Adverse Infant Health Outcomes Increased After the 2016 U.S. Presidential Election Among Non-White U.S.-born and Foreign-born Mothers

Abstract

Macro-level events such as elections can improve or harm population health across existing axes of stratification through policy changes and signals of inclusion or threat. This study investigates whether rates of, and disparities in, adverse birth outcomes between racialized and nativity groups changed after Donald Trump's November 2016 election, a period characterized by increases in xenophobic and racist messages, policies, and actions in the United States. Using data from 15,568,710 U.S. births between November 2012 and November 2018, we find that adverse birth outcomes increased after Trump's election among U.S.- and foreign-born mothers racialized as Black, Hispanic, and Asian and Pacific Islander (API), compared with the period encompassing the two Obama presidencies. Results for Whites suggest no change or a slight decrease in adverse outcomes following Trump's election, yet this finding was not robust to checks for seasonality. Black–White, Hispanic–White, and API–White disparities in adverse birth outcomes widened among both U.S.- and foreign-born mothers after Trump's election. Our findings suggest that Trump's election was a racist and xenophobic macro-level political event that undermined the health of infants born to non-White mothers in the United States.

Introduction

Macro-level political events, such as wars, strikes, protests, and presidential elections, impact entire populations and can improve or harm population health through multiple social determinants of health (Rodriguez 2019; Torche and Rauf 2021; Williams and Medlock 2017). By altering the distribution of public goods and services, as well as the collective norms and boundaries of national identity, macro-level political events link national politics and population health in enduring ways (O'Campo and Dunn 2012; Rodriguez 2019; Torche and Rauf 2021). The health impacts of such events often vary along preexisting and intersecting axes of inequality, such as race, class, and nativity (Aquino et al. 2022; Torche et al. 2024). When these events are economically disruptive or restrict rights, they can disproportionately harm groups that are already disadvantaged or marginalized within a social system—groups that are denied sufficient resources and power to shield themselves from harm while maintaining or enhancing health for more privileged groups. These impacts can widen preexisting health disparities (Brown et al. 2019).

As macro-level political events, elections can impact health through both policy implementation and signals of inclusion or threat communicated via the candidate's persona, campaign platform, and rhetoric (Gemmill et al. 2019; Morey et al. 2021; Rodriguez 2019; Torche and Rauf 2021). Throughout his 2016 campaign and presidency, Donald Trump mobilized White supremacist rhetoric and committed to social policies that would disproportionately and negatively impact groups racialized as non-White in the United States and elsewhere (Blow 2017; Bobo 2017; Clayton et al. 2021; Gray 2017; Woolhandler et al. 2021).¹ Trump also targeted immigrant communities, promising and later delivering on the promise to restrict immigration into the United States, limit the rights of immigrants already living in the United States, and increase government power to detain and deport immigrants from within the United States. Many observers commented that Trump's anti-immigration platform was used to communicate a general message of White supremacy, such as when he characterized Mexicans as rapists and Muslims as terrorists (Anbinder 2019; Arce 2019; Reilly 2016). We therefore posit that the 2016 U.S. presidential election was a racist and xenophobic macro-level political event—one that might have been especially harmful to the health of racially marginalized U.S.-born and immigrant groups (Albright and Hurd 2020; Chavez et al. 2019; Gemmill et al. 2019; Morey et al. 2021; Williams and Medlock 2017).

In this study, we investigate whether and how much adverse infant health outcomes changed in the two years following the Trump election and whether they changed differentially across groups defined by racialized and nativity groups. We focus on adverse birth outcomes because they are sensitive to changes in public policies and environmental stressors (Redd et al. 2022; Torche 2011). Furthermore, infant health is a critical indicator of current and future population health and has been linked to multiple measures of well-being across the life course (Behrman and Stith Butler 2007). Using data from 15,568,710 U.S. birth records collected between November 2012 and November 2018 (National Center for Health Statistics 2021), we compare birth outcomes for U.S.- and foreign-born mothers² across four major racialized groups: non-Hispanic Black (hereafter “Black”), Hispanic,³ non-Hispanic Asian or Pacific Islander (hereafter “API”), and non-Hispanic White (hereafter “White”). We also investigate whether mothers’ socioeconomic characteristics and prenatal care use mediated changes in adverse birth outcomes following Trump's election.

Our analyses reveal four major findings. First, adverse health outcomes for infants born to mothers racialized as non-White increased after Trump's election, and infants born to U.S.- and foreign-born mothers racialized as Black and Hispanic experienced the largest increases. Results for Whites suggest no change or a slight decrease in adverse outcomes following Trump's election, yet this finding was not robust to checks for seasonality. Second, Black–White, Hispanic–White, and API–White gaps in adverse health outcomes grew after Trump's election. Third, some changes in adverse health outcomes after Trump's election varied by nativity. Foreign-born mothers racialized as Black experienced a smaller increase in preterm births than U.S.-born mothers racialized as Black, and foreign-born mothers racialized as White had larger decreases in low birth weight births than U.S.-born mothers racialized as White. Foreign-born mothers racialized as Hispanic and API experienced larger increases in preterm births following the Trump election than their U.S.-born counterparts. Finally, compositional changes in mothers’ socioeconomic characteristics and prenatal care use after Trump's election explain only some of the association between Trump's election and changes in birth outcomes.

