The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families
The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families
Andrew F. Beck 1 2
Erika M. Edwards 3 4 5
Jeffrey D. Horbar 3 4
Elizabeth A. Howell 6 7 8
Marie C. McCormick 0 9 10
DeWayne M. Pursley 0 9
0 Department of Pediatrics, Harvard Medical School , Boston, MA , USA
1 Department of Pediatrics, University of Cincinnati College of Medicine , Cincinnati, OH , USA
2 Division of General & Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center , Cincinnati, OH , USA
3 Vermont Oxford Network , Burlington, VT , USA
4 Department of Pediatrics , Robert Larner, MD , College of Medicine, University of Vermont , Burlington, VT , USA
5 Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont , Burlington, VT , USA
6 Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai , New York, NY , USA
7 Department of Obstetrics , Gynecology , and Reproductive Science, Icahn School of Medicine at Mount Sinai , New York, NY , USA
8 Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai , New York, NY , USA
9 Department of Neonatology, Beth Israel Deaconess Medical Center , Boston, MA , USA
10 Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health , Boston, MA , USA
REVIEW ARTICLE Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.
Racism, segregation, and inequality contribute to disparities in
health outcomes across the life course.11 In this review, we
address their effects on the health and well-being of newborn
infants and their families with a focus on preterm birth. We
explore three causal pathways that adversely and differentially
affect outcomes for newborn infants and their families: increased
risk; lower-quality care; and socioeconomic disadvantages that
persist into infancy, childhood, and beyond. We propose
interventions that health professionals, multidisciplinary care
teams, and health-care organizations can adopt to remedy the
adverse effects of racism, segregation, and inequality (Fig. 1) and
research priorities to inform more effective action.
An underlying theme is that we as health professionals have the
responsibility to act. The old paradigm of “follow-up” must be
replaced with a new paradigm of “follow through,” the
understanding that our responsibility extends beyond the hospital walls.
All infants and their families will not realize the full benefit of the
dramatic technical advances in perinatal and neonatal care that
will occur in the 21st century unless we accept our responsibility
for addressing the full range of determinants of health that
ultimately shape long-term outcomes.
In 2018, 10.0% of infants in the United States (U.S.) were born
before 37 completed weeks’ gestation,12 often requiring care
in a neonatal intensive care unit (NICU).13 Overall, 9.1% of white
non-Hispanic infants were born preterm compared to 14.1% of
Black non-Hispanic infants and 9.7% of Hispanic infants.12
Structural racism describes mutually enforcing forms of
discrimination11 such as neighborhood deprivation,14–16 economic
inequalities,16,17 educational disparities,16,18–20 and differential
access to health care21 with sequelae like nutritional deficiencies22
and unhealthy environmental exposures.23 These factors are the
social determinants of health (SDH), defined as the “conditions in
which people are born, grow, work, live, and age.”24 Consistently,
the SDH increase the risk for preterm birth and infant mortality.25
However, exposure to the SDH alone may be an insufficient
explanation for increased risk for preterm birth.26 The early
programming life course theory suggests that exposures during
the perinatal period, such as maternal stress27,28 and depression,29
increase vulnerability to preterm birth. The cumulative pathway
life course theory posits that additive stressors and exposures
Interventions to reduce racial and ethnic
inequalities in preterm birth
Racism, segregation, and inequality
Lower quality care
Implicit bias education
to eliminate modifiable
process with coordinated
Culture of equity
Access to quality prenatal
and interconception care
hydroxyprogesterone access and adherence
Cerclage placement in high
Screening and treatment of
specific genital infections
Early intervention and
intensive early education
Quality health care across
the lifespan for infants
EHR data for
populationlevel pattern recognition
resulting in allostatic load and inflammation increase the risk for
preterm birth.30–33 The weathering hypothesis, in which chronic
stress leads to accelerated aging and earlier onset of adverse
health conditions, may also be a risk factor in preterm birth.34
While the contribution of genetics alone likely plays a small role
in differential risk for preterm birth,35 gene–environment
interactions may explain differences.36–39 There is evidence of an
association between DNA methylation and preterm birth among
black women.40 Risk for preterm birth may be heritable among
African-American women.41–43 Immigrant African women are less
likely to give birth preterm than native-born black women.44,45 All
of these findings illustrate the potential role of epigenetics in
preterm birth. However, genetic and epigenetic studies must
include people of diverse ancestry.46
Numerous experts have suggested ways to reduce differences
in preterm birth rates.47–50 Improving and adherence to 17-alpha
hydroxyprogesterone caproate after a previous preterm birth,51
identifying and monitoring cervical insufficiency,28 cerclage
placement in high-risk women,52 screening and treatment of
