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Request for Information (RFI): 2022 Health and Human Services’ Environmental Justice Strategy and Implementation Plan Draft Outline

Joint request for explicit statement of commitment to reproductive justice

June 18, 2022

Request for Information (RFI): 2022 Health and Human Services’ Environmental Justice Strategy and Implementation Plan Draft Outline

Dear Arsenio Mataka,

Many thanks for the opportunity to contribute to your office’s “Request for Information (RFI): 2022 HHS Environmental Justice Strategy and Implementation Plan Draft Outline.”

We are a group of organizations and partners working to bring attention to the many ways the climate crisis and other environmental harms are worsening the maternal health crisis in the United States, including contributing to unjust racial disparities in maternal health and birth outcomes.

We appreciate your proposed outline and the strong focus on communities facing disproportionate environmental health impacts. As you note, “for years studies have demonstrated that people of color and disadvantaged, vulnerable, low-income, marginalized, and [I]ndigenous populations are disproportionately burdened by environmental hazards.”

We are writing to request that you explicitly include a statement of commitment to reproductive justice from the start in your analysis and stated principles. We also ask that you commit to spending resources at the intersection of environmental health and sexual and reproductive health and rights with a clear focus on pregnant people and adolescents from marginalized communities because of the specific biological vulnerabilities of these stages of the life course. Pregnant people are often included in lists of vulnerable populations but otherwise marginalized in plans for managing climate change-related and other environmental crises.

We have been increasingly concerned about the impact of climate change and other mounting harms from environmental degradation on the health of all people, and in particular on the health of pregnant people and newborn babies. These negative impacts, which reflect specific biological as well as socioeconomic vulnerabilities of pregnancy, are inequitably distributed. Such impacts compound and interact with poverty, racism, and other forms of marginalization, and can have life-long ramifications that in turn exacerbate inequality and corrode future community resilience, including to disasters arising from the climate crisis. 

Known impacts arising from air pollution, climate change, and other environmental factors include preterm birth, low birth weight, still birth, and higher rates of some maternal diseases. Without action, environmental injustices will continue to worsen the US maternal health crisis, deepening unjust inequities in rates of maternal morbidity and mortality and adverse birth outcomes, with far worse rates for Black, Indigenous, and other women and birthing people of color.

Please see the end of this email for a list of just some of the scientific studies available indicating links between poor environmental health and adverse maternal health and birth outcomes.

We suggest the following be included in the plan:

A. For Section I, “Services”: We recommend that you specify in your plan that you will engage birth workers, reproductive justice workers, maternal and newborn health care clinicians, and others working closely with pregnant people and newborns beyond the traditional healthcare setting.

Maternal and newborn health organizations and workers, including, for example, community-based doulas, midwives and other maternal health care clinicians, and lactation consultants, and reproductive justice organizations, do life-saving work in communities with the highest rates of poor maternal health and adverse birth outcomes. Their work does, or could, include crucial environmental justice work. Birth workers could help provide environmental health information tailored to a local and community context, for example.

But because of silos between environmental health/justice and reproductive health/justice efforts, these may be especially important organizations and individuals to reach with education about HHS grants and technical assistance to access these funds.

B. For your Section II, “Partnership and Community Engagement”: We recommend you commit to engaging with maternal and newborn health workers, reproductive justice organizations, and pregnant people specifically as a priority action, not just “disadvantaged communities” as a whole. Pregnancy health and the specific experiences, concerns, and capacities of reproductive justice and health workers and activists, as well as of pregnant people, parents, and caregivers, may not always be fully represented unless these voices are intentionally sought out.

C. For your Section III “Policy Development and Implementation”: We recommend ensuring that maternal and newborn health and reproductive justice are centered in the roll out of the Justice 40 mechanism and that indicators for success reflect that commitment. Home cooling, air purification, and weatherization subsidies or related efforts should include pregnant people as a target recipient.

D. Similarly, we hope that for Section IV, “Research and Data Collection,” the plan will include efforts to better understand the impacts of environmental injustice on pregnant people, and that you will partner with reproductive rights, justice, and health workers to collect, analyze, and disseminate data. We also hope that you will specifically commit to engaging reproductive health workers and especially community-based health workers in your proposed V “Education and Training” actions. 

Lastly, we recommend that you uplift reproductive justice in your proposed list of environmental justice principles, perhaps along the lines of SisterSong Women of Color Reproductive Justice Collective’s definition that emphasizes that reproductive justice and sexual and reproductive health and rights necessitate “safe and sustainable communities.”