Background

Structural Racism as a Fundamental Cause of Health

Structural racism is a fundamental cause of health, producing persistent racial inequalities in health (Bailey et al. 2017; Phelan and Link 2015; Williams and Mohammed 2009). Bailey et al. (2017:1453) defined structural racism as “the totality of ways in which societies foster racial discrimination through mutually reinforcing systems such as housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice.” Structural racism harms the health of groups racialized as non-White by constraining opportunities for obtaining health-promoting resources and by disproportionately exposing these groups to harm (Clouston and Link 2021; Williams and Williams-Morris 2000). Structural racism is reflected in residential segregation, voter suppression, racial violence, and criminalizing immigration policies, which affect health via an array of “pathways of embodiment,” such as economic and social deprivation; excess exposure to toxins, hazards, and pathogens; stress; and social trauma (Hardeman et al. 2022; Hing 2019; Homan and Brown 2022; Homan et al. 2021; Jahn et al. 2021; Krieger 2014). Structural racism creates political environments that fundamentally shape the economic, legal, institutional, and symbolic environment and therefore influence population health via multiple pathways (Phelan and Link 2015). These patterns and practices reinforce discriminatory beliefs, values, and actions. Stress and harm from racist interpersonal exchanges, such as the threat or experience of a humiliating or violent encounter with law enforcement officers, community members, or strangers, create physiological strain on an individual's body, contributing to wear and tear on the cardiovascular, metabolic, and immune systems (for a summary of research, see Williams and Williams-Morris 2000).

Theory and research have demonstrated that structural racism is harmful to racially minoritized groups, but its impact on Whites’ health has received less scholarly attention. Some research has found that structural privileges might indirectly contribute to adverse health outcomes. For example, the White population was found to have preferential access to opioid prescriptions (Woolhandler et al. 2021). In contrast, evidence suggests that contemporary White health might continue to benefit from links to historical, racist institutions, such as chattel slavery, which simultaneously deprived Black people of basic rights and enabled White populations to extract resources and accumulate intergenerational wealth (Gabriel et al. 2021). We assess health changes among infants born to mothers racialized as White or non-White in the two years following Trump's election in 2016, an event implicitly and explicitly tied to racist and xenophobic rhetoric and actions.

Racialized Disparities in Infant Health

Racialized health disparities have stubbornly persisted in infant health. Low birth weight and preterm birth—two leading risk factors for infant morbidity and mortality (Behrman and Stith Butler 2007)—are twice as likely to occur among mothers racialized as Black relative to mothers racialized as White (Womack et al. 2018). Substantial evidence suggests that racism impacts birth outcomes (Culhane and Elo 2005; Giscombé and Lobel 2005; Hobel and Culhane 2003; McEwen and McEwen 2017). A systematic review of 15 studies found a significant relationship between racial discrimination and low birth weight and preterm birth among non-White mothers (Alhusen et al. 2016). Mothers who experience a racist event during pregnancy develop psychological and physical symptoms of distress over and above more general stressors (Alhusen et al. 2016; Jahn et al. 2021; Klonoff and Landrine 1999).

Lifelong exposure to racism can increase susceptibility to stress during pregnancy, regardless of the source of in utero distress (McEwen and McEwen 2017). The weathering framework suggests that women racialized as Black experience health decrements owing to the cumulative impact of repeated experience with social, economic, and political exclusion, which impacts their infants’ health (Geronimus 1992; Geronimus et al. 2006; Goosby and Heidbrink 2013). An added stressful event could thus cause greater harm to those already impacted by multiple long-term disadvantages (Curtis et al. 2022; Geronimus et al. 2006).

Infant health can also be influenced by political factors, such as political ideology and macro-level events that disproportionately harm or protect racialized communities. For example, Torche and Rauf (2021) found that Democratic presidencies have a beneficial effect on infant health outcomes in the United States, with stronger effects for infants born to Black mothers than for infants born to White mothers, likely because of distinct ideological commitments to social and economic issues of the U.S. Democratic and Republican political parties. In another case, Lauderdale (2006) found that the 2001 terrorist attacks of 9/11 increased adverse birth outcomes among infants born to women with Arab-sounding names in California following the attack and the corresponding response from the U.S. government to crack down on U.S.- and foreign-born Arab and Muslim communities in the United States.

Anti-Immigration Policies and Legal Status as a Fundamental Cause of Health

Critical race scholars have argued that the rise of restrictive immigration policy in the United States is a racist response to demographic change with negative consequences for racialized minority groups (Browne et al. 2023; Rodríguez-Muñiz 2021; Romero 2008). Anti-immigration policies and rhetoric are a manifestation of xenophobia linked to multiple health outcomes through multiple risk factors (Amuedo-Dorantes et al. 2022; Castañeda et al. 2015; Cervantes and Menjívar 2020; Martinez et al. 2015; Potochnick et al. 2017; Viruell-Fuentes et al. 2012; Watson 2014). Indeed, anti-immigration policies and xenophobic rhetoric exert a disproportionate burden on racial and ethnic minorities through stigmatization and by withholding social and political rights from people who hold certain legal statuses, with spillover impacts to entire racialized communities regardless of legal status (Asad and Clair 2018). One study found an association between the 2017 Muslim ban, a series of executive orders that prohibited travel and refugee resettlement from select Muslim majority countries to the United States, and preterm births among infants of mothers from banned countries (Samari et al. 2020); another documented lower birth weight among infants born to immigrant women racialized as Latina following the passage of an anti-immigrant bill in Arizona in 2010 (Torche and Sirois 2019); and yet another found a greater risk of low birth weight among infants born to mothers racialized as Latina following an immigration raid in Iowa in 2008 (Novak et al. 2017).