specific genital infections,53,54 and increasing interpregnancy
intervals55 will help. Research with standardized definitions of
race, ethnicity, and discrimination that seeks to disentangle
the contributions of structural racism and its sequelae may
inform interventions but will be difficult to conduct. Instead,
research into interventions to improve access to health care,
financial, and social supports for families and children, to reduce
stress, and to identify and treat infections, inflammation, mental
health issues, and nutritional deficiencies may have greater
short-term impacts. Regardless, while broader structural issues
are evaluated and being addressed, there is a clear argument for
ensuring that women and their families receive the highest
Substantial improvements in perinatal and neonatal care have led
to decreasing rates of death before discharge and serious
morbidities in NICUs across the U.S. Yet wide variation in mortality
and serious morbidities persists.56,57 Black neonates die at more
than twice the rate of non-Hispanic white neonates, and black and
Hispanic infants remain at increased risk for severe neonatal
morbidities.58–60 Further, the magnitude of these disparities is
larger than previously reported.61 Disparities in severe neonatal
morbidities are associated with later neurodevelopmental,
behavioral, and physical impairments that disadvantage very preterm
birth infants over the life course, perpetuating health and
Quality of care is a crucial and potentially modifiable factor that
contributes to disparities and is one of the causal pathways by
which racism, segregation, and inequality adversely affect
outcomes of very preterm infants. Differences in quality of care
contribute to racial and ethnic disparities in two ways.63 First,
white and minority preterm infants may receive care in different
NICUs, and NICUs primarily serving minority infants may have
structural characteristics associated with lower quality or have
organizational models or clinical processes that lead to
lowerquality care.63 Second, the quality of care received by preterm
infants can differ by race and ethnicity in individual NICUs. These
pathways may be related to organizational (e.g., culture) and
clinical processes (e.g., communication) rather than structural
characteristics and can confer disadvantages to minority infants.
There is accumulating evidence that both mechanisms are
Evidence over the past two decades has documented that black
very low birth weight (VLBW) infants are cared for in a
concentrated set of hospitals64 and that minority-serving hospitals
have higher neonatal mortality rates for both black and white
infants.65,66 More recent research has expanded beyond mortality
to include severe neonatal morbidities with similar findings. Black
and Hispanic very preterm infants are more likely to be born in
hospitals with higher risk-adjusted neonatal morbidity and
mortality rates than white VLBW infants, and disparate utilization
patterns can explain 40% of the black–white disparity and nearly
one third of the Hispanic–white disparity in very preterm neonatal
morbidity and mortality rates.59 These findings have prompted
investigators to evaluate the origins of outcome differences
between hospitals and the potential role of differential quality of
care. Investigators also found that minority infants were less likely
to be born at hospitals that achieved Magnet status and infants at
non-Magnet hospitals had significantly higher rates of morbidity
and mortality.67 Similarly, VLBW infants born in hospitals that
served higher proportions of minority patients had higher rates of
infection, discharge without breast milk, nurse understaffing, and
worse practice environments for nurses.68 The patient-to-nurse
ratios and missed care in minority-serving hospitals were much
higher than in other hospitals suggesting that improving staffing
and workloads would improve quality of care at minority-serving
hospitals.69 Recent investigations utilizing national data found
significant segregation across NICUs and that black infants
received care at lower-quality NICUs.64 These studies suggest that
improving care provided at lower-quality hospitals would result in
a significant narrowing of disparities.66
While previous studies primarily investigated between-hospital
disparities, additional research has examined within-hospital
disparities. Using a composite measure of quality (including both
process and outcomes measures), investigators found that
significant racial and ethnic variation in quality of care also
existed within NICUs.70 Studies have highlighted within-hospital
differences in the use of evidence-based practices. Hispanic
mothers were found to be less likely than white mothers to
receive antenatal steroids and to be feeding human milk at
discharge within a given institution.71,72 Additional research
suggests that adverse interactions with families may be a
mechanism for disparate care, interactions that may be driven
by clinician implicit bias and other failures in staff–family
communication. These factors can affect the health of the neonate
and have the potential to incite disparities that will last beyond
discharge.73 While studies have examined the role of racism in
preterm birth, few studies have examined the role of racism and
bias in the NICU setting.32 A growing body of research in maternal
health acknowledges the role that structural racism plays in
generating disparities.74 More research on how behaviors and
attitudes impact clinical outcomes in the NICU setting is needed.
