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Syndemic Perspectives to Guide Black Maternal Health Research and Prevention During the COVID-19 Pandemic

Syndemic Perspectives to Guide Black Maternal Health Research and Prevention During the COVID-19... The coronavirus 2019 (COVID-19) pandemic and related policies have led to an unequal distribution of morbidity and mor- tality in the U.S. For Black women and birthing people, endemic vulnerabilities and disparities may exacerbate deleterious COVID-19 impacts. Historical and ongoing macro-level policies and forces over time have induced disproportionately higher rates of maternal morbidity and mortality among Black women and birthing people, and contemporary macroeconomic and healthcare policies and factors continue to hold particular consequence. These factors induce detrimental psychologi- cal, health, and behavioral responses that contribute to maternal health disparities. The COVID-19 pandemic is likely to disproportionately impact Black women and birthing people, as policy responses have failed to account for the their unique socioeconomic and healthcare contexts. The resulting consequences may form a ‘vicious cycle’, with upstream impacts that exacerbate upstream macro-level policies and forces that can further perpetuate the clustering of maternal morbidity and mortality in this population. Understanding the impacts of COVID-19 among Black women and birthing people requires theo- retical frameworks that can sufficiently conceptualize their multi-level, interacting, and dynamic nature. Thus, we advocate for the proliferation of syndemic perspectives to guide maternal disparities research and prevention during the COVID-19 pandemic. These perspectives can enable a holistic and nuanced understanding of the intersection of endemic and COVID- 19-specific vulnerabilities and disparities experienced by Black women and birthing people. Syndemic-informed research can then lead to impactful multi-level prevention strategies that simultaneously tackle both endemic and COVID-19-specific factors and outcomes that lead to the clustering of vulnerabilities and disparities over time. Keywords COVID-19 · Syndemic · Maternal health services · African american · Maternal mortality Significance What This Study Adds? What is Already Know on This Subject? This paper advocates for the proliferation of syndemic perspectives to guide maternal disparities research and Black women and birthing people are more likely to die from prevention during the COVID-19 pandemic. Syndemic pregnancy-related causes than white women in the United perspectives can conceptualize the array of endemic and States. Emerging evidence suggests that the COVID-19 pan- COVID-19-specific vulnerabilities and disparities among demic and related policies have exacerbated racial maternal Black women and birthing people, and this understanding health disparities and worsened Black maternal health. can lead to high-impact prevention strategies. * Michael Kenneth Lemke Introduction LemkeM@uhd.edu The coronavirus 2019 (COVID-19) pandemic, along with Department of Social Sciences, One Main Street, University of Houston-Downtown, Suite N1025, Houston, TX 77002, the numerous policy changes that it has triggered, has led USA to an unequal distribution of morbidity, mortality, and other Department of Kinesiology, University of Texas At consequences in the U.S. For populations with existing vul- Arlington, 500 W. Nedderman, Maverick Activities Center, nerabilities and endemic disparities across racial/ethnic, sex/ Box 19259, Arlington, TX 76019, USA Vol.:(0123456789) 1 3 Maternal and Child Health Journal gender, life course, and socioeconomic lines, the impacts of difficult to secure jobs that provide livable wages, opportu- COVID-19 have been especially pronounced (Singer 2013; nity for advancement, and pay comparable to White coun- Gausman and Langer 2020; Raifman and Raifman 2020). terparts. These inequalities are especially relevant, as most Black women and birthing people (BWBP), who have Black women (81%) of single and married households in been burdened by long-standing population-level maternal the U.S. are the primary economic support for their families morbidity and mortality vulnerabilities and disparities, are (Anderson 2016). Due to systemic gendered racism in the typically at the intersection of most or all of these and other workforce and other multi-level and longstanding economic demarcations, and emerging evidence suggests that these forces, Black women earn $0.62 for every dollar that a White same characteristics may similarly intersect to exacerbate man earns (National Partnership for Women & Families deleterious COVID-19 impacts, such as maternal morbidity 2020). This structural economic disparity differentially and mortality (Zaigham and Andersson 2020). impacts BWBP from varying economic backgrounds. For Understanding the complex intersection of endemic and example, BWBP with lower income may have to reside in COVID-19-specific vulnerabilities and disparities experi- neighborhoods that induce stress related to safety or resource enced by BWBP requires theoretical frameworks that can availability, while those individuals with middle to high overcome the limitations of prevalent epidemiological, incomes may reside in more affluent and oftentimes pre- biomedical, and public health frameworks (Singer 2013; dominately White neighborhoods, which can induce stress Mendenhall 2017) and holistically conceptualize the multi- related to racism and social isolation (Al-Bayan et al. 2016). level, interacting, and dynamic nature of the impacts of In the healthcare system, BWBP are disproportion- COVID-19 and corresponding policy changes. Thus, we ately impacted by policy changes (e.g., efforts to scale advocate in this manuscript that is not based upon clinical back Affordable Care Act legislation) and consistently study or patient data for the proliferation of syndemic per- experienced discrimination or suffered the consequences spectives to guide maternal disparities research and preven- of implicit racial bias (Davis 2019). These experiences tion during the COVID-19 pandemic. Syndemic perspec- can lead to mistrust