Many thanks for considering our proposed suggestions to create a plan with a strong reproductive justice component that includes clear actions to prevent climate and other environmental injustices from worsening the US maternal health crisis and deepening unjust disparities in maternal health and birth outcomes.

Please be in touch if we can be of further assistance.


Cara Cook, Alliance of Nurses for Healthy Environments
Elise Brannen, Medical Students for a Sustainable Future
Jessie Losch, American Society for Reproductive Medicine
Molly Rauch, Moms Clean Air Force
Sarah Brafman, A Better Balance
Shahyd Khalil, National Resources Defense Council
Skye Wheeler, Human Rights Watch
Zainab Jah, National Birth Equity Collaborative



Examples of Relevant Studies

[A] Studies describing important links between environmental and maternal and/or birth health outcomes:

Burris, Heather H., Scott A. Lorch, Haresh Kirpalani, DeWayne M. Pursley, Michal A. Elovitz, and Jane E. Clougherty. “Racial disparities in preterm birth in USA: a biosensor of physical and social environmental exposures.” Archives of Disease in Childhood 104, no. 10 (2019): 931-935.

Robinson, Oliver, and Martine Vrijheid. “The Pregnancy Exposome.” Current Environmental Health Reports 2, no. 2 (2015): 204-213.

[B] Studies indicating links between air pollution and adverse birth outcomes:

Basu, Rupa, Maria Harris, Lillian Sie, Brian Malig, Rachel Broadwin, and Rochelle Green. “Effects of fine particulate matter and its constituents on low birth weight among full-term infants in California.” Environmental Research 128 (2014): 42-51.

Bekkar, Bruce, Susan Pacheco, Rupa Basu, and Nathaniel DeNicola. “Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US: a systematic review.” JAMA Network Open 3, no. 6 (2020): e208243-e208243, doi: 10.1001/jamanetworkopen.2020.8243.

Chen, Gongbo, Yuming Guo, Michael J. Abramson, Gail Williams, and Shanshan Li. “Exposure to low concentrations of air pollutants and adverse birth outcomes in Brisbane, Australia, 2003–2013.” Science of the Total Environment 622 (2018): 721-726, doi: 10.1016/j.scitotenv.2017.12.050.

DeFranco, Emily, William Moravec, Fan Xu, Eric Hall, Monir Hossain, Erin N. Haynes, Louis Muglia, and Aimin Chen. “Exposure to airborne particulate matter during pregnancy is associated with preterm birth: a population-based cohort study.” Environmental Health 15, no. 1 (2016): 1-8, doi: 10.1186/s12940-016-0094-3.

Ebisu, Keita, Brian Malig, Sina Hasheminassab, Constantinos Sioutas, and Rupa Basu. “Cause-specific stillbirth and exposure to chemical constituents and sources of fine particulate matter.” Environmental Research 160 (2018): 358-364.

Ghosh, Rakesh, Kate Causey, Katrin Burkart, Sarah Wozniak, Aaron Cohen, and Michael Brauer. “Correction: Ambient and household PM2. 5 pollution and adverse perinatal outcomes: A meta-regression and analysis of attributable global burden for 204 countries and territories.” PLoS Medicine 18, no. 11 (2021): e1003852, DOI: 10.1371/journal.pmed.1003952.

Dugandzic, Rose, Linda Dodds, David Stieb, and Marc Smith-Doiron. “The association between low level exposures to ambient air pollution and term low birth weight: a retrospective cohort study.” Environmental Health 5, no. 1 (2006): 1-8, doi: 10.1186/1476-069X-5-3.

Ha, Sandie, Hui Hu, Dikea Roussos-Ross, Kan Haidong, Jeffrey Roth, and Xiaohui Xu. “The effects of air pollution on adverse birth outcomes.” Environmental Research 134 (2014): 198-204.

Hansen, Craig, Anne Neller, Gail Williams, and Rod Simpson. "Low levels of ambient air pollution during pregnancy and fetal growth among term neonates in Brisbane, Australia." Environmental Research 103, no. 3 (2007): 383-389, doi: 10.1016/j.envres.2006.06.010.

Hao, Hua, Howard H. Chang, Heather A. Holmes, James A. Mulholland, Mitch Klein, Lyndsey A. Darrow, and Matthew J. Strickland. “Air pollution and preterm birth in the US state of Georgia (2002–2006): associations with concentrations of 11 ambient air pollutants estimated by combining Community Multiscale Air Quality Model (CMAQ) simulations with stationary monitor measurements.” Environmental Health Perspectives 124, no. 6 (2016): 875-880, doi: 10.1289/ehp.1409651.