There is an urgent need to go beyond describing disparities to
understand their causes, and develop and implement
interventions to eliminate their occurrence. An abundance of evidence
demonstrates that the quality of care is one of the causal
pathways by which segregation and inequality adversely affect
outcomes of very preterm infants. Lessons from efforts in maternal
health to reduce peripartum disparities can be applied to the NICU
setting to help us further the shift from “follow-up” to “follow
through.”74,75 Critical steps to such a shift include: enhancing
communication with families by educating clinicians and staff
about racial and ethnic disparities in neonatal outcomes, the
importance of shared decision making, cultural competency, and
assessing non-English language proficiency and providing
interpreter services; education on implicit bias that can affect a
clinician’s perceptions and decisions; creating disparities
dashboards that stratify quality measures by race/ethnicity, insurance,
language, and other attributes so that NICUs can assess how well
they are taking care of infants from different backgrounds;
applying quality improvement tools to narrow the disparities that
are identified; engaging families and communities in quality and
safety teams; and promoting a culture of equity by employing
many of the tools we have used to emphasize a culture of safety.
These strategies and steps must also consider, identify, and
address socioeconomic disadvantages that will accompany an
infant home as they are discharged from the NICU.
SOCIOECONOMIC DISADVANTAGES IN INFANCY AND
Infants of women of color begin life with greater risks of vulnerability
through their well-documented increased risk for being delivered
preterm and experiencing greater morbidity and mortality. In part,
this disparity reflects higher parallel rates of socioeconomic
disadvantage among women of color. Such disadvantage both
increases the risk of preterm birth and of subsequent poorer infant
health and developmental outcomes.76,77
Characterizing factors that underlie racial and ethnic disparities
in the health and well-being among premature infants can be
difficult. While the study of long-term outcomes of preterm infants
has progressed over the past quarter century, much of this work
has focused on simple associations between prematurity, birth
weight, and NICU complications (exposures) and measures of
neurodevelopment (outcomes), generally within the first few
years. Because of the interest in attributing outcomes to
“prematurity,” the research often employs restrictive study
designs, rarely considers post-discharge factors influencing child
health and development, and fails to consider variations in the
quality of care on outcomes.78 More recent work has considered a
broader range of outcomes including physical health, social and
emotional well-being, and cognitive development. Studies have
also examined the influence of neonatal care, illness severity, and
NICU length of stay on outcomes. Nonetheless, the
conceptualization of outcomes remains simplistic, failing to consider the joint
effect of sociodemographic factors, chronic child illness, and
maternal physical and mental health over time.
Of course, factors related to the NICU course can significantly
influence physical health status in all preterm and low birth
weight infants, but these infants remain vulnerable to the factors
that worsen health in all children, like poverty and adverse
childhood events. To the extent that infants of color are
disproportionately exposed to these post-NICU stressors, they will
continue to experience disparities in health outcomes of all types.
Life course health development formulations suggest that the
adverse effects of such stressors can be buffered by interventions
that reduce the effect of stress and foster resiliency.30 To that
effect, greater attention is now being paid to NICU-to-home
transitions and to enhancing family caregiving skills via specific
therapeutic and developmental interventions for the infant.