and fear of the healthcare system and tives can provide researchers with a theoretical grounding missed opportunities for the provision of high-quality care to advance scientific inquiry into the interacting, multi- and patient education. This is crucial, considering the inter- level, and co-occurring maternal health afflictions that have action of patient factors (e.g., presence of chronic health emerged from dynamic macro-level policies and forces that conditions) and provider/system factors (e.g., misdiagnosis; have led to the clustering of health disparities among preg- ineffective treatment; poorly coordinated care) are key con- nant Black women over time. Further, these perspectives tributors to preventable maternal morbidity and mortality can shed light on how these endemic policies, forces, and (Building U.S. Capacity to Review and Prevent Maternal afflictions, along with novel COVID-19-specific factors and Deaths 2018). outcomes, may synergistically perpetuate population-level These multi-level contextual factors induce detrimen- vulnerabilities and exacerbate disparities, with upstream tal psychological, health, and behavioral responses among impacts that constitute ‘vicious cycles’. Syndemic-informed BWBP and contribute to disparate maternal health out- research can then lead to holistic, multi-level prevention comes through multiple mechanisms. One such mechanism strategies that simultaneously tackle both endemic and is chronic exposure to stress resulting in the accumulation COVID-19-specific factors and outcomes that lead to the of allostatic load, which undermines the physical health and clustering of vulnerabilities and disparities over time. reproductive potential of BWBP (Lu et al. 2010). Moreo- ver, even in the presence of social and structural supports, chronic exposure to unique stressors related to pervasive Endemic Vulnerabilities and Disparities gendered racism may contribute to diminished mental well- among Black Women and Birthing People being and coping behaviors that elevate risk for or exac- erbate chronic health conditions (Suvarna et al. 2019) and Macro-level macroeconomic, healthcare, and other policies exacerbate maternal morbidity and mortality risks. Another and forces over time have contributed to disproportionately key mechanism is the impact of healthcare actions or inac- higher rates of maternal morbidity and mortality among tions, rooted in systemic racism endemic to healthcare sys- BWBP in the U.S. Longstanding structural inequities, driven tems, on maternal morbidity and mortality (Hall et al. 2015). by systemic racism, have created barriers that have made it We use the term “birthing people” to recognize that not all peo- ple who have a uterus, become pregnant, and give birth identify as a woman or a mother. 1 3 Maternal and Child Health Journal more difficult to achieve for BWBP, as these individuals Disproportionate and Exacerbatory disproportionately live in households and neighborhoods Impacts of COVID‑19 among Black Women with higher population densities and are more dependent and Birthing People on public transportation (Hooper et al. 2020; Mein 2020; Raifman and Raifman 2020; Vahidy et al. 2020). As the COVID-19 pandemic and corresponding policy The current pandemic and related policies are also likely changes continue to unfold in the U.S., they are likely to to worsen existing healthcare inequities among BWBP, disproportionately impact vulnerable populations and per- with multi-fold consequences for maternal well-being. petuate and worsen population-level morbidity and mortal- Physical distancing policies have increased unemployment ity disparities through novel and exacerbatory risks that rates, with corresponding losses in income (Mein 2020). will impact prone populations across racial/ethnic, sex/ Because BWBP of all socioeconomic backgrounds sys- gender, life course, and socioeconomic demarcations due tematically earn less than their White counterparts for the to deeply rooted macro-level racism/discrimination, mac- same amount of labor, losses in income can be especially roeconomic, healthcare, and other forces (Singer 2013; stressful. Increases in unemployment have also led to losses Gausman and Langer 2020; Hooper et  al. 2020; Mein in employer-based health insurance coverage (Mein 2020). 2020). In the United States, BWBP are typically at the These impacts are especially detrimental to low-income intersection of these characteristics and thus are especially individuals, who are likely to forego preventive care that likely to experience disproportionate morbidity and mor- they are no longer able to afford; as a result chronic disease tality burden, and policy responses to COVID-19 have disparities may further increase over time (Kim et al. 2020). failed to account for the unique socioeconomic and health- Healthcare and socioeconomic factors have led to dispari- care contexts experienced by these populations. ties in COVID-19 testing and transmission that may also The COVID-19 pandemic is likely to exacerbate exist- impact future COVID-19 vaccination rates (Mein 2020). ing socioeconomic disparities among BWBP and increase For BWBP, COVID-19 policies have interfered with rou- vulnerabilities to COVID-19 acquisition and transmis- tine prenatal care appointments, and the consequences of sion, especially those vulnerabilities related to employ- the pandemic have likely reduced quality of care (Gausman ment in low-wage, ‘essential’ occupations. Because of an and Langer 2020). The lack of knowledge about COVID-19 array of structural inequalities, including those caused has led to ambiguities about how to best provide care and by systemic racism, BWBP are more likely to experience have led to policy decisions that have been consequential lower socioeconomic status and low incomes (Mein 2020; for maternal and infant health outcomes (Stuebe 2020). For Vahidy et al. 2020). Individuals with lower income are example, geographically heterogeneous physical distancing often employed in occupations that render them especially policies designed to reduce potential exposure to COVID-19 vulnerable to COVID-19 infection and transmission due have perpetuated social isolation among