Variations in neonatal mortality, infant mortality, preterm birth and birth weight in England and Wales according to ethnicity and maternal country or region of birth: an analysis of linked national data from 2006 to 2012

BackgroundRisks of adverse birth outcomes in England and Wales are relatively low but vary across ethnic groups. We aimed to explore the role of mother’s country of birth on birth outcomes across ethnic groups using a large population-based linked data set.MethodsWe used a cohort of 4.6 million singleton live births in England and Wales to estimate relative risks of neonatal mortality, infant mortality and preterm birth, and differences in birth weight, comparing infants of UK-born mothers to infants whose mothers were born in their countries or regions of ethnic origin, or elsewhere.ResultsThe crude neonatal and infant death risks were 2.1 and 3.2 per 1000, respectively, the crude preterm birth risk was 5.6% and the crude mean birth weight was 3.36 kg. Pooling across all ethnic groups, infants of mothers born in their countries or regions of ethnic origin had lower adjusted risks of death and preterm birth, and higher gestational age-adjusted mean birth weights than those of UK-born mothers. White British infants of non-UK-born mothers had slightly lower gestational age-adjusted mean birth weights than White British infants of UK-born mothers (mean difference −3 g, 95% CI −5 g to −0.3 g). Pakistani infants of Pakistan-born mothers had lower adjusted risks of neonatal death (adjusted risk ratio (aRR) 0.84, 95% CI 0.72 to 0.98), infant death (aRR 0.84, 95% CI 0.75 to 0.94) and preterm birth (aRR 0.85, 95% CI 0.82 to 0.88) than Pakistani infants of UK-born Pakistani mothers. Indian infants of India-born mothers had lower adjusted preterm birth risk (aRR 0.91, 95% CI 0.87 to 0.96) than Indian infants of UK-born Indian mothers. There was no evidence of a difference by mother’s country of birth in risk of birth outcomes among Black infants, except Black Caribbean infants of mothers born in neither the UK nor their region of origin, who had higher neonatal death risks (aRR 1.71, 95% CI 1.06 to 2.76).ConclusionThis study highlights evidence of better birth outcomes among UK-born infants of non-UK-born minority ethnic group mothers, and could inform the design of future interventions to reduce the risks of adverse birth outcomes through improved targeting of at-risk groups.

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Joint contribution of socioeconomic circumstances and ethnic group to variations in preterm birth, neonatal mortality and infant mortality in England and Wales: a population-based retrospective cohort study using routine data from 2006 to 2012

BMJ Open ◽

10.1136/bmjopen-2018-028227 ◽

2019 ◽

Vol 9 (7) ◽

pp. e028227 ◽

Cited By ~ 2

Author(s):

Charles Opondo ◽

Ron Gray ◽

Jennifer Hollowell ◽

Yangmei Li ◽

Jennifer J Kurinczuk ◽

...

Keyword(s):

Preterm Birth ◽

Infant Mortality ◽

Ethnic Group ◽

Ethnic Groups ◽

Neonatal Mortality ◽

Birth Outcomes ◽

Secondary Outcome ◽

Adverse Birth Outcomes ◽

England And Wales ◽

Deprived Areas

ObjectivesThis study aimed to describe the variation in risks of adverse birth outcomes across ethnic groups and socioeconomic circumstances, and to explore the evidence of mediation by socioeconomic circumstances of the effect of ethnicity on birth outcomes.SettingEngland and Wales.ParticipantsThe data came from the 4.6 million singleton live births between 2006 and 2012.ExposureThe main exposure was ethnic group. Socioeconomic circumstances, the hypothesised mediator, were measured using the Index of Multiple Deprivation (IMD), an area-level measure of deprivation, based on the mother’s place of residence.Primary and secondary outcome measuresThe primary outcomes were birth outcomes, namely: neonatal death, infant death and preterm birth. We estimated the slope and relative indices of inequality to describe differences in birth outcomes across IMD, and the proportion of the variance in birth outcomes across ethnic groups attributable to IMD. We investigated mediation by IMD on birth outcomes across ethnic groups using structural equation modelling.ResultsNeonatal mortality, infant mortality and preterm birth risks were 2.1 per 1000, 3.2 per 1000 and 5.6%, respectively. Babies in the most deprived areas had 47%–129% greater risk of adverse birth outcomes than those in the least deprived areas. Minority ethnic babies had 48%–138% greater risk of adverse birth outcomes compared with white British babies. Up to a third of the variance in birth outcomes across ethnic groups was attributable to differences in IMD, and there was strong statistical evidence of an indirect effect through IMD in the effect of ethnicity on birth outcomes.ConclusionThere is evidence that socioeconomic circumstances could be contributing to the differences in birth outcomes across ethnic groups.