The American Academy of Pediatrics recommended guidelines
for the discharge of high-risk newborns that focus on risk
identification, the optimal timing of discharge, and planning for
care after discharge.79 The guidelines emphasized discharge
planning, highlighting objectives for parental education, routine
health-care maintenance, management planning for unresolved
medical problems, comprehensive home-care planning,
identification and involvement of support services, and the determination
and designation of follow-up care. These recommendations have
led to greater emphasis placed on comprehensive discharge
preparation programs to ensure a systematic and individualized
approach for each family,80 including more consistent
measurement, standardized discharge approaches, and the incorporation
of quality improvement practices.80–82 As noted above, evidence
suggests that some minority families experience lower-quality
interactions with NICU staff, which might reduce effectiveness in
discharge planning and family readiness.73 Deeper study of new
and existing programs that support discharged preterm infants as
they grow and age is also occurring.
In the years following NICU discharge, intervention programs
that focus on family factors and the home environment are
proving effective.83 Indeed, early intervention programs improve
cognitive outcomes and, to a lesser extent, motor outcomes
during infancy. Such intensive early educational programs are
even effective for very preterm infants.84,85 Cognitive
improvements are seen to preschool age. Those programs that focus on
both the parent–infant relationship and on infant development
using standardized curricula have been shown to be the most
effective; however, the longer-term benefits of these programs
remain to be established. Despite the evidence of their
effectiveness, research has documented poorer access to such services for
An important component of how longer-term outcomes are
measured is to ensure adequate characterization of the functional
impact of prematurity and its complications as well as the effects
of interventions. Test scores and neurologic exams may fail to
provide a complete picture of child well-being. Depending on a
variety of circumstances, functioning may be influenced by
comorbidities (e.g., asthma, obesity, sensory deficits), movement
disorders, and behavioral (e.g., attention and autism disorders)
factors. To the extent that children of color experience more of
these morbidities,87 they are at greater risk for poor functional
The life course models mentioned above also suggest other
targets for research and intervention. Most have incorporated
advances in biological, behavioral, and social science disciplines to
define child development as a dynamic process that begins before
conception and continues through the life span.30 The
incorporation of emerging investigations in gene–environment interactions
and epigenetic mechanisms shows promise in maternal and child
health by highlighting the importance of fetal development and
early childhood on the life span. These models provide an
opportunity to focus on the impact of a variety of risk and
protective factors in early childhood for all children and foster a
shift to the promotion of more effective prevention and
intervention strategies to optimize healthy development. This, in
turn, informs health measurement, health-care organization, and
health systems financing.88 It also highlights ways in which health
care can meaningfully connect and collaborate with the
NICUs are increasingly turning toward community-based
prevention strategies and partnerships to improve perinatal outcomes.
Strategies often precede the birth of a child, support provision of
high-value care during NICU stays, and optimize transitions as
patients and families return to their medical and neighborhood
homes after discharge.59,89,90 This pivot from “follow-up” to “follow
through” is accelerated by patient-level social needs screening,
the use of electronic health record (EHR) data in combination with
complementary datasets to support population-level pattern
recognition, and bolstered clinical–community partnerships
driving both patient- and population-level action.91–96 Many such
actions elevate the relevance of SDH, which, in many ways, are
thought to be “fundamental causes” of disease, factors that place
individuals and populations at “risk of [having] risks.”97
The National Academy of Medicine and American Academy of
Pediatrics, among others, now recommend routine SDH-related
screening.98,99 They encourage routine assessment of factors like
race/ethnicity, social isolation, parental educational attainment,
financial strain, and residential address (to enable linkage to
complementary information like neighborhood-level median
household income).98,100 Evaluation of SDH-related risks and
assets using one of the many available screening tools101–104
could influence clinical care from the moment of first patient/
family contact, ensuring that supports are deployed to match
identified needs. Assessments could start prenatally in obstetrical
clinics and extend across the NICU stay to bring an awareness of
context to the bedside. Indeed, families with a daily life that is
characterized by racial discrimination, housing instability, food
insecurity, and inflexible work schedules may have a far more
difficult time adhering to complex medical regimens without
additional, complementary supports.
Although screening is critical, a broader prevention mindset
would benefit from strategies capable of discerning
populationwide patterns in adverse health outcomes.100,105,106 EHR data can
be leveraged to do just this, employed to inform data-driven
action.98 For instance, EHR data can define numerators for key
population health (or risk) measures. Pooling EHR data from
networked birth hospitals, nurseries, NICUs, and health
departments could enumerate preterm birth or infant mortality rates
across geographies and in association with a range of potentially
underlying sociodemographic factors. When mapped to certain
neighborhoods or regions, geographic patterns could be
identified. Where are “hot spots” of preterm birth and infant mortality?