Racist Macro-Level Events: The Case of Trump's Election

Presidential elections are macro-level political events that have been linked to racially stratified health outcomes (Albright and Hurd 2020; Chavez et al. 2019; Gemmill et al. 2019; Malat et al. 2011; Morey et al. 2021; Rodriguez 2019; Torche and Rauf 2021). One study found that the socially conservative ideology of Republican U.S. presidents was associated with slower declines in infant mortality rates and accounted for approximately half of the White–Black infant mortality gap in the United States between 1965 and 2010 (Rodriguez 2019). Health effects materialized one year following the presidential election, a lag the authors attributed to the timing of policy implementation by new presidential administrations. But elections can also have anticipatory effects on infant health, even before the elected official assumes office and passes or implements new policy, perhaps especially if the president engages in particularly threatening, racist, or xenophobic language (Gemmill et al. 2019; Morey et al. 2021).

President Trump's election in 2016 created a uniquely hostile sociopolitical context for groups marginalized by racism and xenophobia (American Immigration Council 2017; Clayton et al. 2021; Finnigan and Barabak 2018; Gonyea 2015; “Here's Donald” 2015). Throughout his campaign and presidency, Donald Trump mobilized White supremacist rhetoric and committed to social policies that disproportionately and negatively impacted groups racialized as non-White in the United States (Blow 2017; Bobo 2017; Clayton et al. 2021). His campaign slogan, “Make America Great Again,” idealized a past of formal White dominance (Gabriel et al. 2021), and he portrayed White nationalists who marched through Charlottesville in 2017 as “people that were very fine” (Gray 2017). As president, Trump enacted policies that disproportionately harmed people racialized as non-White. For example, he upended federal oversight of local police forces implicated in civil rights abuses and rolled back the Affordable Care Act and Medicaid coverage (Balko 2019; Rosenberg 2019; Woolhandler et al. 2021).

Trump's campaign and presidency might also have enhanced implicit bias and enabled discriminatory behavior in society at large. Trump's campaign, election, and social media activism have been linked to aggravated racist attitudes among ordinary citizens (Newman et al. 2021), increased hate crimes (Feinberg et al. 2022), and intensified racially biased behavior by law enforcement (Grosjean et al. 2023). Feinberg et al. (2022) found that counties that hosted a Trump campaign rally experienced a large increase in hate crimes in the month after hosting a rally relative to counties that did not host a rally. Studies also linked Trump's election to distress; anxious symptoms; web searches for “depression,” “anxiety,” “therapy,” and antidepressant medications; and poorer self-rated health among individuals with targeted social identities, such as people racialized as Black, Latino, and Muslim, and sexual minorities (Albright and Hurd 2020; Krupenkin et al. 2019; McCann and Jones-Correa 2021; Patler et al. 2019; Rogers et al. 2017). Two studies examined the association between Trump's election and adverse birth outcomes among Latinas; both found that adverse birth outcomes increased among Latina mothers after the election (Gemmill et al. 2019; Gutierrez and Dollar 2023). No study has examined changes in birth outcomes across women in different racialized groups.

In addition to creating substantial stress, a racist and xenophobic macro-level political event such as the Trump election could also prompt behavioral adaptations to avoid or reduce risk. Two potential responses are fertility adjustments and changes to health care–seeking behaviors (Dehejia and Lleras-Muney 2004; Torche and Villarreal 2014). If fertility responses are heterogeneous across the population, they may induce changes in birth outcomes by altering the composition of those giving birth at a particular moment. Indeed, one study documented an increase in the utilization of long-acting reversible contraceptive (LARC) methods among women during the 30 business days after the 2016 presidential election (Pace et al. 2019). Our study examines whether changes in the composition of birthing mothers and in mothers’ prenatal care use following Trump's election were associated with changes in adverse birth outcomes.

Research Questions

We assess whether and how much adverse birth outcomes changed after Donald Trump's 2016 election among infants born in the United States to U.S.- and foreign-born mothers across four racialized groups. Our analyses are guided by four research questions:

1. Did adverse birth outcomes change within racialized groups following Trump's election?

2. Did gaps in adverse birth outcomes between groups racialized as White and non-White change following Trump's election?

3. Within racialized groups, did adverse birth outcomes change by mother's nativity following Trump's election?

4. Were compositional changes in the socioeconomic status and prenatal care usage of mothers associated with changes in adverse birth outcomes following Trump's election?