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Mass incarceration and public health: the association between black jail incarceration and adverse birth outcomes among black women in Louisiana

BMC Pregnancy and Childbirth ◽

10.1186/s12884-019-2690-z ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Lauren Dyer ◽

Rachel Hardeman ◽

Dovile Vilda ◽

Katherine Theall ◽

Maeve Wallace

Keyword(s):

Birth Weight ◽

Preterm Birth ◽

Black Women ◽

Low Birth Weight ◽

Racial Disparities ◽

Population Health ◽

Birth Outcomes ◽

Mass Incarceration ◽

Interquartile Range ◽

Adverse Birth Outcomes

Abstract Background A growing body of evidence is beginning to highlight how mass incarceration shapes inequalities in population health. Non-Hispanic blacks are disproportionately affected by incarceration and criminal law enforcement, an enduring legacy of a racially-biased criminal justice system with broad health implications for black families and communities. Louisiana has consistently maintained one of the highest rates of black incarceration in the nation. Concurrently, large racial disparities in population health persist. Methods We conducted a cross-sectional analysis of all births among non-Hispanic black women in Louisiana in 2014 to identify associations between parish-level (county equivalent) prevalence of jail incarceration within the black population and adverse birth outcomes (N = 23,954). We fit a log-Poisson model with generalized estimating equations to approximate the relative risk of preterm birth and low birth weight associated with an interquartile range increase in incarceration, controlling for confounders. In sensitivity analyses, we additionally adjusted for the parish-level index crime prevalence and analyzed regression models wherein white incarceration was used to predict the risk of adverse birth outcomes in order to quantify the degree to which mass incarceration may harm health above and beyond living in a high crime area. Results There was a significant 3% higher risk of preterm birth among black women associated with an interquartile range increase in the parish-level incarceration prevalence of black individuals, independent of other factors. Adjusting for the prevalence of index crimes did not substantively change the results of the models. Conclusion Due to the positive significant associations between the prevalence of black individuals incarcerated in Louisiana jails and estimated risk of preterm birth, mass incarceration may be an underlying cause of the persistent inequities in reproductive health outcomes experienced by black women in Louisiana. Not only are there economic and social impacts stemming from mass incarceration, but there may also be implications for population health and health inequities, including the persistence of racial disparities in preterm birth and low birth weight.

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Maternal exposure to airborne polychlorinated biphenyls (PCBs) and risk of adverse birth outcomes

European Journal of Epidemiology ◽

10.1007/s10654-021-00793-x ◽

2021 ◽

Author(s):

Ane Bungum Kofoed ◽

Laura Deen ◽

Karin Sørig Hougaard ◽

Kajsa Ugelvig Petersen ◽

Harald William Meyer ◽

...

Keyword(s):