What are the characteristics of those areas with respect to racial
segregation and socioeconomic disadvantages? By layering data
elements atop one another, and by ensuring that findings are
shared transparently with partners inside and outside health-care
settings, new research questions and intervention strategies may
Ultimately, the pivot from risk assessment and pattern
recognition to action is what will ensure the shift from
“followup” to “follow through.” With this as the goal, we suggest that
health-care systems, including academic health centers, consider
their role in population health improvement and social justice.91,94
Such a re-envisioned mission, one that elevates the importance of
community well-being, is likely to require the added,
complementary expertise that comes from meaningful community
integration.107,108 Indeed, although health-care systems and
providers have expertise in managing medical complexity, they
may not always have the expertise necessary to manage social
complexity. This is where clinical–community partnerships
become important, valuable adjuvants. Henize et al. defined
how such clinical–community partnerships can be developed,
enhanced, and sustained. They described the importance of jointly
defining the problem, identifying program champions, agreeing
upon mutually beneficial metrics, ensuring clear and consistent
communication, and planning for sustainability.109
The Medical–Legal Partnership (MLP) model is an example of a
successful clinical–community partnership, one where legal
expertise is brought into health-care settings.110–112 Although MLPs look
different from partnership to partnership and region to region, their
focus on context is consistent. For example, consider a patient in the
NICU requiring ongoing respiratory and nutritional support. The
intensity of their medical needs would challenge any family; that
challenge is sure to be magnified by co-existent social needs.
Imagine if this child were discharged to a home filled with
cockroaches, a building managed by a landlord who threatened
eviction with any complaint. How might this social complexity affect
a family’s ability to manage the child’s medical complexity?
Although health-care providers may be able to advocate for this
child’s well-being, a housing attorney would amplify their voices.
Through an MLP, such legal experts can advocate for remediation of
adverse housing exposures and guard against illegal evictions. They
may also illuminate population-level patterns.113 Perhaps the family
from the NICU may have similarly effected neighbors. There may be
other children, or expectant mothers, in the unit next door or a
building located across town with the same landlord. Partnerships
like MLPs work best when they extend the reach of each partner,
authentically engage key stakeholders, and consistently evaluate
whether they are achieving the desired outcomes.107,114–117
Clinical–community partnerships can extend to broader
community-based investment strategies considered by
healthcare systems. The Healthy Neighborhood, Healthy Families
Initiative in Columbus, OH involves a hospital making direct
housing interventions within a “blighted” neighborhood. A
multidisciplinary team identified a racially segregated neighborhood
filled with vacant housing units and characterized by high rates of
poverty that was home to many of the hospital’s patients and
employees. The resulting initiative involved a series of
interventions focused on enhancing housing stability and quality.116
Although a motivated, mission-driven anchor institution
galvanized the program, it coincided with the hospital assuming
financial risk for community children who were insured through
Medicaid. With this reality, the team suggested that investments
in communities and in clinical–community partnerships, are likely
to be most successful when they have both mission- and
Despite meaningful progress in screening, pattern recognition,
and clinical–community partnership and action, questions clearly
remain.115 First, the ways in which we screen warrant further
assessment. When is it best to screen? What are the most relevant,
important questions? For patients who remain hospitalized for
months, such as those in the NICU, how frequently should screens
be revisited? Second, the EHR provides us with new opportunities
to consider how to document SDH-related assessments, integrate
complementary data streams, and recognize population-level
patterns. With these new capabilities, are there shared metrics on
which obstetricians, neonatologists, and primary care pediatricians
can collectively track and hold one another to account? How
should metrics be shared across the clinical–community
continuum (e.g., with parent advisory boards, health departments,
legal aid societies, school districts, city councils)? How can we
ensure that such metrics add value and are not driven by
enshrined biases? Third, as we move toward action, how can we
maintain ongoing stakeholder engagement, a view that stretches
across the life course, and strategies that pair rigor with the reality
of the real world? How can we translate this engagement across
the clinical–community continuum into lasting, value-added
partnerships? And finally, what is the role of the health-care
system in moving toward community well-being or toward a
dismantling of generations-old structural issues at the heart of
unjust health outcomes? Many patients encountered in
healthcare settings, particularly NICUs, are medically complex. Yet their
social complexity frequently determines how they ultimately
experience health across the life course. As we shift our focus from
“follow-up” to “follow through” for patients and populations, we
must, in parallel, shift toward a more balanced approach to
medical and social needs. This may require health-care systems
and providers to embrace social needs screening, population-level
pattern recognition, and investment in social supports and
community well-being. It may also push us to identify our
limitations, gaps that could be filled by willing, capable, and
complementary community partners.
