Historical redlining linked to modern reproductive health disparities in women

A pair of studies are the first to examine how the decades-old discriminatory mortgage lending practice may contribute to present-day reproductive health problems, which disproportionately burden Black residents and other communities of color.

Living in a historically redlined neighborhood may reduce a person's ability to become pregnant, according to two new studies led by researchers at Boston University School of Public Health (BUSPH).

Published in the American Journal of Epidemiology (AJE) and Epidemiology, the studies found that people residing in redlined neighborhoods-neighborhoods that were subjected to the historic practice of mortgage lending discrimination by the federal government-were less likely to conceive than those who lived in neighborhoods the government deemed favorable for mortgage lending. 

The racist practice ran from the 1930s to 1968, during which the federal Home Owners' Loan Corporation (HOLC) drew maps that graded neighborhoods based on how risky the organization thought it would be to provide home loans. Neighborhoods with larger Black populations and other marginalized groups were frequently deemed too risky, which prevented many people of color from building generational wealth and discouraged broader neighborhood investment.

The new findings provide sobering insight into how structural racism borne from past harmful policies, laws, and practices continues to influence health in the present day.

Infertility affects up to 15 percent of reproductive-aged couples in the United States, and communities of color experience a disproportionate share of this burden. Our findings support a growing body of fertility research that suggests individual-level factors such as education, income, nutrition, medication, and exercise do not fully explain the disparities we observe across racial and ethnic groups. Redlining, along with other historical and contemporary neighborhood conditions such as racial zoning and segregation, may play a role. In our studies, we hypothesized that redlining is an antecedent of present-day disparities that initiated or reinforced place-based social, economic, and environmental processes." 

Dr. Sharonda Lovett, lead author of the AJE study, and postdoctoral research associate in epidemiology at BUSPH

Lovett's study was the first to explore how historical practices shape fertility outcomes today, followed shortly by the study in Epidemiology, led by Dr. Mary Willis, assistant professor of epidemiology at BUSPH. Both researchers contributed to the pair of studies, allowing for comparison of methods and results across two unique study populations. 

Both analyses link US residential addresses to neighborhoods that received HOLC grading on perceived riskiness for mortgage lending, with an A or B grade denoting a "desirable," neighborhood, a C for "declining," and a D for "hazardous," or redlined. The research teams then applied probability models to measure residents' fecundability, or the per-cycle probability of conception among couples who are not using contraception.

The AJE analysis assessed sociodemographic and reproductive data among more than 1,900 US residents in 37 states who participated in BUSPH's Pregnancy Study Online (PRESTO), the largest web-based preconception cohort study of pregnancy planners in North America. The results show that currently living in a historically redlined, "hazardous" neighborhood was associated with a 14-percent lower fecundability compared with participants living in a neighborhood that received an A or B rating. This association was even stronger among people with less education and lower household income, reflecting the multiple forms of inequities that can develop due to the lack of resources and opportunities in disinvested communities. 

The study in Epidemiology focuses on more than 600 participants in the Boston University's Black Women's Health Study, the largest epidemiological study focused on the health of Black women in the US. Similarly, the researchers found that participants were 9 percent and 18 percent less likely to become pregnant if they lived in neighborhoods that received a C or D HOLC rating, respectively.

"Our pair of studies contribute to the body of evidence that historical programs and policies that reinforce structural racism can impact contemporary population health outcomes," says Dr. Willis. 

There are a number of mechanisms that may contribute to these disparities, she says. "Neighborhoods that received the lowest grades often have more air pollution, fewer parks and tree cover, limited societal resources such as employment opportunities and medical care, and more factories or highways nearby. Living in a neighborhood that has been neglected and underfunded can also yield chronic stress on the body, and be compounded by increased inflammation and other harmful physical changes from environmental hazards."

Together, these conditions create a "double jeopardy" situation where communities that were already facing discrimination are also more likely to face social and environmental hazards that yield worse health outcomes, including infertility, Dr. Willis says.

Notably, the researchers also observed that people who obtained higher education or currently live in neighborhoods with a higher socioeconomic status were less likely to encounter problems with conceiving, suggesting that efforts to develop equitable opportunities and resources in these communities could mitigate or prevent some of the harmful consequences of structural racism. Currently, Black families' homeownership rate is about 46 percent, compared to nearly 76 percent of White families.

"Reinvesting in the infrastructure of redlined neighborhoods and programs to reduce the uneven mortgage costs for Black, Hispanic, or immigrant homeowners are two of the long-term interventions that have the potential to offset the long-running impact of historical redlining," says Dr. Willis.