Birth Weight ◽

Preterm Birth ◽

Sex Ratio ◽

Polychlorinated Biphenyls ◽

Birth Outcomes ◽

Gestational Age ◽

Small For Gestational Age ◽

Maternal Exposure ◽

Adverse Birth Outcomes ◽

Secondary Sex Ratio

AbstractHuman health effects of airborne lower-chlorinated polychlorinated biphenyls (LC-PCBs) are largely unexplored. Since PCBs may cross the placenta, maternal exposure could potentially have negative consequences for fetal development. We aimed to determine if exposure to airborne PCB during pregnancy was associated with adverse birth outcomes. In this cohort study, exposed women had lived in PCB contaminated apartments at least one year during the 3.6 years before conception or the entire first trimester of pregnancy. The women and their children were followed for birth outcomes in Danish health registers. Logistic regression was performed to estimate odds ratios (OR) for changes in secondary sex ratio, preterm birth, major congenital malformations, cryptorchidism, and being born small for gestational age. We performed linear regression to estimate difference in birth weight among children of exposed and unexposed mothers. All models were adjusted for maternal age, educational level, ethnicity, and calendar time. We identified 885 exposed pregnancies and 3327 unexposed pregnancies. Relative to unexposed women, exposed women had OR 0.97 (95% CI 0.82, 1.15) for secondary sex ratio, OR 1.13 (95% CI 0.76, 1.67) for preterm birth, OR 1.28 (95% CI 0.81, 2.01) for having a child with major malformations, OR 1.73 (95% CI 1.01, 2.95) for cryptorchidism and OR 1.23 (95% CI 0.88, 1.72) for giving birth to a child born small for gestational age. The difference in birth weight for children of exposed compared to unexposed women was − 32 g (95% CI—79, 14). We observed an increased risk of cryptorchidism among boys after maternal airborne LC-PCB exposure, but due to the proxy measure of exposure, inability to perform dose–response analyses, and the lack of comparable literature, larger cohort studies with direct measures of exposure are needed to investigate the safety of airborne LC-PCB exposure during pregnancy

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Association of US state policy orientation with adverse birth outcomes: a longitudinal analysis

Journal of Epidemiology & Community Health ◽

10.1136/jech-2020-214858 ◽

2021 ◽

pp. jech-2020-214858

Author(s):

Alicia R Riley ◽

Daniel Collin ◽

Jacob M Grumbach ◽

Jacqueline M Torres ◽

Rita Hamad

Keyword(s):

Birth Weight ◽

Preterm Birth ◽

Low Birth Weight ◽

Birth Outcomes ◽

State Policy ◽

Fixed Effects ◽

State Policies ◽

Adverse Birth Outcomes ◽

Lower Odds ◽

Policy Orientation

BackgroundThe current US context is marked by extreme right–left partisanship, which means that state policies tend to bundle together and are not experienced in isolation. While prior work has leveraged abrupt shifts in single policies to examine the effects of state policy on birth outcomes, we examined a holistic measure that captures political polarisation.MethodsData were drawn from national birth certificates for 2003–2017 (N=56 770 470). Outcomes included preterm birth, low birth weight, small-for-gestational age and other perinatal health measures. The primary exposure was a composite index of right–left state policy orientation, generated from historical data on 135 state policies. Multivariable regressions were used to estimate the association between state policy orientation and each outcome, adjusting for relevant covariates.ResultsCompared with infants born in states with right-leaning policy orientations, those born in left-leaning states had lower odds of adverse birth outcomes (eg, low birth weight: OR 0.95 (0.93, 0.97), preterm birth: OR 0.94 (0.92, 0.95)). Subgroup analyses revealed stronger associations for US-born and White mothers. With the inclusion of state fixed effects, left-leaning policy orientation was no longer associated with lower odds of adverse birth outcomes. Models were otherwise robust to alternative specifications.ConclusionWhile left-leaning state policy orientation has protective associations with a range of birth outcomes, the associations may be explained by stable characteristics of states, at least during the study period. Future studies should examine state policy orientation in association with other health outcomes and study periods.

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Febrile Rhinovirus Illness During Pregnancy Is Associated With Low Birth Weight in Nepal

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx073 ◽

2017 ◽

Vol 4 (2) ◽

Cited By ~ 6

Author(s):

Erin K Philpott ◽

Janet A Englund ◽

Joanne Katz ◽

James Tielsch ◽

Subarna Khatry ◽

...

Keyword(s):