women and birth- to increased workplace exposures related to lack of sick ing people, with detrimental psychological (e.g., psychoso- leave, inadequate provision of personal protective equip- cial stress) and physical (e.g., domestic violence) impacts ment, and the inability to work from home (Bohn et al. (Gausman and Langer 2020). These policies have also made 2020; Hooper et al. 2020; Mein 2020). These populations it more difficult for women and birthing people to acquire are also associated with higher rates of employment in jobs contraception or other obstetric and gynecologic medical that have been classified as ‘essential’ and therefore have procedures considered to be elective (Gausman and Langer remained open during the pandemic (Bohn et al. 2020; 2020). Healthcare ambiguities may also pose a threat to Hooper et al. 2020; Raifman and Raifman 2020). Because the effective delivery of treatments or vaccines for BWBP low-income workers are vulnerable to and more likely to (Gausman and Langer 2020). Further, concerns about the live in single-income households, they experience greater possibility of vertical transmission during childbirth or by pressures to continue their participation in these occupa- breastfeeding, and parent-infant separation policies, may tions despite COVID-19 risks (Mein 2020). BWBP in par- result in clinical decisions that can have negative impacts ticular are most commonly employed in essential health- on maternal and child well-being (Stuebe 2020; Zaigham care, service, and education occupations that have been and Andersson 2020). For BWBP, who already experience associated with heightened risks of COVID-19 infection disparities in maternal and infant morbidity and mortality, (Baker et al. 2020; Bohn et al. 2020; Frye 2020; Gausman such clinical decisions may be especially detrimental. and Langer 2020). Policy responses to COVID-19 have As the impacts of COVID-19 and related policies forced the closures of daycare centers and schools and interact with macroeconomic, healthcare, and other have caused additional financial hardships and psychoso- macro-level forces, all of which are entrenched in sys- cial stress (Bohn et al. 2020; Gausman and Langer 2020). temic racism, population-level comorbidities are likely Further, physical distancing has appeared to have been to emerge that further widen disparities among BWBP. 1 3 Maternal and Child Health Journal Black Americans and low-income households have been Syndemic Perspectives to Guide COVID‑19 found to have a higher risk of COVID-19 infection and Research and Prevention among Black associated comorbidities (Raifman and Raifman 2020; Women and Birthing People Stein and Ometa 2020; Vahidy et al., 2020). In particular, long-standing disparities in comorbidities such as cardio- The exacerbatory and novel impacts of the COVID-19 pan- vascular, metabolic, respiratory, liver, and kidney diseases demic and corresponding policy changes interact with exist- in racial and ethnic minority populations present enhanced ing macro-level vulnerabilities and endemic comorbidities to risks for COVID-19 disease severity (Hooper et al. 2020; induce maternal health disparities among BWBP in the U.S., Mein 2020; Stein and Ometa 2020). Racial and ethnic and these outcomes may create upstream impacts that further minorities are also more likely to have existing diagnosed exacerbate these outcomes over time. Because prevalent the- and undiagnosed medical conditions; for these individuals, oretical perspectives cannot adequately conceptualize these they are faced with the dilemma of either seeking medi- complex and dynamic influences, syndemic perspectives are cal care and risking nosocomial COVID-19 acquisition, warranted in maternal health research and action to under- or delaying care and increasing future risk of more severe stand the intersection of endemic and COVID-19-specific outcomes or complications (Kim et  al. 2020). Psycho- vulnerabilities and disparities experienced by BWBP and logical comorbidities related to COVID-19 and policies, guide preventive strategies. Further, although the focus of especially novel and exacerbatory psychosocial stressors this paper is on BWBP in the U.S., syndemic perspectives associated with disruptions to daily life, uncertainty about can be harnessed across a wide array of geographic, demo- socioeconomic and other consequences, fear of COVID- graphic, and other demarcations to conceptualize the multi- 19 acquisition, and physical distancing policies that have level and interrelated impacts of COVID-19 and endemic induced social isolation, are perpetuated by lack of access disparities and vulnerabilities on maternal morbidity and to mental health care among racial and ethnic minorities mortality and inform high-leverage solutions. and existing disparities in general, maternal, and racism- Syndemics refer to the clustering of multiple afflictions related stressors experienced by BWBP during pregnancy within a population due to macro-level forces, where these (Gausman and Langer 2020; Stein and Ometa 2020). These co-occurring afflictions interact to exacerbate their detri- stressors accompany existing disparities in general, mater- mental impacts and create excessive population-level dis- nal, and racism-related stressors experienced by BWBP ease burden (Singer 2013; Singer et al. 2017). Syndemic during pregnancy, which are likely to be worsened due to perspectives can expand the theoretical lens through which novel COVID-19 risks of unintended pregnancies due to endemic and COVID-related vulnerabilities and disparities difficulties in obtaining contraception or related medical are understood by embodying interactions among a diverse procedures and increased rates of domestic violence due to array of afflictions, including both communicable and non- COVID-19 physical distancing policies (Dominguez et al. communicable diseases, and interactions across multiple lev- 2008; Gausman and Langer 2020). els of influence. By understanding syndemogenesis (Singer Finally, the exacerbation of population-level vulnerabili- et al. 2017) – the processes involved in the development and ties and disparities among BWBP due to COVID-19 and perpetuation