Data and Methods

Data

We analyze U.S. birth records from the National Vital Statistics System, comprising all births occurring and registered in the 50 U.S. states and U.S. territories from November 2012 to November 2018 (National Center for Health Statistics 2021). Birth certificates include information on the mother's country of birth and self-reported racial and ethnic identification, as well as information about the infant's health at birth. We restrict the analysis to singleton births with plausible weeks of gestation (22–44 weeks) and birth weight (more than 500 grams). Our analytical sample includes 15,568,710 U.S. births to mothers racialized as White, Black, Hispanic, and API between November 2012 and November 2018.

Variables

Outcomes

The outcomes of interest are low birth weight (defined as birth weight of less than 2,500 grams) and preterm birth (defined as births before 37 weeks of gestation).⁴ These outcomes are linked to morbidity, mortality, and well-being measures across the life course (Behrman and Stith Butler 2007; Boardman et al. 2002; Case et al. 2005; Morenoff 2003). Preterm birth and low birth weight are highly correlated. Preterm delivery is a predominant cause of low birth weight, with two thirds of low-weight infants born preterm (Dunkel Schetter 2011). However, given that birth weight is also determined by the fetal growth rate, births carried to term can also be characterized as low birth weight. Both outcomes have been linked to environmental stressors, including political events (Torche and Sirois 2019), racism (Alhusen et al. 2016), and public policy (Redd et al. 2022). We therefore include both outcomes in our study, following prior studies of macro-level events and birth outcomes (Torche and Rauf 2021).

Mother's Race and Ethnicity

We use the mother's self-reported racial and ethnic identification. Self-identification into racial and ethnic groups is a decision made in response to a socially constructed set of categories determined by history, culture, political agendas, and social scientific imperatives (Zuberi and Bonilla-Silva 2008). These categories are not biological or genetic but reflect social and cultural experiences as well as ancestry (Office of Management and Budget 2017; Roth 2016). We study adverse birth outcomes among four racialized groups: White, Black, Hispanic, and API. Hispanic is defined following the 1997 U.S. Census Bureau's classification, which divides ethnicity into Hispanic or Latino versus not Hispanic or Latino. Hispanic individuals may be of any race, and members of any race may be either Hispanic or non-Hispanic.

Nativity

To measure nativity, we recode the mother's country of birth into two categories: U.S.-born (birthplace = United States and its territories) and foreign-born (birthplace = outside the United States and its territories).

Covariates

Infant's characteristics include sex at birth (0 = female, 1 = male), parity (first, second, third or higher birth), and Medicaid birth (0 = birth not paid with Medicaid, 1 = birth paid with Medicaid). Mother's characteristics include married (0 = not married, 1 = married), highest level of education (1= less than high school, 2 = high school, but less than bachelor's degree, 3 = bachelor's degree or higher), and age at the child's birth (in years). We also control for the adequacy of prenatal care using the Adequacy of the Prenatal Care Utilization index, which combines information on prenatal care initiation and the number of prenatal care visits (0 = inadequate, 1 = intermediate, 3 = adequate, 4 = intensive) (Kotelchuck 1994).

Analysis

The association between the 2016 U.S. presidential election and birth outcomes could be affected by changes in the composition of mothers if the election affected who had births during this period and how those mothers accessed health care. To address this possibility, we compare models with and without compositional covariates. The first model includes only year fixed effects, and the second adds controls for infant's and mother's characteristics (Elo et al. 2014; Hummer 1996; Hummer et al. 1999; Reichman et al. 2008).

We estimate ordinary least-squares regressions with year fixed effects, expressed as follows:

$BOik$ identifies the birth outcomes (low birth weight and preterm birth) of infant i born in month k. Both equations include two variables to assess the association between Trump's election and adverse birth outcomes. First, we include a dummy variable for the election (“Trump”), where 0 = infant was born in the four years before Trump's election (between November 2012 and October 2016) and 1 = infant was born after Trump's election (November 2016 through November 2018). Second, to test whether birth outcomes changed differently by racial, ethnic, and nativity groups following Trump's election, we incorporate an interaction term between the postelection period and racialized and nativity groups (⁠$β4(Trump×Race×Nativity))$⁠.

The pre–Trump election period encompasses President Obama's second term, which constituted the macro-political environment (as related to the presidential administration) that Trump's election disrupted (Gemmill et al. 2019). We focus on the two years after Trump's election and include births that were exposed in utero to his election (those born in the first 9 months following November 2016) as well as births up to November 2018.

One issue with estimating changes in birth outcomes after Trump's election is that changes could be due to other temporal shocks or trends. We include year fixed effects to control for year-specific characteristics or shocks common to all mothers. In alternative specifications, we estimate the models using a continuous term and a quadratic term for month of birth, and the results are consistent (see Figures A2 and A3; all tables and figures designated with an “A” appear in the online appendix).

Another issue relates to identifying the appropriate postelection period. The period between November 2016 and February 2017 combines the end of Obama's presidency with the post–Trump election period. Our main models define the postelection period as beginning at the election rather than the inauguration and include Obama's lame-duck presidential period. To test whether the inclusion of these months changes the findings, we estimate models excluding the postelection, preinauguration period and find results that are substantively similar to those of our main models (see the online appendix, section 3).