Birth Weight ◽

Infant Mortality ◽

Low Birth Weight ◽

Pregnant Women ◽

Birth Outcomes ◽

Febrile Illness ◽

Respiratory Illness ◽

Adverse Birth Outcomes ◽

Increased Risk ◽

Febrile Respiratory Illness

Abstract Background Adverse birth outcomes, including low birth weight (LBW), defined as <2500 grams, small-for-gestational-age (SGA), and prematurity, contribute to 60%–80% of infant mortality worldwide and may be related to infections during pregnancy. The aim of this study was to assess whether febrile human rhinovirus (HRV) illness is associated with adverse birth outcomes. Methods Active household-based weekly surveillance was performed for respiratory illness episodes in pregnant women as part of a community-based, prospective, randomized trial of maternal influenza immunization in rural Nepal. Rhinovirus (HRV) febrile illness episodes were defined as fever plus cough, sore throat, runny nose, and/or myalgia with HRV detected on mid-nasal swab. Multivariate regression analysis evaluated the association between febrile HRV respiratory illness and adverse birth outcomes. Results Overall, 96 (3%) of 3693 pregnant women had HRV-positive febrile respiratory illnesses. Infants born to pregnant women with HRV febrile illness had a 1.6-fold increased risk of being LBW compared with those with non-HRV febrile illness (28 of 96 [38%] vs 109 of 458 [24%]; relative risk [RR], 1.6; 95% confidence interval [CI], 1.1–2.3). No difference in risk of LBW was observed between infants born to mothers with non-HRV febrile respiratory illness and those without respiratory illness during pregnancy (109 of 458 [24%] vs 552 of 2220 [25%], respectively; RR, 1.0; 95% CI, 0.8–1.2). Conclusions Febrile illness due to rhinovirus during pregnancy was associated with increased risk of LBW in a rural South Asian population. Interventions to reduce the burden of febrile respiratory illness due to rhinovirus during pregnancy may have a significant impact on LBW and subsequent infant mortality.

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Perspective: L-arginine and L-citrulline Supplementation in Pregnancy: A Potential Strategy to Improve Birth Outcomes in Low-Resource Settings

Advances in Nutrition ◽

10.1093/advances/nmz015 ◽

2019 ◽

Vol 10 (5) ◽

pp. 765-777 ◽

Cited By ~ 4

Author(s):

Andrea M Weckman ◽

Chloe R McDonald ◽

Jo-Anna B Baxter ◽

Wafaie W Fawzi ◽

Andrea L Conroy ◽

...

Keyword(s):

Nitric Oxide ◽

Birth Weight ◽

Preterm Birth ◽

Birth Outcomes ◽

Fetal Growth ◽

Adverse Birth Outcomes ◽

Low Resource Settings ◽

Low Resource ◽

Arginine Supplementation ◽

In Pregnancy

ABSTRACT The available data support the hypothesis that L-arginine or L-citrulline supplementation would be suitable for implementation in resource-constrained settings and will enhance placental vascular development and improve birth outcomes. In resource-constrained settings, the rates of adverse birth outcomes, including fetal growth restriction, preterm birth, and low birth weight, are disproportionately high. Complications resulting from preterm birth are now the leading cause of mortality in children <5 y of age worldwide. Despite the global health burden of adverse birth outcomes, few effective interventions are currently available and new strategies are urgently needed, especially for low-resource settings. L-arginine is a nutritionally essential amino acid in pregnancy and an immediate precursor of nitric oxide. During pregnancy, placental and embryonic growth increases the demand for L-arginine, which can exceed endogenous synthesis of L-arginine from L-citrulline, necessitating increased dietary intake. In many low-resource settings, dietary intake of L-arginine in pregnancy is inadequate owing to widespread protein malnutrition and depletion of endogenous L-arginine due to maternal infections, in particular malaria. Here we examine the role of the L-arginine–nitric oxide biosynthetic pathway in pregnancy including placental vascular development and fetal growth. We review the evidence for the relations between altered L-arginine bioavailability and pregnancy outcomes, and strategies for arginine supplementation in pregnancy. Existing studies of L-arginine supplementation in pregnancy in high-resource settings have shown improved maternal and fetal hemodynamics, prevention of pre-eclampsia, and improved birth outcomes including higher birth weight and longer gestation. Arginine supplementation studies now need to be extended to pregnant women in low-resource settings, especially those at risk of malaria.

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Atrazine Contamination of Drinking Water and Adverse Birth Outcomes in Community Water Systems with Elevated Atrazine in Ohio, 2006–2008

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph15091889 ◽

2018 ◽

Vol 15 (9) ◽

pp. 1889 ◽

Cited By ~ 16

Author(s):

Kirsten Almberg ◽

Mary Turyk ◽

Rachael Jones ◽

Kristin Rankin ◽

Sally Freels ◽

...