of syndemics – these frameworks can facilitate related policies may form a ‘vicious cycle’, with upstream conceptualizations of how extant and long-standing syn- impacts that reinforce and worsen upstream macro-level demic risk factors (Singer et al. 2017) – macro-level drivers forces that perpetuate the clustering of maternal dispari- that lead to the clustering of such afflictions – induce syn- ties (Stein and Ometa 2020). These impacts may play out demic vulnerabilities (Singer et al. 2017) among BWBP that across generations, with damaging prenatal and postnatal have led to the emergence of clusters of synergistic mater- COVID-19 comorbidities creating consequences for parent nal health and other afflictions within these populations and child across the life course that reinforce or exacerbate over time. Syndemic-informed COVID-19 maternal health population-level socioeconomic and healthcare disparities research can then contextualize the novel and exacerbatory and perpetuate the clustering of afflictions among BWBP impacts of the pandemic and corresponding policy changes (Gausman and Langer 2020; Kapur and Hod 2020). These on BWBP within the long-standing and deeply rooted syn- upstream impacts are not limited to communicable diseases; demic experienced by these populations. Syndemic frame- for example, physical distancing policies that prohibit birth- works can be especially powerful in understanding pandem- ing with a companion present or require parent-infant sep- ics such as COVID-19, as epidemics typically emerge in aration can have prolonged impacts on the mental health conjunction with existing and dynamic macro-level vulnera- of BWBP (Gausman and Langer 2020), and these impacts bilities and co-occurring disease states to dramatically shape may induce upstream socioeconomic and healthcare conse- the impacts of infection and transmission within populations quences that perpetuate the vicious cycle of disproportionate (Mendenhall 2017; Singer et al. 2017). maternal morbidity and mortality in this population. 1 3 Maternal and Child Health Journal The holistic and nuanced understanding of the emer- Compliance with Ethical Standards gence and exacerbation of epidemics afforded by syndemic Conflict of interest The authors declare that they have no conflict of frameworks can be especially powerful for designing interest. impactful preventive strategies to mitigate endemic and COVID-19 disparities among BWBP (Mendenhall 2017). Corresponding strategies can address the multifaced impacts the COVID-19 pandemic and related policies References within endemic maternal health disparities, the historical and ongoing macro-forces that have induced them, and the Al-Bayan, M., Islam, N., Edwards, S., & Duncan, D. T. (2016). Neigh- borhood perceptions and hypertension among low-income black potentially reinforcing nature of the resulting afflictions. women: A qualitative study. BMC Public Health, 16(1), 1075. Syndemic-informed strategies can then simultaneously Anderson, J. (2016). Breadwinner mothers by race/ethnicity and state. tackle each co-occurring affliction and the macro-level Retrieved from Washington, DC: https ://iwpr .org/wp-conte nt/ syndemic risk factors that have initiated and perpetuated uploa ds/wpall impor t/files /iwpr-expor t/publi catio ns/Q054.pdf Baker, M. G., Peckham, T. K., & Seixas, N. S. (2020). Estimating the the syndemic vulnerabilities that shape the clustering of burden of United States workers exposed to infection or disease: a these afflictions over time (Mendenhall 2017; Singer et al. key factor in containing risk of COVID-19 infection. PLoS ONE, 2017). As a result, such strategies constitute innovative 15(4), e0232452. and holistic multi-level preventive efforts that hold the Bohn, S., Mejia, M.C., LaFortune, J. (2020). Essential works and COVID-19. https ://www .ppic.or g/blog/essen tial-wor k e rs-and- promise to be impactful and long-lasting in the face of covid -19/ deeply rooted and persistent maternal health disparities. Building U.S. Capacity to Review and Prevent Maternal Deaths. For example, a syndemic-informed prevention initiative (2018). Report from nine maternal mortality review committees. to address maternal health disparities by targeting lower https: //review toact ion.org/sites/ defaul t/files/ nation al-portal -mater ial/Repor t%2520f rom%2520N ine%2520M MRCs%2520 final_0. breastfeeding rates among BWBP during COVID-19 could pdf simultaneously address policies and structural factors that Davis, D.-A. (2019). Obstetric racism: The racial politics of pregnancy, are endemic (e.g., economic pressures to return to the labor, and birthing. Medical Anthropology, 38(7), 560–573. workforce) and COVID-19 related (e.g., disproportionate Dominguez, T. P., Dunkel-Schetter, C., Glynn, L. M., Hobel, C., & Sandman, C. A. (2008). Racial differences in birth outcomes: The workplace exposures to COVID-19) that shape the cluster- role of general, pregnancy, and racism stress. Health Psychology, ing of low breastfeeding rates among BWBP, while also 27(2), 194–203. including components at the patient-level that encourage Frye, J. (2020). On the frontlines of work and at home: The dispropor- breastfeeding while also minimizing COVID-19 transmis- tionate economic effects of the Coronavirus pandemic on women of color. https ://www.ameri canpr ogres s.org/issue s/women /repor sion risks related to parent-infant physical contact. ts/2020/04/23/48384 6/front lines -work-home/ Gausman, J., & Langer, A. (2020). Sex and gender disparities in the COVID-19 pandemic. Journal of Women’s Health, 29(4), 465–466. Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. Conclusions W., Payne, B. K., et al. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care out- Macro-level policies and forces have disproportionately comes: A systematic review. American Journal of Public Health, higher rates of maternal morbidity and mortality among 105(12), e60–e76. Hooper, M.W., Nápoles, A.M., Pérez-Stable, E.J. (2020). COVID-19 BWBP in the U.S., and emerging evidence indicates and racial/ethnic disparities. JAMA, E1-E2. that the COVID-19 pandemic and corresponding policy Kapur, A., Hod, M. (2020). Maternal health and non‐communicable changes introduce novel and exacerbatory risks to these disease prevention: An investment case for the post COVID‐19 populations. Understanding the complex intersection of world and need for better health economic data. International Journal of Gynecology & Obstetrics. endemic and COVID-19-specific vulnerabilities and dis- Kim, E. J., Marrast, L., Conigliaro, J. (2020). COVID-19: Magnify- parities experienced by BWBP requires syndemic frame- ing the effect of health disparities. Journal of General Internal works to holistically conceptualize the multi-level, inter- Medicine, 1. acting, and dynamic nature of the impacts of COVID-19 Lu, M. C., Kotelchuck, M., Hogan, V., Jones, L., Wright, K., & Halfon, N. (2010). Closing the Black-White gap in birth outcomes: A life- and corresponding policy changes. Syndemic-informed course approach. Ethnicity and Disease, 20(102), 62–76. strategies can then simultaneously tackle each co-occur- Mein, S.A. (2020). COVID-19 and health disparities: The reality of ring affliction and the macro-level syndemic risk factors The Great Equalizer. Journal of General Internal Medicine. that have initiated and perpetuated the clustering of these Mendenhall, E. (2017). Syndemics: A new path for global health research. The Lancet, 389, 889–891. afflictions over time to mitigate endemic and emerging National Partnership for Women & Families. (2020). Black women and COVID-19 disparities among BWBP. the wage gap. Washington, DC. https://www .nationalpa r tnership. org/our-work/resou rces/econo mic-justi ce/fair-pay/afric an-ameri can-women -wage-gap.pdf 1 3 Maternal and Child Health Journal Raifman, M., & Raifman, J. (2020). Disparities in the population A systematic review. Neuroscience and Biobehavioral Reviews, at risk of severe illness from COVID-19 by race/ethnicity and 108, 694–711. income. American Journal of Preventive Medicine. https ://doi. Vahidy, F.S., Nicolas, J.C., Meeks, J.R., Khan, O., Jones, S.L., Masud, org/10.1016/j.amepr e.2020.04.003. F., Kash, B.A. (2020). Racial and ethnic disparities in SARS- Singer, M. (2013). Development, coinfection, and the syndemics of CoV-2 pandemic: Analysis of a COVID-19 observational registry pregnancy in Sub-Saharan Africa. Infectious Diseases of Poverty, for a diverse US metropolitan population. medRxiv. 2(1), 26. https ://doi.org/10.1186/2049-9957-2-26. Zaigham, M., Andersson, O. (2020). Maternal and perinatal outcomes Singer, M., Bulled, N., Ostrach, B., & Mendenhall, E. (2017). Syn- with COVID‐19: A systematic review of 108 pregnancies. Acta demics and the biosocial conception of health. The Lancet, 389, Obstetricia et Gynecologica Scandinavica. 941–950. Stein, R.A., Ometa, O. (2020). When public health crises collide: Publisher’s Note Springer Nature remains neutral with regard to Social disparities and COVID-19. International Journal of Clini- jurisdictional claims in published maps and institutional affiliations. cal Practice, e13524-e13524. Stuebe, A. (2020). Should infants be separated from mothers with COVID-19? First, do no harm. Breastfeeding Medicine. Suvarna, B., Suvarna, A., Phillips, R., Juster, R.-P., McDermott, B., & Sarnyai, Z. (2019). Health risk behaviours and allostatic load: 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Maternal and Child Health Journal Pubmed Central

Syndemic Perspectives to Guide Black Maternal Health Research and Prevention During the COVID-19 Pandemic

Maternal and Child Health JournalJul 21, 2020

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Pubmed Central
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© Springer Science+Business Media, LLC, part of Springer Nature 2020
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1092-7875
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10.1007/s10995-020-02983-7
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Abstract

The coronavirus 2019 (COVID-19) pandemic and related policies have led to an unequal distribution of morbidity and mor- tality in the U.S. For Black women and birthing people, endemic vulnerabilities and disparities may exacerbate deleterious COVID-19 impacts. Historical and ongoing macro-level policies and forces over time have induced disproportionately higher rates of maternal morbidity and mortality among Black women and birthing people, and contemporary macroeconomic and healthcare policies and factors continue to hold particular consequence. These factors induce detrimental psychologi- cal, health, and behavioral responses that contribute to maternal health disparities. The COVID-19 pandemic is likely to disproportionately impact Black women and birthing people, as policy responses have failed to account for the their unique socioeconomic and healthcare contexts. The resulting consequences may form a ‘vicious cycle’, with upstream impacts that exacerbate upstream macro-level policies and forces that can further perpetuate the clustering of maternal morbidity and mortality in this population. Understanding the impacts of COVID-19 among Black women and birthing people requires theo- retical frameworks that can sufficiently conceptualize their multi-level, interacting, and dynamic nature. Thus, we advocate for the proliferation of syndemic perspectives to guide maternal disparities research and prevention during the COVID-19 pandemic. These perspectives can enable a holistic and nuanced understanding of the intersection of endemic and COVID- 19-specific vulnerabilities and disparities experienced by Black women and birthing people. Syndemic-informed research can then lead to impactful multi-level prevention strategies that simultaneously tackle both endemic and COVID-19-specific factors and outcomes that lead to the clustering of vulnerabilities and disparities over time. Keywords COVID-19 · Syndemic · Maternal health services · African american · Maternal mortality Significance What This Study Adds? What is Already Know on This Subject? This paper advocates for the proliferation of syndemic perspectives to guide maternal disparities research and Black women and birthing people are more likely to die from prevention during the COVID-19 pandemic. Syndemic pregnancy-related causes than white women in the