In Model 2, we additionally include covariates for mother's and infant's characteristics. Following Graetz et al. (2022), we interact all covariates in Model 2 (Eq. (2)) with the four racialized group categories. Because any racial health disparity is the result of historic and contemporary projects of racism, control variables that differ in their exposure and effects across racialized categories are more appropriately considered mediators rather than confounders. Indeed, systemic racism likely affects every socioeconomic variable included in typical social scientific regression analysis of adverse birth outcomes. Fully interacted models therefore account for how multiple and mutually reinforcing racialized systems shape health because they allow mediator variables to vary in their associations with the outcome across groups.

Results

We start by providing a descriptive analysis of trends in low birth weight and preterm births from November 2012 to November 2018 for each group of mothers. We show unadjusted monthly proportions of low birth weight (Figure 1) and preterm birth (Figure 2), with a line representing the linear time trend in the pre– and post–Trump election periods. A visual assessment of the data suggests that all mothers experienced a change in trends in adverse birth outcomes in November 2016. Consistent with our hypotheses regarding the racialized harms of Trump's election, for all non-White mothers except for U.S.-born API mothers, the election corresponds with an increase in the slope of the trend line. For example, among U.S.- and foreign-born Hispanic mothers, the monthly preterm birth rate declined in the pre–Trump election period but increased in the post–Trump election period (Figure 2).

Table 1 shows the means of all variables in our analysis for each group of mothers, comparing the pre– and post–Trump election periods using two-tailed tests. We highlight five findings from this table. First, within each nativity group, infants born to mothers racialized as Black have the highest rates of low birth weight and preterm births in both periods, followed by mothers racialized as Hispanic, API, and White, respectively. Second, within each racialized group, infants born to U.S.-born mothers have higher rates of adverse birth outcomes than infants born to foreign-born mothers, with an especially large nativity gap for mothers racialized as Black. Third, we observe greater social disadvantage for mothers racialized as Black and Hispanic. For example, Medicaid births were most common among mothers racialized as Black and Hispanic and were least common among White mothers of any nativity. In addition, mothers racialized as White and API, especially those who were foreign-born, were more likely to be married and have a higher level of education (bachelor's degree or higher) than mothers racialized as Black and Hispanic. Fourth, comparing mothers’ characteristics between the pre– and post–Trump election periods reveals that among most groups, mothers were older, more likely to be married, more educated, and more likely to have a third or higher order birth after Trump's election. Inadequate and intensive prenatal care usage also increased in the post–Trump election period relative to the pre–Trump election period. Finally, Table 1 reveals a significant difference between the pre– and post–Trump election periods in both birth outcomes for nearly every group of mothers. Among U.S.-born mothers racialized as White, Black, Hispanic, and API and foreign-born mothers racialized as Hispanic and API, the rate of low birth weight births increased after Trump's election. Among all women, the rate of preterm births increased after the 2016 election relative to the preelection period.

Changes in Adverse Birth Outcomes After Trump's Election

To assess our first research question, Figure 3 shows the predicted percentages of low birth weight and preterm births before and after Trump's election for each group of mothers, controlling only for year fixed effects (Tables A1 and A2, Model 1, display full parameter estimates). For U.S.- and foreign-born mothers racialized as Black, Hispanic, and API, the rate of low birth weight rose from the pre– to the post–Trump election period, net of annual trends. Births to mothers racialized as Black experienced the largest absolute increases in low birth weight: from the pre– to the post–Trump election period, the rate of low birth weight rose from 13.27% to 13.89% among U.S-born mothers racialized as Black, and from 8.60% to 8.83% among foreign-born mothers racialized as Black. Comparatively, mothers racialized as White experienced a decrease in adverse birth outcomes net of annual trends: the rate of low birth weight declined from 6.67% to 6.60% for U.S.-born White mothers and from 6.10% to 5.87% for foreign-born White mothers. Preterm births also rose among U.S.-born mothers racialized as Black and Hispanic and among foreign-born mothers racialized as Hispanic and API from the pre– to the post–Trump election period.

Figure 4 transforms the results from Figure 3 into the predicted average percentage-point change in adverse birth outcomes after Trump's election when we control first for year fixed effects (Model 1) and then for mother's and infant's characteristics (Model 2). (Tables A1 and A2 present full parameter estimates from Models 1 and 2. Figure A1 presents predicted rates net of all control variables included in Model 2.) Model 2 reveals that adjusting for racialized compositional changes reduces the degree of change in adverse outcomes after Trump's election, which allows us to assess one of our research questions. Thus, compositional changes likely partially account for the higher rate of adverse outcomes after Trump's election. Overall, adjustment for compositional changes attenuates birth outcome changes across groups by 6% to 40%. For example, for infants born to U.S.-born Black mothers, the unadjusted model (Model 1) predicts that preterm births increased by 0.5 percentage points in the two years after Trump's election, whereas the adjusted model (Model 2) predicts an increase of 0.3 percentage points. Thus, including control variables reduces the change in preterm births in the two years following Trump's election among U.S.-born Blacks by 0.2 percentage points (40%).

Racialized Health Gaps Before and After Trump's Election

In assessing our second research question, we now examine the gaps in adverse infant health outcomes. Table 2 summarizes the White–Black, White–Hispanic, and White–API (absolute) differences in the predicted rates of adverse birth outcomes pre- and post-Trump's election for U.S.- and foreign-born mothers. The table also shows tests of whether the racial gaps differ between the pre– and post–Trump election periods (i.e., the contrasts, or tests of second difference). Table A3 presents the same information for relative differences, which follow the same pattern as the absolute differences. We present gaps relative to mothers racialized as White, given the role of structural racism in privileging White people and harming people racialized as non-White and the corresponding research expectation that Trump's election, as a racialized macro-level political event, would widen racial disparities.