Keyword(s):

Drinking Water ◽

Birth Weight ◽

Preterm Birth ◽

Low Birth Weight ◽

Birth Outcomes ◽

Very Low Birth Weight ◽

Monitoring Program ◽

Water Systems ◽

Adverse Birth Outcomes ◽

The U.S

Atrazine, a common water contaminant in the U.S., has been associated with adverse birth outcomes in previous studies. This study aimed to determine if atrazine concentrations in drinking water are associated with adverse birth outcomes including small for gestational age (SGA), term low birth weight (term LBW), very low birth weight (VLBW), preterm birth (PTB), and very preterm birth (VPTB). This study included 14,445 live singleton births from Ohio communities served by 22 water systems enrolled in the U.S. Environmental Protection Agency’s Atrazine Monitoring Program between 2006 and 2008. Mean gestational and trimester-specific atrazine concentrations were calculated. Significantly increased odds of term LBW birth was associated with atrazine exposure over the entire gestational period (OR 1.27, 95% CI 1.10, 1.45), as well as the first (OR 1.20, 95% CI 1.08, 1.34) and second trimesters (OR 1.13, 95% CI 1.07, 1.20) of pregnancy. We observed no evidence of an association between atrazine exposure via drinking water and SGA, VLBW, PTB, or VPTB. Our results suggest that atrazine exposure is associated with reduced birth weight among term infants and that exposure to atrazine in drinking water in early and mid-pregnancy may be most critical for its toxic effects on the fetus.

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Pregnant women with COVID-19 and risk of adverse birth outcomes and maternal-fetal vertical transmission: a population-based cohort study in Wuhan, China

BMC Medicine ◽

10.1186/s12916-020-01798-1 ◽

2020 ◽

Vol 18 (1) ◽

Author(s):

Rong Yang ◽

Hui Mei ◽

Tongzhang Zheng ◽

Qiang Fu ◽

Yiming Zhang ◽

...

Keyword(s):

Cohort Study ◽

Birth Weight ◽

Preterm Birth ◽

Cesarean Section ◽

Pregnant Women ◽

Birth Outcomes ◽

Population Based ◽

Adverse Birth Outcomes ◽

Cesarean Section Delivery ◽

Increased Risk

Abstract Background The coronavirus disease 2019 (COVID-19) outbreak is evolving rapidly worldwide. However, little is known about the association between pregnant women with COVID-19 and the risk of adverse birth outcomes. Method We conducted a retrospective cohort study based on the Maternal and Child Health Information System (MCHIMS) of Wuhan, China. All pregnant women with singleton live birth recorded by the system between January 13 and March 18, 2020, were included. The adverse birth outcomes were preterm birth, low birth weight, neonatal asphyxia, premature rupture of membrane (PROM), and cesarean section delivery. Multivariate logistic regression was used to evaluate the associations between maternal COVID-19 diagnosis and adverse birth outcomes. Results Out of 11,078 pregnant women, 65 were confirmed with coronavirus disease 2019 (COVID-19). No deaths occurred from these confirmed cases or their newborns. Compared to pregnant women without COVID-19, pregnant women with a confirmed COVID-19 diagnosis had an increased risk of preterm birth (OR 3.34, 95% CI 1.60–7.00) and cesarean section (OR 3.63, 95% CI 1.95–6.76). There was no statistical difference in low birth weight, neonatal asphyxia, and PROM between the mothers with and without COVID-19. Among these newborns that were born to mothers with confirmed COVID-19, none was tested severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive or had abnormal CT results. Only one had diarrhea and three had a fever. Conclusions This population-based cohort study suggests that COVID-19 during the later pregnancy is associated with an increased risk of adverse birth outcomes, including iatrogenic preterm birth and cesarean section delivery. Our data provide little evidence for maternal-fetal vertical transmission of SARS-CoV-2. It is important to monitor the long-term health effects of SARS-CoV-2 infection on pregnant women and their children.

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Maternal Dietary Diversity and Dietary Quality Scores in Relation to Adverse Birth Outcomes in Tanzanian Women

Current Developments in Nutrition ◽

10.1093/cdn/nzaa054_103 ◽

2020 ◽

Vol 4 (Supplement_2) ◽

pp. 1031-1031

Author(s):

Isabel Madzorera ◽

Sheila Isanaka ◽

Molin Wang ◽

Gernard Msamanga ◽

Willy Urassa ◽

...