United perspectives can conceptualize the array of endemic and States. Emerging evidence suggests that the COVID-19 pan- COVID-19-specific vulnerabilities and disparities among demic and related policies have exacerbated racial maternal Black women and birthing people, and this understanding health disparities and worsened Black maternal health. can lead to high-impact prevention strategies. * Michael Kenneth Lemke Introduction LemkeM@uhd.edu The coronavirus 2019 (COVID-19) pandemic, along with Department of Social Sciences, One Main Street, University of Houston-Downtown, Suite N1025, Houston, TX 77002, the numerous policy changes that it has triggered, has led USA to an unequal distribution of morbidity, mortality, and other Department of Kinesiology, University of Texas At consequences in the U.S. For populations with existing vul- Arlington, 500 W. Nedderman, Maverick Activities Center, nerabilities and endemic disparities across racial/ethnic, sex/ Box 19259, Arlington, TX 76019, USA Vol.:(0123456789) 1 3 Maternal and Child Health Journal gender, life course, and socioeconomic lines, the impacts of difficult to secure jobs that provide livable wages, opportu- COVID-19 have been especially pronounced (Singer 2013; nity for advancement, and pay comparable to White coun- Gausman and Langer 2020; Raifman and Raifman 2020). terparts. These inequalities are especially relevant, as most Black women and birthing people (BWBP), who have Black women (81%) of single and married households in been burdened by long-standing population-level maternal the U.S. are the primary economic support for their families morbidity and mortality vulnerabilities and disparities, are (Anderson 2016). Due to systemic gendered racism in the typically at the intersection of most or all of these and other workforce and other multi-level and longstanding economic demarcations, and emerging evidence suggests that these forces, Black women earn $0.62 for every dollar that a White same characteristics may similarly intersect to exacerbate man earns (National Partnership for Women & Families deleterious COVID-19 impacts, such as maternal morbidity 2020). This structural economic disparity differentially and mortality (Zaigham and Andersson 2020). impacts BWBP from varying economic backgrounds. For Understanding the complex intersection of endemic and example, BWBP with lower income may have to reside in COVID-19-specific vulnerabilities and disparities experi- neighborhoods that induce stress related to safety or resource enced by BWBP requires theoretical frameworks that can availability, while those individuals with middle to high overcome the limitations of prevalent epidemiological, incomes may reside in more affluent and oftentimes pre- biomedical, and public health frameworks (Singer 2013; dominately White neighborhoods, which can induce stress Mendenhall 2017) and holistically conceptualize the multi- related to racism and social isolation (Al-Bayan et al. 2016). level, interacting, and dynamic nature of the impacts of In the healthcare system, BWBP are disproportion- COVID-19 and corresponding policy changes. Thus, we ately impacted by policy changes (e.g., efforts to scale advocate in this manuscript that is not based upon clinical back Affordable Care Act legislation) and consistently study or patient data for the proliferation of syndemic per- experienced discrimination or suffered the consequences spectives to guide maternal disparities research and preven- of implicit racial bias (Davis 2019). These experiences tion during the COVID-19 pandemic. Syndemic perspec- can lead to mistrust and fear of the healthcare system and tives can provide researchers with a theoretical grounding missed opportunities for the provision of high-quality care to advance scientific inquiry into the interacting, multi- and patient education. This is crucial, considering the inter- level, and co-occurring maternal health afflictions that have action of patient factors (e.g., presence of chronic health emerged from dynamic macro-level policies and forces that conditions) and provider/system factors (e.g., misdiagnosis; have led to the clustering of health disparities among preg- ineffective treatment; poorly coordinated care) are key con- nant Black women over time. Further, these perspectives tributors to preventable maternal morbidity and mortality can shed light on how these endemic policies, forces, and (Building U.S. Capacity to Review and Prevent Maternal afflictions, along with novel COVID-19-specific factors and Deaths 2018). outcomes, may synergistically perpetuate population-level These multi-level contextual factors induce detrimen- vulnerabilities and exacerbate disparities, with upstream tal psychological, health, and behavioral responses among impacts that constitute ‘vicious cycles’. Syndemic-informed BWBP and contribute to disparate maternal health out- research can then lead to holistic, multi-level prevention comes through multiple mechanisms. One such mechanism strategies that simultaneously tackle both endemic and is chronic exposure to stress resulting in the accumulation COVID-19-specific factors and outcomes that lead to the of allostatic load, which undermines the physical health and clustering of vulnerabilities and disparities over time. reproductive potential of BWBP (Lu et al. 2010). Moreo- ver, even in the presence of social and structural supports, chronic exposure to unique stressors related to pervasive Endemic Vulnerabilities and Disparities gendered racism may contribute to diminished mental well- among Black Women and Birthing People being and coping behaviors that elevate risk for or exac- erbate chronic health conditions (Suvarna et al. 2019) and Macro-level macroeconomic, healthcare, and other policies exacerbate maternal morbidity and mortality risks. Another and forces over time have contributed to disproportionately key mechanism is the impact of healthcare actions or inac- higher rates of maternal morbidity and mortality among tions, rooted in systemic racism endemic to healthcare sys- BWBP in the U.S. Longstanding structural inequities, driven tems, on maternal morbidity and mortality (Hall et al. 2015). by systemic racism, have created barriers that have made it We use the term “birthing people” to recognize that not all peo- ple who have a uterus, become pregnant, and give birth identify as a woman or a mother. 