Table 2 shows that the racial gaps in adverse outcomes significantly increased for nearly all group comparisons during the post–Trump election period. Beginning with Model 1, for example, U.S.-born Black mothers experienced low birth weight births 6.60 percentage points more often than White mothers before Trump's election. This gap increased to 7.29 percentage points after the election (an increase of 0.69 percentage points, equivalent to roughly 10% [0.69 / 6.60 × 100]). White–Hispanic gaps in adverse birth outcomes also grew after Trump's election among both U.S.- and foreign-born mothers. U.S.-born Hispanic mothers experienced low birth weight births 0.71 percentage points more often than U.S.-born White mothers before the election, but the White–Hispanic gap increased to 1.15 percentage points (a 62% [0.44 / 0.71 × 100] increase) after the election. Foreign-born Hispanic mothers experienced 0.14 percentage points more low birth weight births than foreign-born White mothers before the election. After the election, this gap increased to 0.62 percentage points, equivalent to roughly a 300% (0.48 / 0.14 × 100) increase. Among U.S.- and foreign-born mothers, White–API gaps in low birth weight births also increased significantly: the predicted probability of low birth weight births was 1.69 percentage points higher for U.S.-born mothers racialized as API than for White mothers in the preelection period, a gap that increased by 46% (0.78 / 1.69 × 100) to 2.47 percentage points after the election. Among foreign-born mothers, the API–White gap in low birth weight births was 1.89 percentage points in the preelection period. This gap increased to 2.63 percentage points after the election, equivalent to a 39% (0.74 / 1.89 × 100) increase.

Including compositional controls in Model 2 reduces the magnitude of the change in the racial gaps in birth outcomes. For example, the Black–White gap declines from 0.69 in Model 1 to 0.50 percentage points in Model 2, suggesting that the inclusion of control variables decreases the predicted Black–White gap in the post–Trump election period by 0.19 percentage points—by roughly 27% (0.19 / 0.69 × 100). However, all significant racial gaps from Model 1 remain robust in Model 2, suggesting that measured compositional changes in mothers giving birth do not fully explain why racialized gaps increased after the election.

Nativity Differences in Adverse Birth Outcomes After Trump's Election

Our third research question is whether adverse birth outcomes changed similarly or differently across mother's nativity following Trump's election. Figure 5 summarizes the difference in the change in adverse birth outcomes associated with Trump's election between U.S.-born mothers and foreign-born mothers within each racialized group, expressed as a percentage-point difference. For most groups, changes in adverse birth outcomes in the postelection period were roughly similar by nativity status within racialized groups, with a few exceptions. Foreign-born mothers racialized as White had larger decreases in low birth weight births following Trump's election than their U.S.-born counterparts (−0.17 and −0.22 percentage points in Models 1 and 2, respectively). Among those racialized as Black, foreign-born mothers experienced a smaller increase in preterm births than U.S.-born mothers (−0.43 percentage points in Model 1 and −0.47 percentage points in Model 2). Thus, foreign-born nativity might have had a protective effect for mothers racialized as White and Black following the Trump election, above and beyond compositional changes. Among those racialized as Hispanic, foreign-born mothers experienced greater increases in preterm births than U.S.-born mothers, but only in Model 2 (0.23 percentage points). Among those racialized as API, foreign-born mothers experienced a larger postelection increase in preterm births than U.S.-born mothers (0.44 percentage points in Model 1). These findings suggest that for API and Hispanic mothers, Trump's election was more harmful for foreign-born mothers than for their U.S.-born counterparts, with compositional characteristics likely explaining much of the observed effect.

Robustness Checks

The observed postelection changes in birth outcomes could be driven by other temporal processes, including temporal autocorrelation and long-term trends. Our main models account for time trends with year fixed effects, which control for observed and unobserved year-specific characteristics or shocks that are common to all mothers. We also implement two alternative de-trending strategies, adding to our model (1) a continuous month-of-birth control (see Figure A2) and (2) a quadratic month-of-birth control (see Figure A3). We include a month-lagged dependent variable to control for autocorrelation (see Figure A4). These approaches yield substantively similar results for Black, Hispanic, and API mothers, indicating that the observed postelection increases in adverse birth outcomes among mothers racialized as non-White are not likely the result of time trends. For mothers racialized as White, however, the supplemental models do not indicate a significant change in adverse birth outcomes following Trump's election. This finding suggests that the observed postelection decreases in low birth weight and preterm births for mothers racialized as White in the main models might be the consequence of time trends rather than a change coinciding with the 2016 election.

