04, 1.93), but associations among White birthing people were not statistically significant. Conclusions. Taken together with previous research, high rates of proactive policing likely contribute to Black‒White inequities in reproductive health. Public Health Implications. Proactive policing is widely implemented to deter violence, but alternative strategies without police should be considered to prevent potential adverse health consequences. (Am J Public Health. 2023;113(S1):S21-S28. https://doi.org/10.2105/AJPH.2022.307079).

Policing sexuality: Sexual minority youth, police contact, and health inequity.

Police contact is increasingly recognized as an adverse childhood experience and determinant of poor mental health. While targeting of LGBTQ sex and community spaces by law enforcement has a long precedent in US history-and while LGBTQ people continue to protest unfair police treatment-little population-level research has examined police contact disparities by sexual orientation or gender identity. We test whether sexual minority (SM) youth have higher risk of police contact through young adulthood. We analyze a nationally representative cohort of >15,000 US young adults who were in middle/high school in the mid-1990s, with police contact histories collected at age 18-25. Using four different, equally reasonable approaches to coding youth-reported sexual orientation, we identified ∼500-1900 SMs. Compared to heterosexual youth, SM youth had 1.86 times the odds of ever being stopped by police (95% CI = 1.56-2.22, p < 0.001), were stopped 1.60 times as often (CI = 1.38-1.86, p < 0.001), and were stopped at younger ages (survival time ratio = 0.91, CI = 0.88-0.93, p < 0.001). Inequities were particularly driven by SM women, among whom disparities were severe (ever stopped OR = 2.18, stop count ratio = 2.44, survival time ratio = 0.87). For men, inequities only emerged once a broad definition of SM was adopted, suggesting that young SM men who do not identify as LGB (or who are reticent to report themselves as such) may be at particular risk. Results were robust to adjustment for race/ethnicity and parental nativity, though small cells meant models stratified by race/ethnicity were underpowered. Given substantially heightened police contact among SM youth (particularly, young SM women), care providers and educators working with them should explicitly combat homophobic and criminal legal system stigma and screen for police contact and its psychological sequelae. More data on LGBTQ communities' criminal legal system contact throughout life is essential for preventing the causes and consequences of related sexual orientation-based health inequities.

Association Between Racial Wealth Inequities and Racial Disparities in Longevity Among US Adults and Role of Reparations Payments, 1992 to 2018.

Importance: In the US, Black individuals die younger than White individuals and have less household wealth, a legacy of slavery, ongoing discrimination, and discriminatory public policies. The role of wealth inequality in mediating racial health inequities is unclear. Objective: To assess the contribution of wealth inequities to the longevity gap that exists between Black and White individuals in the US and to model the potential effects of reparations payments on this gap. Design, Setting, and Participants: This cohort study analyzed the association between wealth and survival among participants in the Health and Retirement Study, a nationally representative panel study of community-dwelling noninstitutionalized US adults 50 years or older that assessed data collected from April 1992 to July 2019. Participants included 7339 non-Hispanic Black (hereinafter Black) and 26 162 non-Hispanic White (hereinafter White) respondents. Data were analyzed from January 1 to September 17, 2022. Exposures: Household wealth, the sum of all assets (including real estate, vehicles, and investments), minus the value of debts. Main Outcomes and Measures: The primary outcome was all-cause mortality by the end of survey follow-up in 2018. Using parametric survival models, the associations among household wealth, race, and survival were evaluated, adjusting for age, sex, number of household members, and marital status. Additional models controlled for educational level and income. The survival effects of eliminating the current mean wealth gap with reparations payments ($828 055 per household) were simulated. Results: Of the 33 501 individuals in the sample, a weighted 50.1% were women, and weighted mean (SD) age at study entry was 59.3 (11.1) years. Black participants' median life expectancy was 77.5 (95% CI, 77.0-78.2) years, 4 years shorter than the median life expectancy for White participants (81.5 [95% CI, 81.2-81.8] years). Adjusting for demographic variables, Black participants had a hazard ratio for death of 1.26 (95% CI, 1.18-1.34) compared with White participants. After adjusting for differences in wealth, survival did not differ significantly by race (hazard ratio, 1.00 [95% CI, 0.92-1.08]). In simulations, reparations to close the mean racial wealth gap were associated with reductions in the longevity gap by 65.0% to 102.5%. Conclusions and Relevance: The findings of this cohort study suggest that differences in wealth are associated with the longevity gap that exists between Black and White individuals in the US. Reparations payments to eliminate the racial wealth gap might substantially narrow racial inequities in mortality.

Considering multiple governance levels in epidemiologic analysis of public policies.

Epidemiology is increasingly asking questions about the use of policies to address structural inequities and intervene on health disparities and public health challenges. However, there has been limited explicit consideration of governance structures in the design of epidemiologic policy analysis. To advance empirical and theoretical inquiry in this space, we propose a model of governance analysis in which public health researchers consider at what level 1) decision-making authority for policy sits, 2) policy is implemented, 3) and accountability for policy effects appear. We follow with examples of how these considerations might improve the evaluation of the policy drivers of population health. Consideration and integration of multiple levels of governance, as well as interactions between levels, can help epidemiologists design studies including new opportunities for quasi-experimental designs and stronger counterfactuals, better quantify the policy drivers of inequities, and aid research evidence and policy development work in targeting multiple levels of governance, ultimately supporting evidence-based policy making.

Disaggregating Asian American and Pacific Islander Risk of Fatal Police Violence.