1 3 Maternal and Child Health Journal more difficult to achieve for BWBP, as these individuals Disproportionate and Exacerbatory disproportionately live in households and neighborhoods Impacts of COVID‑19 among Black Women with higher population densities and are more dependent and Birthing People on public transportation (Hooper et al. 2020; Mein 2020; Raifman and Raifman 2020; Vahidy et al. 2020). As the COVID-19 pandemic and corresponding policy The current pandemic and related policies are also likely changes continue to unfold in the U.S., they are likely to to worsen existing healthcare inequities among BWBP, disproportionately impact vulnerable populations and per- with multi-fold consequences for maternal well-being. petuate and worsen population-level morbidity and mortal- Physical distancing policies have increased unemployment ity disparities through novel and exacerbatory risks that rates, with corresponding losses in income (Mein 2020). will impact prone populations across racial/ethnic, sex/ Because BWBP of all socioeconomic backgrounds sys- gender, life course, and socioeconomic demarcations due tematically earn less than their White counterparts for the to deeply rooted macro-level racism/discrimination, mac- same amount of labor, losses in income can be especially roeconomic, healthcare, and other forces (Singer 2013; stressful. Increases in unemployment have also led to losses Gausman and Langer 2020; Hooper et  al. 2020; Mein in employer-based health insurance coverage (Mein 2020). 2020). In the United States, BWBP are typically at the These impacts are especially detrimental to low-income intersection of these characteristics and thus are especially individuals, who are likely to forego preventive care that likely to experience disproportionate morbidity and mor- they are no longer able to afford; as a result chronic disease tality burden, and policy responses to COVID-19 have disparities may further increase over time (Kim et al. 2020). failed to account for the unique socioeconomic and health- Healthcare and socioeconomic factors have led to dispari- care contexts experienced by these populations. ties in COVID-19 testing and transmission that may also The COVID-19 pandemic is likely to exacerbate exist- impact future COVID-19 vaccination rates (Mein 2020). ing socioeconomic disparities among BWBP and increase For BWBP, COVID-19 policies have interfered with rou- vulnerabilities to COVID-19 acquisition and transmis- tine prenatal care appointments, and the consequences of sion, especially those vulnerabilities related to employ- the pandemic have likely reduced quality of care (Gausman ment in low-wage, ‘essential’ occupations. Because of an and Langer 2020). The lack of knowledge about COVID-19 array of structural inequalities, including those caused has led to ambiguities about how to best provide care and by systemic racism, BWBP are more likely to experience have led to policy decisions that have been consequential lower socioeconomic status and low incomes (Mein 2020; for maternal and infant health outcomes (Stuebe 2020). For Vahidy et al. 2020). Individuals with lower income are example, geographically heterogeneous physical distancing often employed in occupations that render them especially policies designed to reduce potential exposure to COVID-19 vulnerable to COVID-19 infection and transmission due have perpetuated social isolation among women and birth- to increased workplace exposures related to lack of sick ing people, with detrimental psychological (e.g., psychoso- leave, inadequate provision of personal protective equip- cial stress) and physical (e.g., domestic violence) impacts ment, and the inability to work from home (Bohn et al. (Gausman and Langer 2020). These policies have also made 2020; Hooper et al. 2020; Mein 2020). These populations it more difficult for women and birthing people to acquire are also associated with higher rates of employment in jobs contraception or other obstetric and gynecologic medical that have been classified as ‘essential’ and therefore have procedures considered to be elective (Gausman and Langer remained open during the pandemic (Bohn et al. 2020; 2020). Healthcare ambiguities may also pose a threat to Hooper et al. 2020; Raifman and Raifman 2020). Because the effective delivery of treatments or vaccines for BWBP low-income workers are vulnerable to and more likely to (Gausman and Langer 2020). Further, concerns about the live in single-income households, they experience greater possibility of vertical transmission during childbirth or by pressures to continue their participation in these occupa- breastfeeding, and parent-infant separation policies, may tions despite COVID-19 risks (Mein 2020). BWBP in par- result in clinical decisions that can have negative impacts ticular are most commonly employed in essential health- on maternal and child well-being (Stuebe 2020; Zaigham care, service, and education occupations that have been and Andersson 2020). For BWBP, who already experience associated with heightened risks of COVID-19 infection disparities in maternal and infant morbidity and mortality, (Baker et al. 2020; Bohn et al. 2020; Frye 2020; Gausman such clinical decisions may be especially detrimental. and Langer 2020). Policy responses to COVID-19 have As the impacts of COVID-19 and related policies forced the closures of daycare centers and schools and interact with macroeconomic, healthcare, and other have caused additional financial hardships and psychoso- macro-level forces, all of which are entrenched in sys- cial stress (Bohn et al. 2020; Gausman and Langer 2020). temic racism, population-level comorbidities are likely Further, physical distancing has appeared to have been to emerge that further widen disparities among BWBP. 1 3 Maternal and Child Health Journal Black Americans and low-income households have been Syndemic Perspectives to Guide COVID‑19 found to have a higher risk of COVID-19 infection and Research and Prevention among Black