The Fourth Encounter

“In addition to fatal encounters, researchers often discuss police brutality associated with physical, emotional, or sexual abuse perpetrated by officers,” Karbeah said. “But there is a fourth type of police encounter that is much more common and sometimes overlooked: routine contacts such as stops, frisking and searches that don’t result in detainment.”

In a study published in JAMA Open Network in December 2021, Karbeah and coauthors found that greater police presence in Black vs. white neighborhoods appears to contribute to the persistent Black-white preterm birth disparity in Minneapolis. Their research found that of 1,059 Minneapolis residents who gave birth in 2016, the odds of preterm births for those living in a neighborhood with a high police presence were 10% greater compared to their racial counterparts in low-presence neighborhoods.

The paper notes that pregnant Black women nationwide experience preterm birth at rate approximately double that of whites and Black women are also twice as likely to experience the death of an infant younger than 1 year. SHP’s Maya Rossin-Slater also bore this out in a recent study that showed that wealthy Black mothers and infants fare worse than the poorest white mothers and infants in the United States.

“Black pregnant people who live in areas with high levels of racial segregation are more likely to give birth prematurely,” Karbeah writes in the study. “Residential segregation relegates Black people to neighborhoods disproportionately affected by poverty, violence, and crime. In lieu of policy solutions to address these issues, greater police presence has been the answer in many communities.”

Karbeah points to research showing that high police presence in neighborhoods is associated with adverse psychological outcomes for Black residents. Karbeah and colleagues suggest that pregnant people may experience these same psychological effects in ways that lead to increased stress — which in turn can lead to an increase in preterm births.

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Adolescent Health and Policing

Karbeah told the SHP lecture audience that adolescent health is another key area of her research as young people carry police encounters with them into adulthood. Their brains are still developing, and decisions made during this period can shape the rest of their lives. They are coming into their own, deciding where they fit in and who they can trust.

“An important aspect of policing that often gets lost when we start to think about police contact as a determinant of health is why people might come into to contact with the police,” Karbeah said. “Instinctively you might think, well, you usually do something bad and that is why you encounter law enforcement.”

But a cultural shift in policing, she notes, has gone from police focused on responding to crimes to a proactive model in which policing is attempting to prevent crime, leading to more officers in communities, turning more civilians into potential suspects and leading to more encounters.

“Research shows that stops are associated with stigma and shame,” Karbeah said, pointing to a study published in the Journal of Adolescent Health which shows that adolescents frequently stopped by police were more likely to report heightened emotional stress and PTSD symptoms.

“These stops are seen as unsettling or traumatic for young people and can alter a youth’s self-perception and their overall well-being,” she said. “The impact of these interactions accrues over time and becomes internalized.”

A young person may be stopped by police on the way home from school, for example, and might be left with feelings of shame, prompting them to turn away from family and friends. This can have life-course implications, she said, such as substance abuse, anxiety and depression, job loss and socioeconomic shifts.

“We were honored to host Dr. Karbeah at Stanford Health Policy for the Health Equity Lecture Series,” said Sherri Rose, a professor of health policy who leads the lecture series. “Her research on police encounters and health equity tackles challenging questions that have far-reaching implications across health policy.” 

The second privacy concern is the potential use of health-care facility records to incriminate an institution or its clinicians for providing abortion services. Relevant records could include electronic health records, employee emails or paging information and mandatory reports to state agencies. Clinicians may not realize that if they are using an institutional email address or server, their institution likely has direct access to information and communications stored there, which can be used to search for violations. State Freedom of Information Act (FOIA) laws also allow citizens to request public records from employees of government hospitals and clinics.

“Additionally, state mandatory reporting laws for child abuse might be interpreted to cover abortions — particularly if life is defined as beginning at fertilization,” the authors note.

The third scenario is that information generated from a woman’s online activity could be used to show she sought an abortion or helped someone to do so. Many women use websites and apps that are not HIPAA-regulated or protected by patient-physician privilege, such as period-tracking apps used by millions of women that collect information on the timing of menstruation and sexual activity.

“There are many instances of internet service providers sharing user data with law enforcement, and prosecutors obtaining and using cellphone data in criminal prosecutions,” write Mello and Spector-Bagdady, adding commercially collected data are also frequently sold to or shared with third parties.

“Thus, pregnant persons may unwittingly create incriminating documentation that has scant legal protection and is useful for enforcing abortion restrictions,” they said.

The immediate problem, Mello notes, is in the states that have already banned abortion or passed restrictive laws.

“There could be a problem with states trying to reach outside their borders to prosecute people, but that could well be unconstitutional,” Mello said.

Some states’ laws sweep abortion pills into the definition of illegal abortions, she said, and there are legal obstacles to supplying the pills across state lines.

“There is a lot of energy going into figuring out a workaround right now, but it’s too soon to call,” Mello said.

Recommended Protections

So how can clinicians and health-care facilities protect their patients and themselves?

When counseling patients of childbearing age about reproductive health issues, clinicians should caution their patients about putting too much medical data online and refer them to expert organizations that will help them minimize their digital footprint.

When documenting reproductive health encounters, the authors said, clinicians should ask themselves: “What information needs to be in the medical record to assure safe, good-quality care, buttress our claim for reimbursement, or comply with clear legal directives?” For example, does information about why a patient may have experienced a miscarriage need to be recorded?

Patients and clinicians should be aware that email and texting may be seen by others, so conversations among staff about reproductive health issues may best be conducted by phone or in person.

Finally, if abortion-related patient information is sought by state law enforcement officials, a facility’s attorney should be consulted about asserting physician-patient privilege and determining whether the disclosure is mandated by law.

The women in the digital app group receive in-app health education and resources to improve well-being for mothers and their infants. The app includes a social interaction feature designed to foster social connections and promote self-care. They have enrolled 30 women during the pilot phase and 15 mother-infant dyads in the randomized control trial, with a goal of reaching 250.

“The digital approach also allows us to administer brief surveys and gather information on dynamic social determinants of health more frequently than can be done through traditional means,” said Shilpa Jani, an SHP project manager. She said social determinants of health — such as persistent housing instability, food insecurity and concerns of personal safety — contribute to chronic stress and health issues as well as an increased risk of pregnancy and birth complications.

“Adverse effects of social determinants of health along with health complications of preterm deliveries may exacerbate morbidities for the mother and child,” Jani said, adding that preterm-related causes of death accounted for two-thirds of infant deaths in 2019 in the United States.

Wang and Jani said the immediate project goals include increasing health education for preterm baby care, improving postpartum maternal health, and encouraging usage of local resources in Allegheny County. They eventually hope to see reductions in risk for subsequent preterm delivery and infant mortality and postpartum depression, as well as increases in mother-infant bonding and larger proportions of breastmilk feeding.