A Mixed Methods Investigation of Race, Income, Food Insecurity and Maternal and Infant Health

Objective: To examine how race, income, and food insecurity (FI) interact during pregnancy, and whether FI contributes to disparities in maternal and infant health outcomes. Design: Observational cohort study employed sequential explanatory mixed methods design, with a survey phase (including HFSSM 6-item) and medical record abstraction followed by semi-structured interviews. Setting: Online survey, virtual interviews. Participants: Individuals who gave birth in Louisiana, USA, between June 2020 - June 2021. The quantitative phase comprised 1,691 individuals who completed the survey. A nested cohort of 40 individuals (evenly split by race [Black vs. White] and income [low vs. high]) subsequently completed semi-structured interviews. Results: Race and income were independently associated with both FI and maternal and infant health outcomes. When considering both income and FI, low-income individuals with FI were 1.73 times more likely to deliver low birthweight (LBW) infants (aOR 95% CI; 1.07, 2.82) and 1.43 times more likely to experience adverse infant outcomes (aOR 95% CI; 1.02–2.00) than high-income individuals without FI. Black individuals with FI were 2.49 times more likely to deliver LBW infants (aOR 95% CI; 1.45–4.29) than White individuals without FI. Interview findings revealed low-income individuals faced disproportionate barriers to accessing healthy food and making dietary choices, which were further complicated by pregnancy-related conditions. Conclusions: The interplay between race, income, and FI significantly increases the risk of adverse infant health outcomes, demonstrating a synergistic effect. Targeted efforts to address FI, particularly among low-income pregnant individuals, are essential to improving maternal and infant health outcomes.