Racial and Socioeconomic Disparities in Preconception Health Risk Factors and Access to Care

Abstract

Background: Black birthing people have significantly higher risks of maternal mortality and morbidity compared with White people. Preconception chronic conditions increase the risk of adverse pregnancy outcomes, yet little is known about disparities in preconception health. This study applies an intersectional framework to examine the simultaneous contributions of racial marginalization and economic deprivation in determining disparities in preconception risk factors and access to care. Methods: Using data from the Pregnancy Risk Assessment Monitoring System, 2016-2020 (N = 123,697), we evaluated disparities by race and income in self-reported preconception hypertension, diabetes, obesity, depression, and smoking, as well as preconception insurance coverage and utilization of health care. We estimated linear regression models and calculated predicted probabilities. Results: Black respondents experienced higher probabilities of preconception obesity and high blood pressure at every income level compared with White respondents. Higher income did not attenuate the probability of obesity for Black respondents (linear trend p = 0.21), as it did for White respondents (p < 0.001). Conversely, while White respondents with low income were at higher risk of preconception depression and smoking than their Black counterparts, higher income was strongly associated with reduced risk, with significantly steeper reductions for White compared with Black respondents (difference in trends p < 0.001 for both risk factors). White respondents had higher probabilities of utilizing preconception care across all income levels, despite similar probabilities of insurance coverage. Conclusions: Higher income does not protect against the risk of preconception obesity and other preconception risk factors for Black birthing people as it does for White birthing people. Results point to the need to consider multiple forms of intersecting structural factors in policy and intervention research to improve preconception and maternal health.

Keywords: PRAMS; chronic disease; health equity; maternal health; preconception health; social determinants of health; structural determinants of health.

FIG. 1.

Predicted probabilities of preconception risk factors by race and income level. Predicted probabilities are weighted to account for sample design. The predicted probability values are multiplied by 100 to be reported as percentages. Data are adjusted for age, state, and year. FPL, federal poverty limit.

FIG. 2.

Predicted probabilities of preconception insurance coverage and utilization of preconception health care by race and income level. Predicted probabilities are weighted to account for sample design. The predicted probability values are multiplied by 100 to be reported as percentages. Data are adjusted for age, state, and year.