Keyword(s):

Risk Factors ◽

Birth Weight ◽

Preterm Birth ◽

Birth Outcomes ◽

Diet Quality ◽

Lower Risk ◽

Dietary Diversity ◽

Fetal Loss ◽

Adverse Birth Outcomes ◽

Very Preterm

Abstract Objectives Preterm birth, small for gestational age (SGA) and low birth weight (LBW) are risk factors for morbidity and mortality among infants. High-quality maternal diets during pregnancy may protect against these adverse birth outcomes. The objective of this research is to prospectively examine the association of maternal dietary diversity and quality during pregnancy with birth outcomes among women in Dar es Salaam, Tanzania. Methods We analyzed data from 7553 HIV-negative pregnant women enrolled in a multivitamin trial at 12–27 weeks gestation. Dietary intake was assessed using 24-hour dietary recalls. Log binomial regression methods were used to assess associations of Minimum Dietary Diversity for Women (MDD-W) and Prime Diet Quality Score (PDQS) with preterm, SGA, LBW, fetal loss, very preterm, severe SGA and very low birth weight (VLBW). Results In the previous 24 hours, 99.9% of women reported consuming grains, roots and tubers, 57.9% meats, 4.7% eggs and 0.5% nuts and seeds. Median MDD-W score was 3.0 ± 1.0. For the PDQS, women consumed at least 4 servings/week of green leafy vegetables (100%) and other vegetables (64.7%) and consumption of refined grains was high (99.6%). Higher MDD-W scores were associated with lower risk of SGA (RR highest vs. lowest quintile 0.74, 95% CI: 0.62, 0.89). Higher PDQS scores were associated with lower risk of preterm birth (RR: 0.55, 95% CI: 0.46, 0.67); LBW (RR: 0.53, 95% CI: 0.40, 0.71); fetal loss (RR: 0.53, 95% CI: 0.34,0.82), very preterm (RR: 0.33, 95% CI: 0.17, 0.64) and VLBW (RR: 0.49, 95% CI: 0.26, 0.92) comparing women in highest vs. lowest quintiles. Conclusions PDQS was inversely associated with preterm, very preterm, LBW, VLBW and fetal loss, and MDD-W was inversely associated with SGA. These findings suggest that in addition to diet diversity, diet quality should be considered as important in understanding dietary risk factors for poor birth outcomes. Funding Sources This work has been supported by the National Institutes of Child Health and Human Development. Co-authors were supported by a grant from the National Institute of Child Health and Human Development and the National Institutes of Health.

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Maternal experiences of ethnic discrimination and subsequent birth outcomes in Aotearoa New Zealand

BMC Public Health ◽

10.1186/s12889-019-7598-z ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 2

Author(s):

Zaneta Thayer ◽

Laia Bécares ◽

Polly Atatoa Carr

Keyword(s):

New Zealand ◽

Birth Weight ◽

Ethnic Groups ◽

Birth Outcomes ◽

Gestation Length ◽

Adverse Birth Outcomes ◽

Lower Birth Weight ◽

Aotearoa New Zealand ◽

Unfair Treatment ◽

The Relationship

Abstract Background Interpersonal discrimination experience has been associated with adverse birth outcomes. Limited research has evaluated this relationship within multicultural contexts outside the United States where the nature and salience of discrimination experiences may differ. Such research is important in order to help identify protective and risk factors that may mediate the relationship between discrimination experience and adverse birth outcomes. Methods Evaluated the relationship between perceived discrimination, as measured in pregnancy, with birth weight and gestation length among Māori, Pacific, and Asian women from Aotearoa New Zealand (N = 1653). Results Thirty percent of the sample reported some type of unfair treatment that they attributed to their ethnicity. For Māori women specifically, unfair treatment at work (β = − 243 g) and in acquiring housing (β = − 146 g) were associated with lower birth weight when compared to Māori women not experiencing these types of discrimination, while an ethnically motivated physical attack (β = − 1.06 week), and unfair treatment in the workplace (β = − 0.95 week), in the criminal justice system (β = − 0.55 week), or in banking (β = − 0.73 week) were associated with significantly shorter gestation. Conclusions Despite a high prevalence of discrimination experience among women from all ethnic groups, discrimination experience was a strong predictor of lower birth weight and shorter gestation length among indigenous Māori women only. Additional research is needed to better understand the risk and protective factors that may moderate the relationship between discrimination experience and adverse birth outcomes among women from different ethnic groups.

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