The Structural and Social Determinants of Intergenerational Health Inequities: How State Policy Contexts and Discrimination Shape Birth Outcomes

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In the United States, geographic and racial-ethnic disparities in adverse birth outcomes have increased over the past decade. High and rising rates of low birth weight, preterm delivery, and infant mortality are concentrated in the South and Midwest and among non-Hispanic Black and other birthing persons of color. These divergent trends are rooted in structural and social systems of inequality, such that cumulative experiences of discrimination and disparate access to resources related to policy contexts and one’s social standing systematically place some birthing persons at greater risk of adverse birth outcomes compared to others. Because these outcomes are associated with both birthing persons’ social positioning and offspring’s later-life socioeconomic status and health, they become mechanisms through which inequality is passed across generations. This dissertation explores the structural and social determinants of intergenerational health inequities by examining how the state policy contexts and discrimination that a mother is exposed to contribute to differences in adverse birth outcomes across US states and two distinct but related status characteristics: race and ethnicity and skin tone. Chapters 2 and 3 use birth cohort-linked birth/infant death restricted-use micro-data from the National Center for Health Statistics. Chapter 2 focuses on a single policy context and evaluates how rates of preterm birth and infant mortality responded to two policies restricting access to reproductive health care in Texas between 2005 and 2017. Using demographic standardization and decomposition techniques, I find that age-education-prenatal care standardized rates of infant mortality increased significantly in the years immediately following restrictions to family planning care (2011), but only for births to non-Hispanic (NH) Black mothers. Standardized preterm birth rates increased slightly and temporarily following 2013 restrictions on abortion providers across all racial-ethnic groups. These salient findings underscore the need to consider the infant health and heterogeneous consequences of rapidly evolving reproductive rights across the US. Chapter 3 takes a multidimensional policy approach to consider, first, how state policies and related characteristics co-occur to form distinct, underlying policy contexts and, second, how those contexts are related to low birth weight and infant mortality. Building on the World Health Organization’s structural determinants of health framework and compiling state-level data from several publicly available sources, results from the latent profile analysis suggest three distinct contexts. Contexts defined by high intervention or high constituent engagement (compared to low intervention) are negatively associated with risks of low birth weight and infant mortality. Overall, the protective effects are most pronounced among births to NH white mothers (compared to NH Black or Hispanic). These findings demonstrate how state policies and characteristics combine to shape health and underscore the importance of considering how racialized experiences may reduce the benefits of certain state contexts among minoritized groups. In Chapter 4, I marry weathering and skin tone stratification frameworks to examine how risks of low birth weight differ across maternal age and skin tone, a marker of cumulative discrimination, among NH Black mothers. Using data from the National Longitudinal Study of Adolescence to Adult Health, I find that, despite similar risks of low birth weight across skin tone at maternal age 16, risks diverge with age such that mothers with the darkest skin tones experience the sharpest increases. These findings underscore the transgenerational consequences of life course exposures to discrimination. Overall, these findings contribute to health equity, maternal and child health, and life course studies by demonstrating how both “protective” and “harmful” policies contribute to racial-ethnic disparities in birth outcomes and by underscoring the importance of considering heterogeneous experiences across the life course and within racial-ethnic groups when addressing birth inequities. Future research should continue to interrogate how the “protective” effects of policies and contexts vary across race and ethnicity to clarify if such policies exacerbate or mitigate inequities, as well as examine how other cumulative and early life course stressors shape birth outcomes.






Stolte, Allison (2023). The Structural and Social Determinants of Intergenerational Health Inequities: How State Policy Contexts and Discrimination Shape Birth Outcomes. Dissertation, Duke University. Retrieved from


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