Koman, Patricia D., Kelly A. Hogan, Natalie Sampson, Rebecca Mandell, Chris M. Coombe, Myra M. Tetteh, Yolanda R. Hill‐Ashford et al. “Examining Joint Effects of Air Pollution Exposure and Social Determinants of Health in Defining “At‐Risk” Populations Under the Clean Air Act: Susceptibility of Pregnant Women to Hypertensive Disorders of Pregnancy.” World Medical & Health Policy 10, no. 1 (2018): 7-54.

Lamichhane, Dirga Kumar, Jong-Han Leem, Ji-Young Lee, and Hwan-Cheol Kim. “A meta-analysis of exposure to particulate matter and adverse birth outcomes.” Environmental Health and Toxicology 30 (2015).

Lavigne, Eric, Abdool S. Yasseen III, David M. Stieb, Perry Hystad, Aaron Van Donkelaar, Randall V. Martin, Jeffrey R. Brook et al. “Ambient air pollution and adverse birth outcomes: differences by maternal comorbidities.” Environmental Research 148 (2016): 457-466.

Li, Xiangyu, Shuqiong Huang, Anqi Jiao, Xuhao Yang, Junfeng Yun, Yuxin Wang, Xiaowei Xue et al. “Association between ambient fine particulate matter and preterm birth or term low birth weight: an updated systematic review and meta-analysis.” Environmental Pollution 227 (2017): 596-605, doi: 10.1016/j.envpol.2017.03.055.

Malley, Christopher S., Johan CI Kuylenstierna, Harry W. Vallack, Daven K. Henze, Hannah Blencowe, and Mike R. Ashmore. “Preterm birth associated with maternal fine particulate matter exposure: a global, regional and national assessment.” Environment International 101 (2017): 173-182.

Melody, Shannon M., Jane Ford, Karen Wills, Alison Venn, and Fay H. Johnston. “Maternal exposure to short-to medium-term outdoor air pollution and obstetric and neonatal outcomes: A systematic review.” Environmental Pollution 244 (2019): 915-925, doi: 10.1186/s12940-016-0094-3.

Mendola, Pauline, Carrie Nobles, Andrew Williams, Seth Sherman, Jenna Kanner, Indulaxmi Seeni, and Katherine Grantz. “Air pollution and preterm birth: do air pollution changes over time influence risk in consecutive pregnancies among low-risk women?” International Journal of Environmental Research and Public health 16, no. 18 (2019): 3365.

Sarovar, Varada, Brian J. Malig, and Rupa Basu. “A case-crossover study of short-term air pollution exposure and the risk of stillbirth in California, 1999–2009.” Environmental Research 191 (2020): 110103.

Stieb, David M., Li Chen, Maysoon Eshoul, and Stan Judek. “Ambient air pollution, birth weight and preterm birth: a systematic review and meta-analysis.” Environmental Research 117 (2012): 100-111, doi: 10.1016/j.envres.2012.05.007.

Trasande, Leonardo, Patrick Malecha, and Teresa M. Attina. “Particulate matter exposure and preterm birth: estimates of US attributable burden and economic costs." Environmental Health Perspectives 124, no. 12 (2016): 1913-1918, DOI: 10.1289/ehp.1510810.

Vinikoor-Imler, Lisa C., J. Allen Davis, Robert E. Meyer, Lynne C. Messer, and Thomas J. Luben. “Associations between prenatal exposure to air pollution, small for gestational age, and term low birthweight in a state-wide birth cohort.” Environmental Research 132 (2014): 132-139.

[C] Studies indicating links between climate change and adverse birth outcomes:

Ha, Sandie. “The Changing Climate and Pregnancy Health.” Current Environmental Health Reports (2022): 1-13, doi: 10.1007/s40572-022-00345-9.

Giudice, Linda C., Erlidia F. Llamas‐Clark, Nathaniel DeNicola, Santosh Pandipati, Marya G. Zlatnik, Ditas Cristina D. Decena, Tracey J. Woodruff, Jeanne A. Conry, and FIGO Committee on Climate Change and Toxic Environmental Exposures. “Climate change, women’s health, and the role of obstetricians and gynecologists in leadership.” International Journal of Gynecology & Obstetrics 155, no. 3 (2021): 345-356, doi: 10.1002/ijgo.13958.