associated comorbidities (Raifman and Raifman 2020; Women and Birthing People Stein and Ometa 2020; Vahidy et al., 2020). In particular, long-standing disparities in comorbidities such as cardio- The exacerbatory and novel impacts of the COVID-19 pan- vascular, metabolic, respiratory, liver, and kidney diseases demic and corresponding policy changes interact with exist- in racial and ethnic minority populations present enhanced ing macro-level vulnerabilities and endemic comorbidities to risks for COVID-19 disease severity (Hooper et al. 2020; induce maternal health disparities among BWBP in the U.S., Mein 2020; Stein and Ometa 2020). Racial and ethnic and these outcomes may create upstream impacts that further minorities are also more likely to have existing diagnosed exacerbate these outcomes over time. Because prevalent the- and undiagnosed medical conditions; for these individuals, oretical perspectives cannot adequately conceptualize these they are faced with the dilemma of either seeking medi- complex and dynamic influences, syndemic perspectives are cal care and risking nosocomial COVID-19 acquisition, warranted in maternal health research and action to under- or delaying care and increasing future risk of more severe stand the intersection of endemic and COVID-19-specific outcomes or complications (Kim et  al. 2020). Psycho- vulnerabilities and disparities experienced by BWBP and logical comorbidities related to COVID-19 and policies, guide preventive strategies. Further, although the focus of especially novel and exacerbatory psychosocial stressors this paper is on BWBP in the U.S., syndemic perspectives associated with disruptions to daily life, uncertainty about can be harnessed across a wide array of geographic, demo- socioeconomic and other consequences, fear of COVID- graphic, and other demarcations to conceptualize the multi- 19 acquisition, and physical distancing policies that have level and interrelated impacts of COVID-19 and endemic induced social isolation, are perpetuated by lack of access disparities and vulnerabilities on maternal morbidity and to mental health care among racial and ethnic minorities mortality and inform high-leverage solutions. and existing disparities in general, maternal, and racism- Syndemics refer to the clustering of multiple afflictions related stressors experienced by BWBP during pregnancy within a population due to macro-level forces, where these (Gausman and Langer 2020; Stein and Ometa 2020). These co-occurring afflictions interact to exacerbate their detri- stressors accompany existing disparities in general, mater- mental impacts and create excessive population-level dis- nal, and racism-related stressors experienced by BWBP ease burden (Singer 2013; Singer et al. 2017). Syndemic during pregnancy, which are likely to be worsened due to perspectives can expand the theoretical lens through which novel COVID-19 risks of unintended pregnancies due to endemic and COVID-related vulnerabilities and disparities difficulties in obtaining contraception or related medical are understood by embodying interactions among a diverse procedures and increased rates of domestic violence due to array of afflictions, including both communicable and non- COVID-19 physical distancing policies (Dominguez et al. communicable diseases, and interactions across multiple lev- 2008; Gausman and Langer 2020). els of influence. By understanding syndemogenesis (Singer Finally, the exacerbation of population-level vulnerabili- et al. 2017) – the processes involved in the development and ties and disparities among BWBP due to COVID-19 and perpetuation of syndemics – these frameworks can facilitate related policies may form a ‘vicious cycle’, with upstream conceptualizations of how extant and long-standing syn- impacts that reinforce and worsen upstream macro-level demic risk factors (Singer et al. 2017) – macro-level drivers forces that perpetuate the clustering of maternal dispari- that lead to the clustering of such afflictions – induce syn- ties (Stein and Ometa 2020). These impacts may play out demic vulnerabilities (Singer et al. 2017) among BWBP that across generations, with damaging prenatal and postnatal have led to the emergence of clusters of synergistic mater- COVID-19 comorbidities creating consequences for parent nal health and other afflictions within these populations and child across the life course that reinforce or exacerbate over time. Syndemic-informed COVID-19 maternal health population-level socioeconomic and healthcare disparities research can then contextualize the novel and exacerbatory and perpetuate the clustering of afflictions among BWBP impacts of the pandemic and corresponding policy changes (Gausman and Langer 2020; Kapur and Hod 2020). These on BWBP within the long-standing and deeply rooted syn- upstream impacts are not limited to communicable diseases; demic experienced by these populations. Syndemic frame- for example, physical distancing policies that prohibit birth- works can be especially powerful in understanding pandem- ing with a companion present or require parent-infant sep- ics such as COVID-19, as epidemics typically emerge in aration can have prolonged impacts on the mental health conjunction with existing and dynamic macro-level vulnera- of BWBP (Gausman and Langer 2020), and these impacts bilities and co-occurring disease states to dramatically shape may induce upstream socioeconomic and healthcare conse- the impacts of infection and transmission within populations quences that perpetuate the vicious cycle of disproportionate (Mendenhall 2017; Singer et al. 2017). maternal morbidity and mortality in this population. 1 3 Maternal and Child Health Journal The holistic and nuanced understanding of the emer- Compliance with Ethical Standards gence and exacerbation of epidemics afforded by syndemic Conflict of interest The authors declare that they have no conflict of frameworks can be especially powerful for designing interest. impactful preventive strategies to mitigate endemic and COVID-19 disparities among BWBP (Mendenhall 2017). 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Published: Jul 21, 2020

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