Discussion

Donald Trump's rise to the presidency was fueled by racist and xenophobic rhetoric that manifested in governmental policies once he became president (Clayton et al. 2021; Gabriel et al. 2021; Manza and Crowley 2018; Woolhandler et al. 2021). Trump's campaign and election have been linked to aggravated racist attitudes among ordinary citizens (Newman et al. 2021), an increased rate in hate crimes (Feinberg et al. 2022), intensified racially biased behavior by law enforcement (Grosjean et al. 2023), and heightened psychological distress and anxiety among Latinx pregnant mothers (Fox 2022; Wiley et al. 2023). Because macro-level political events such as elections can impact infant health differently across existing axes of stratification (Aquino et al. 2022), we assess whether Trump's election was associated with an exacerbation of inequities in adverse birth outcomes by racialized groups and nativity. We examine 15,568,710 U.S. birth records collected between November 2012 and November 2018 to estimate whether rates of adverse birth outcomes and racialized gaps in adverse birth outcomes for U.S.-born infants changed following Trump's election.

We find that rates of low birth weight and preterm births increased for Black, Hispanic, and API mothers in the two years following Trump's 2016 election. We observe these results in descriptive analysis of trends and in models that control for time trends and mother and child characteristics that may have changed after Trump's election. In the two years following Trump's election, the rate of low birth weight births among U.S.-born mothers racialized as Black rose from 13.27% to 13.89% (see Figure 3). Foreign-born mothers racialized as Black and U.S.- and foreign-born mothers racialized as Hispanic and API also experienced increases in low birth weight births after Trump's election. The likelihood of preterm births also increased after the election among foreign-born mothers racialized as Hispanic and API, as well as among U.S.-born mothers racialized as Black and Hispanic.

These changes are substantial at the population level. For example, 610,136 infants were born to U.S.-born Black mothers in the post–Trump election period. Our analyses suggest that without Trump's election, 3,783 fewer infants (= 610,136 × 0.0062) would have been born with low birth weight to U.S.-born women racialized as Black.⁵ This effect is substantial when benchmarked against other research on disruptive events that can impact infant health. For example, birthing parents who were exposed to wildfires that burned at least 5,000 acres in the county of birth during the second or third trimester are roughly 0.2% more likely to give birth to low birth weight infants than mothers in the same county who conceived earlier or later relative to the wildfire (Rauscher and Cao 2024). The 0.62% change in low birth weight we observed for infants born to U.S.-born mothers racialized as Black in the two years after Trump's election is approximately three times as large as that of the wildfires.

Theory and research have not fully grappled with how racism impacts the health of groups who experience structural privilege or disadvantage. The literature has documented that structural racism is harmful to racially minoritized groups, but less is known about its impact on White health (Curtis et al. 2022; Hardeman et al. 2022; Homan and Brown 2022; Homan et al. 2021; Jahn et al. 2021; Krieger 2014; Louie and DeAngelis 2024). We find that rates of adverse birth outcomes decreased during the postelection period among infants born to White mothers, suggesting that racist macro-level political events, such as Trump's election, could benefit people racialized as White. However, robustness checks using various de-trending strategies render inconsistent results, suggesting that changes in adverse health outcomes among infants born to mothers racialized as White could be the consequence of time trends rather than the election. More research is needed to investigate the connections between structural racism and the health of populations racialized as White.

As a result of the disproportionate changes among mothers racialized as non-White, racial disparities in adverse birth outcomes increased in the post–Trump election period. For example, the White–Black gaps in low birth weight increased by 0.69 percentage points and 0.46 percentage points among U.S.- and foreign-born mothers, respectively. White–Hispanic gaps in adverse birth outcomes also grew after Trump's election among U.S.- and foreign-born mothers: the White–Hispanic low birth weight gap increased by 0.44 percentage points among U.S.-born mothers and by 0.48 percentage points among foreign-born mothers. White–API gaps also increased; for low birth weight, the White–API gap increased by 0.78 percentage points for U.S.-born mothers and by 0.74 percentage points for foreign-born mothers.

We also examine changes in adverse infant health outcomes by mother's nativity, given Trump's xenophobic rhetoric and anti-immigrant policies (Gemmill et al. 2019). Our findings show that among most racialized groups, U.S.- and foreign-born mothers experienced similar changes in adverse infant health outcomes after Trump's election. These findings align with the idea that structural racism and (anti-)immigration policies and rhetoric are fundamental determinants of health that impact both U.S.- and foreign-born community individuals and access to health institutions through multiple pathways (Bailey et al. 2017; Cervantes and Menjívar 2020; Novak et al. 2017; Patler and Gonzalez 2021). Yet, we find some evidence of differential changes in birth outcomes by nativity within racialized groups. After Trump's election, foreign-born mothers racialized as White had larger decreases in low birth weight births than U.S.-born mothers racialized as White. In addition, among mothers racialized as Black, foreign-born mothers experienced a smaller postelection increase in preterm births than U.S.-born Black mothers. These findings suggest that foreign-born nativity might have had a protective effect for mothers racialized as White and Black following the Trump election. However, infants born to foreign-born Black women still experienced higher rates of adverse birth outcomes than any other foreign- or U.S.-born racialized group, even after we control for other racialized determinants of health. This finding provides additional, strong evidence that structural racism uniquely harms the health of Black infants regardless of nativity (Curtis et al. 2022; Giscombé and Lobel 2005; Grady 2006).