IPCC, 2022: Summary for Policymakers [H.-O. Pörtner, D.C. Roberts, E.S. Poloczanska, K. Mintenbeck, M. Tignor, A. Alegría, M. Craig, S. Langsdorf, S. Löschke, V. Möller, A. Okem (eds.)]. In: Climate Change 2022: Impacts, Adaptation, and Vulnerability. Contribution of Working Group II to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change [H.-O. Pörtner, D.C. Roberts, M. Tignor, E.S. Poloczanska, K. Mintenbeck, A. Alegría, M. Craig, S. Langsdorf, S. Löschke, V. Möller, A. Okem, B. Rama (eds.)]. Cambridge University Press. In Press.

Jay, A., D.R. Reidmiller, C.W. Avery, D. Barrie, B.J. DeAngelo, A. Dave, M. Dzaugis, M. Kolian, K.L.M. Lewis, K. Reeves, and D. Winner, 2018: Overview. In Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock, and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 33–71. doi: 10.7930/NCA4.2018.CH1.

Poursafa, Parinaz, Mojtaba Keikha, and Roya Kelishadi. “Systematic review on adverse birth outcomes of climate change.” Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences 20, no. 4 (2015): 397.

Roos, Nathalie, Sari Kovats, Shakoor Hajat, Veronique Filippi, Matthew Chersich, Stanley Luchters, Fiona Scorgie et al. “Maternal and newborn health risks of climate change: A call for awareness and global action.” Acta obstetricia et gynecologica Scandinavica 100, no. 4 (2021): 566-570, doi: 10.1111/aogs.14124.

Sorensen, Cecilia, Virginia Murray, Jay Lemery, and John Balbus. “Climate change and women's health: Impacts and policy directions.” PLoS Medicine 15, no. 7 (2018): e1002603, doi: 10.1371/journal.pmed.1002603.

Watts, Nick, Markus Amann, Nigel Arnell, Sonja Ayeb-Karlsson, Kristine Belesova, Maxwell Boykoff, Peter Byass et al. “The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate.” The Lancet 394, no. 10211 (2019): 1836-1878, doi: 10.1016/S0140-6736(19)32596-6.

Zlatnik, Marya. “Climate Change and Pregnancy: Risks, Mitigation and Adaptation.” Forthcoming.

Additional various useful papers and commentaries can be found in this special edition of Paediatric and Perinatal Epidemiology: Climate Change and Reproductive, Perinatal, and Paediatric Health: Paediatric and Perinatal Epidemiology: Vol 36, No 1

  1. Exposure to extreme heat:

Bekkar, Bruce, Susan Pacheco, Rupa Basu, and Nathaniel DeNicola. “Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US: a systematic review.” JAMA Network Open 3, no. 6 (2020): e208243-e208243, doi: 10.1001/jamanetworkopen.2020.8243.

Carolan-Olah, Mary, and Dorota Frankowska. “High environmental temperature and preterm birth: a review of the evidence.” Midwifery 30, no. 1 (2014): 50-59, doi: 10.1016/j.midw.2013.01.011.

Chersich, Matthew Francis, Minh Duc Pham, Ashtyn Areal, Marjan Mosalam Haghighi, Albert Manyuchi, Callum P. Swift, Bianca Wernecke et al. “Associations between high temperatures in pregnancy and risk of preterm birth, low birth weight, and stillbirths: systematic review and meta-analysis.” BMJ 371 (2020), doi: 10.1136/bmj.m3811.

Konkel, Lindsey. “Taking the heat: potential fetal health effects of hot temperatures.” Environmental Health Perspectives 127, no. 10 (2019): 102002, doi: 10.1289/EHP6221.

Kuehn, Leeann, and Sabrina McCormick. “Heat exposure and maternal health in the face of climate change.” International Journal of Environmental Research and Public Health 14, no. 8 (2017): 853, doi: 10.3390/ijerph14080853.

Zhang, Yunquan, Chuanhua Yu, and Lu Wang. “Temperature exposure during pregnancy and birth outcomes: an updated systematic review of epidemiological evidence.” Environmental Pollution 225 (2017): 700-712, doi: 10.1016/j.envpol.2017.02.066.

  1. Exposure to wildfire:

Abdo, Mona, Isabella Ward, Katelyn O’Dell, Bonne Ford, Jeffrey R. Pierce, Emily V. Fischer, and James L. Crooks. “Impact of wildfire smoke on adverse pregnancy outcomes in Colorado, 2007–2015.” International Journal of Environmental Research and Public health 16, no. 19 (2019): 3720, doi: 10.3390/ijerph16193720.