High rates and racial inequities in U.S. fatal police violence are an urgent area of public health concern and policy attention. Asian Americans and Pacific Islanders (AAPIs) have been described as experiencing low rates of fatal police violence, yet AAPI subgroups vary widely on nearly every demographic and economic metric. Here, we calculate fatal police violence rates by AAPI regional and national/ethnic background, finding wide variation. We compile a list of AAPI people killed in interactions with police in 2013-2019, then use web searches and surname algorithms to identify decedents' backgrounds. Rates are then calculated by combining this numerator data with population denominators from the American Community Survey and fitting Poisson models. Excluding 18% of deaths with missing regional backgrounds, East and South Asian Americans died at a rate of 0.05 and 0.04 deaths per 100,000 (95% CI: 0.04-0.06 and 0.02-0.08), respectively, less than a third of Southeast Asian Americans' rate (0.16, CI: 0.13-0.19). Pacific Islanders suffered higher rates (0.88, CI: 0.65-1.19), on par with Native and Black Americans. More granularly, Southeast Asian American groups displaced by US war in Southeast Asia suffered higher rates than others from the same region. Traditional racial classifications thus obscure high risks of fatal police violence for AAPI subgroups. Disaggregation is needed to improve responses to fatal police violence and its racial/ethnic inequities.

Prenatal healthcare after sentencing reform: heterogeneous effects for prenatal healthcare access and equity.

BACKGROUND: High rates of imprisonment in the U.S. have significant health, social, and economic consequences, particularly for marginalized communities. This study examines imprisonment as a contextual driver of receiving prenatal care by evaluating whether early and adequate prenatal care improved after Pennsylvania's criminal sentencing reform reduced prison admissions. METHODS: We linked individual-level birth certificate microdata on births (n = 999,503) in Pennsylvania (2009-2015), to monthly county-level rates of prison admissions. We apply an interrupted time series approach that contrasts post-policy changes in early and adequate prenatal care across counties where prison admissions were effectively reduced or continued to rise. We then tested whether prenatal care improvements were stronger among Black birthing people and those with lower levels of educational attainment. RESULTS: In counties where prison admissions declined the most after the policy, early prenatal care increased from 69.0% to 73.2%, and inadequate prenatal care decreased from 18.1% to 15.9%. By comparison, improvements in early prenatal care were smaller in counties where prison admissions increased the most post-policy (73.5 to 76.4%) and there was no change to prenatal care inadequacy (14.4% pre and post). We find this pattern of improvements to be particularly strong among Black birthing people and those with lower levels of educational attainment. CONCLUSIONS: Pennsylvania's sentencing reforms were associated with small advancements in racial and socioeconomic equity in prenatal care.

Racial Disparities in Neighborhood Arrest Rates during the COVID-19 Pandemic.

Structural racism in police contact is an important driver of health inequities among the U.S. urban population. Hyper-policing and police violence in marginalized communities have risen to the top of the national policy agenda, particularly since protests in 2020. How did pandemic conditions impact policing? We assess neighborhood racial disparities in arrests after COVID-19 stay-at-home orders in Boston, Charleston, Pittsburgh, and San Francisco census tracts (January 2019-August 2020). Using interrupted time series models with census tract fixed effects, we report arrest rates across tract racial and ethnic compositions. In the weeks following stay-at-home orders, overall arrest rates were 39% lower (95% CI: 37-41%) on average compared to rates the year prior. Although arrest rates steadily increased thereafter, most tracts did not reach pre-pandemic arrest levels. However, despite declines in nearly all census tracts, the magnitude of racial inequities in arrests remained unchanged. During the initial weeks of the pandemic, arrest rates declined significantly in areas with higher Black populations, but average rates in Black neighborhoods remained higher than pre-pandemic arrest rates in White neighborhoods. These findings support urban policy reforms that reconsider police capacity and presence, particularly as a mechanism for enforcing public health ordinances and reducing racial disparities.

The consequences of Medicaid expansion under the Affordable Care Act for police arrests.

BACKGROUND & METHODS: National protests in the summer of 2020 drew attention to the significant presence of police in marginalized communities. Recent social movements have called for substantial police reforms, including "defunding the police," a phrase originating from a larger, historical abolition movement advocating that public investments be redirected away from the criminal justice system and into social services and health care. Although research has demonstrated the expansive role of police to respond a broad range of social problems and health emergencies, existing research has yet to fully explore the capacity for health insurance policy to influence rates of arrest in the population. To fill this gap, we examine the potential effect of Medicaid expansion under the Affordable Care Act (ACA) on arrests in 3,035 U.S. counties. We compare county-level arrests using FBI Uniform Crime Reporting (UCR) Program Data before and after Medicaid expansion in 2014-2016, relative to counties in non-expansion states. We use difference-in-differences (DID) models to estimate the change in arrests following Medicaid expansion for overall arrests, and violent, drug, and low-level arrests. RESULTS: Police arrests significantly declined following the expansion of Medicaid under the ACA. Medicaid expansion produced a 20-32% negative difference in overall arrests rates in the first three years. We observe the largest negative differences for drug arrests: we find a 25-41% negative difference in drug arrests in the three years following Medicaid expansion, compared to non-expansion counties. We observe a 19-29% negative difference in arrests for violence in the three years after Medicaid expansion, and a decrease in low-level arrests between 24-28% in expansion counties compared to non-expansion counties. Our main results for drug arrests are robust to multiple sensitivity analyses, including a state-level model. CONCLUSIONS: Evidence in this paper suggests that expanded Medicaid insurance reduced police arrests, particularly drug-related arrests. Combined with research showing the harmful health consequences of chronic policing in disadvantaged communities, greater insurance coverage creates new avenues for individuals to seek care, receive treatment, and avoid criminalization. As police reform is high on the agenda at the local, state, and federal level, our paper supports the perspective that broad health policy reforms can meaningfully reduce contact with the criminal justice system under historic conditions of mass criminalization.