Our study also assesses the roles of changes to the socioeconomic composition of birth mothers and prenatal care usage as possible pathways between Trump's election and adverse birth outcomes. We find that changes in the socioeconomic composition of women giving birth and prenatal care usage reduced the degree of change in adverse outcomes and attenuated some of the postelection increases observed in the gaps between White and non-White mothers. Mothers giving birth after Trump's election were older, more likely to be married, and more likely to have completed college, and their births were more likely to be third or higher order parity. A shift toward older women may account for some of the association between the Trump election and infant health, insofar as age is a risk factor for adverse birth outcomes. We also observe that mothers birthing after Trump's election were more likely to have received inadequate or intensive prenatal care, both of which are associated with an increased risk of adverse birth outcomes. These findings suggest that changes in who gave birth and the care they received are likely on the pathway linking Trump's election to adverse birth outcomes. However, the postelection period remained robust to the inclusion of these controls, suggesting that these controls do not fully account for the observed changes in adverse health outcomes and corresponding racialized health gaps.

Our study contributes new information about the timing of the impacts of presidential elections on birth outcomes. Prior studies found that Trump's election increased preterm births among infants exposed to the election in utero and born to women racialized as Latina (Gemmill et al. 2019; Gutierrez and Dollar 2023), suggesting that stress is a key pathway through which macro-level political events such as Trump's election affect health. Other research has documented a lag in the impact of presidential elections on birth outcomes, a time patterning that scholars attribute to lags in presidential administrations’ policy implementation. Our study, which includes in utero exposure and births in the two years after Trump's election, suggests that a combination of stress and policy impacts explain the postelection changes in birth outcomes among non-White mothers. Indeed, Trump took action on his blatantly racist campaign promises immediately and throughout his presidency. In his first 100 days in office, Trump signed 28 executive orders, including the 2017 Muslim travel ban and efforts to strip federal funding from sanctuary cities that protect immigrants (ACLU 2017; Beck 2017; Exec. Order No. 13768, 2017). Overall, Trump implemented nearly 1,100 actions to restrict immigrant admissions and rights throughout his presidency (Immigration Policy Tracking Project 2024).

Our results should not be interpreted as direct evidence of a causal impact of the election itself because we cannot rule out the possibility that other events occurring around the same time as Trump's election account for the observed changes in adverse birth outcomes among non-White mothers. Indeed, multiple national, overt racist events occurred during Trump's presidency, such as the August 2017 Unite the Right riot at the University of Virginia, broadly considered a White supremacist event. Exposure to (and protection from) interpersonal and population-level experiences of racial discrimination are known predictors of infant health (Alhusen et al. 2016; Krieger et al. 2013). Still, our results provide evidence that Trump's election and its aftermath might have caused harm to racialized minority mothers, worsening preexisting racialized health disparities. Our findings align with other research documenting that Trump's election increased distress among individuals whose social identities Trump targeted rhetorically and through his policies, such as groups racialized as Black and Latino, Muslims, and sexual minorities (Albright and Hurd 2020; Fox 2022; Grosjean et al. 2023; Krupenkin et al. 2019; McCann and Jones-Correa 2021; Patler et al. 2019; Rogers et al. 2017; Wiley et al. 2023).

Future research should seek to examine whether the impacts of the postelection period can be further stratified among mothers, such as among foreign-born mothers by legal status, time in the United States, and region, state, or county of residency (Grosjean et al. 2023; Teitler et al. 2012). Indeed, undocumented immigrant mothers might experience heightened distress because of fear of law enforcement, which could worsen their health and their infants’ health outcomes (Novak et al. 2017; Patler et al. 2019; Ro et al. 2020; Torche and Sirois 2019). Data collection efforts that can estimate mothers’ legal status without increasing their legal vulnerability could help us better understand the links between immigration status and health. The impacts of Trump's election might also vary by geography. Research has found evidence of increased racial bias in policing in counties where Trump held rallies during his 2015–2016 campaign, which might have heightened distress among non-White mothers, who are most likely to experience racialized policing practices (Grosjean et al. 2023). Analyses assessing the association between Trump's election and racialized changes in adverse birth outcomes by county, state, or region of residency could illuminate potential mechanisms linking Trump's rise to power, racism, and infant health.

Although our study is limited in its ability to identify causal effects and mechanisms, our analysis is consistent with the idea that population health is shaped by population-level experiences of macro-level political events, including those that perpetuate or entrench structural racism (Krieger 2014). Structural racism—the organized social system in which the dominant racialized group (those racialized as White) categorizes and ranks people into social groups to devalue, disempower, and differentially allocate social resources and opportunities—is the root cause of racial health inequities (Bailey et al. 2017; Williams et al. 2019). Our results suggest that Trump's rise to power was a racist and xenophobic macro-level political event that was associated with increased racial inequalities in population health. Our study therefore shows that racial disparities in health can change rapidly and substantially following macro-level political events that are racialized or xenophobic. In this case, Trump's election appears to have affected the life chances of even the newest members of U.S. society: infants born in the two years after he took office. The legacy of these health harms could be long-lasting and dire.

Acknowledgments

The authors thank Tim Bruckner, Michael Esposito, Sam Fuller, Florencia Torche, Reem Zaiour, and participants of the UC Davis Global Migration Center seminar for their valuable comments and suggestions. Preliminary results were presented at the annual meeting of the Population Association of America in April 2022.

Notes

References