Amjad, Sana, Dagmara Chojecki, Alvaro Osornio-Vargas, and Maria B. Ospina. “Wildfire exposure during pregnancy and the risk of adverse birth outcomes: A systematic review.” Environment International 156 (2021): 106644, doi: 10.1016/j.envint.2021.106644.

Heft-Neal, Sam, Anne Driscoll, Wei Yang, Gary Shaw, and Marshall Burke. “Associations between wildfire smoke exposure during pregnancy and risk of preterm birth in California.” Environmental Research 203 (2022): 111872, doi: 10.1016/j.envres.2021.111872.

Holstius, David M., Colleen E. Reid, Bill M. Jesdale, and Rachel Morello-Frosch. “Birth weight following pregnancy during the 2003 Southern California wildfires.” Environmental Health Perspectives 120, no. 9 (2012): 1340-1345, doi: 10.1289/ehp.1104515.

Jones, Benjamin A., and Shana McDermott. “Infant health outcomes in mega-fire affected communities.” Applied Economics Letters (2021): 1-11, doi: 10.1080/13504851.2021.1927959.

Park, Bo Young, Ian Boles, Samira Monavvari, Shivani Patel, Arriel Alvarez, Mie Phan, Maria Perez, and Ruofan Yao. “The association between wildfire exposure in pregnancy and foetal gastroschisis: A population‐based cohort study.” Paediatric and Perinatal Epidemiology 36, no. 1 (2022): 45-53, doi: 10.1111/ppe.12823.

Requia, Weeberb J., Stefania Papatheodorou, Petros Koutrakis, Rajarshi Mukherjee, and Henrique L. Roig. “Increased preterm birth following maternal wildfire smoke exposure in Brazil.” International Journal of Hygiene and Environmental Health 240 (2022): 113901, doi: 10.1016/j.ijheh.2021.113901.

[D] Studies indicating links between fossil fuel extraction and adverse birth outcomes:

Cushing, Lara J., Kate Vavra-Musser, Khang Chau, Meredith Franklin, and Jill E. Johnston. “Flaring from unconventional oil and gas development and birth outcomes in the Eagle Ford Shale in South Texas.” Environmental Health Perspectives 128, no. 7 (2020): 077003, doi: 10.1289/EHP6394.

Gonzalez, David JX, Allison R. Sherris, Wei Yang, David K. Stevenson, Amy M. Padula, Michael Baiocchi, Marshall Burke, Mark R. Cullen, and Gary M. Shaw. “Oil and gas production and spontaneous preterm birth in the San Joaquin Valley, CA: a case–control study.” Environmental Epidemiology 4, no. 4 (2020), doi: 10.1097/EE9.0000000000000099.

Nicole, Wendee. “On Wells and Wellness: Oil and Gas Flaring as a Potential Risk Factor for Preterm Birth.” Environmental Health Perspectives 128, no. 11 (2020): 114004, doi: 10.1289/EHP7952.

Willis, Mary D., Elaine L. Hill, Andrew Boslett, Molly L. Kile, Susan E. Carozza, and Perry Hystad. “Associations between residential proximity to oil and gas drilling and term birth weight and small-for-gestational-age infants in Texas: a difference-in-differences analysis.” Environmental Health Perspectives 129, no. 7 (2021): 077002, doi: 10.1289/EHP7678.

A large number of studies on fracking and pregnancy outcomes are included in:

Concerned Health Professionals of New York, & Physicians for Social Responsibility. (2020, December). Compendium of scientific, medical, and media findings demonstrating risks and harms of fracking (unconventional gas and oil extraction) (7th ed.):

[E] Studies indicating links between environmental contaminants and adverse birth outcomes:

Ferguson, Kelly K., Marie S. O'Neill, and John D. Meeker. “Environmental contaminant exposures and preterm birth: a comprehensive review.” Journal of Toxicology and Environmental Health, Part B 16, no. 2 (2013): 69-113, doi: 10.1080/10937404.2013.775048

Ferguson, Kelly K., Thomas F. McElrath, and John D. Meeker. "Environmental phthalate exposure and preterm birth." JAMA Pediatrics 168, no. 1 (2014): 61-67, doi: 10.1001/jamapediatrics.2013.3699.

Porpora, Maria Grazia, Ilaria Piacenti, Sara Scaramuzzino, Luisa Masciullo, Francesco Rech, and Pierluigi Benedetti Panici. “Environmental contaminants exposure and preterm birth: a systematic review.” Toxics 7, no. 1 (2019): 11, doi: 10.3390/toxics7010011.

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