We propose three causal pathways through which racial inequality
has amplified the burden of preterm birth on the health and
wellbeing of minority communities in the U.S.: increased risk;
lowerquality care; and socioeconomic disadvantages that persist into
infancy, childhood, and beyond.
To improve these pathways, we must increase health equity by
removing obstacles, such as discrimination, poverty, and lack of
access to quality education, housing, and health care.119 As
healthcare providers, we have the obligation to “follow through,”
accepting that our responsibility extends beyond the hospital
walls to encompass the long-term health and well-being of the
infants and families we serve. We cannot do this alone. These
injustices are rooted in unconstitutional governmental actions at
the local, state, and federal levels.1 Developing appropriate
remedies must start with a national conversation that honestly
confronts this history.1,120,121 Physicians, nurses, other health-care
providers, and researchers play an important role in this
Eliminating racial disparities in preterm birth and in outcomes
among premature infants and their families is an ambitious
agenda that will not be accomplished quickly. Although many of
the interventions identified in this review can be implemented in
the near term, the sheer scope of the work is daunting, especially
for hospital-based specialists and researchers who may be
unfamiliar in the activities like working with community
organizations or advocating for structural change. There is no tool kit of
specific activities and instruments, although a list of “potentially
better” practices is available in an appendix to this review.
Implementation of various aspects of this agenda must be tailored
to the local context of community characteristics and resources. It
is not expected that health-care providers know and be
responsible for all the potential services. So where to begin?
First, consider developing at least three teams. One team must
address the internal culture of the health care institution and the
extent to which implicit bias and other aspects of care impinge on
the quality of services for all patients. Many institutions already
have such teams in place; if not, models are available.122 A second
team involves parents who can help identify the needs and
potential solutions for differences in care. Principles of diversity
and inclusion should be applied to this team to assure that
concerns of those whose voices have long been ignored are now
heard.73,123 The third is a community resources team with a
bidirectional purpose: health-care personnel can educate
community partners about the health problems and needs of
premature infants and their families, and community partners
can engage with health-care personnel to develop a
comprehensive list of resources and services in the community and to foster
communication across the hospital community. Such a group
might include early intervention workers, primary care physicians,
child physical and occupational therapists, social services,
education services, public health professionals, community leaders, and
representatives from community-based agencies.
The use of more structured data collections is encouraged. As
noted above, there are now measures for screening for and
assessing the SDH in clinical settings,124,125 a practice
recommended by pediatric societies for implementation.99,126
Structured assessments provide assurance of more complete
ascertainment of information and comparability of data over
time and across units and may serve as explicit needs
assessment for implementation of changes. This last step may
generate the advocacy recommended above at whatever level
the clinician can achieve.
We cannot wait for American society to address past injustices
before we act. The interventions that we identified can be
implemented today. If minority women and their infants are to
fully benefit from the technical advances in perinatal and neonatal
care in the 21st century, we must act now. It is our moral and
E.M.E., J.D.H. and E.A.H. receive support from the Eunice Kennedy Shriver National
Institute of Child Health & Human Development of the National Institutes of Health,
E.M.E. and J.D.H. by Award Number R01HD083368, J.D.H. by R01HD084667, and E.A.H.
by Award Number R01HD078565. E.A.H. also receives support from the National
Institute for Minority Health and Health Disparities by Award Number R01MD00765.
A.F.B. receives support from the National Institute of Allergy and Infectious Diseases
by Award Number 1K23AI112916.
The authors are listed alphabetically to indicate that they all made equal
contributions to this work.
The online version of this article (https://doi.org/10.1038/s41390-019-0513-6)
contains supplementary material, which is available to authorized users.
Competing interests: The authors declare no competing interests.
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