Structural gendered racism and preterm birth inequities in the United States

Structural gendered racism - the "totality of interconnectedness between structural racism and sexism" - is conceptualized as a fundamental cause of the persistent preterm birth inequities experienced by Black and Indigenous people in the United States. Our objective was to develop a state-level latent class measure of structural gendered racism and examine its association with preterm birth among all singleton live births in the US in 2019. Using previously-validated inequity indicators between White men and Black women across 9 domains (education, employment, poverty, homeownership, health insurance, segregation, voting, political representation, incarceration), we conducted a latent profile analysis to identify a latent categorical variable with k number of classes that have similar values on the observed continuous input variables. Racialized group-stratified multilevel modified Poisson regression models with robust variance and random effects for state assessed the association between state-level classes and preterm birth. We found four distinct latent classes that were all characterized by higher levels of disadvantage for Black women and advantages for White men, but the magnitude of that difference varied by latent class. We found preterm birth risk among Black birthing people was higher across all state-level latent classes compared to White birthing people, and there was some variation of preterm birth risk across classes among Black but not White birthing people. These findings further emphasize the importance of understanding and interrogating the whole system and the need for multifaceted policy solutions.