# Converging crises and maternal and child health: colonialism, extreme weather, and COVID-19

## TL;DR

This study explores how overlapping disasters and systemic inequalities in Puerto Rico affect maternal and child health, highlighting the role of colonialism and climate change.

## Contribution

The study introduces a novel analysis of cumulative disaster exposure's impact on maternal health in a colonial context.

## Key findings

- Disaster periods in Puerto Rico were linked to increased gestational diabetes and gestational hypertension.
- Newborn health outcomes were mixed, possibly due to reduced birth rates during disasters.
- Structural factors like colonial status and regional disparities modified health risks.

## Abstract

Climate change is a growing threat to human health, particularly in regions facing overlapping environmental hazards and social inequities. Puerto Rico—a U.S. territory with a colonial history—offers a unique case for examining how multiple disasters, including Hurricane Maria, ongoing earthquakes, and the COVID-19 pandemic, interact with structural vulnerabilities to affect maternal and child health. Despite increasing attention to climate-related health outcomes, little is known about the reproductive health impacts of cumulative disaster exposure in colonial contexts.

We used U.S. National Vital Statistics System data (2017–2021) to assess associations between disaster exposure and six maternal and newborn outcomes: preterm birth, low birthweight, term low birthweight, gestational hypertension, gestational diabetes, and excessive weight gain. Disaster exposure was defined based on the timing of hurricanes and the pandemic, using a three-month lag period. We analyzed data from Puerto Rico and used Florida and Texas as comparison sites. Multivariable log-binomial regression models estimated adjusted prevalence ratios. Effect modification was tested for (1) region within Puerto Rico and (2) colonial status, comparing Puerto Rico (territory) to Florida and Texas (states). Simulations were conducted to account for potential live-birth bias.

Across 104,560 births in Puerto Rico, disaster periods were consistently associated with worse maternal health outcomes. For example, during the late post-hurricane period, gestational diabetes increased (RR = 1.19, 95% CI: 1.08, 1.31), while term low birthweight surprisingly appeared to decline (RR = 0.90, 95% CI: 0.83, 0.98). Associations with newborn health were mixed and may have been underestimated due to sharp declines in live births after disasters. Simulations suggested stronger disaster-related risks than observed in primary analyses. Effect modification by region and colonial status showed inconsistent but notable differences, particularly elevated maternal health risks in certain regions of Puerto Rico and compared to U.S. states.

Our findings suggest that multiple disasters negatively affect reproductive health in Puerto Rico and that structural factors, including colonialism, may exacerbate these impacts. Public health responses must account for cumulative disaster exposure and systemic inequities to better support maternal and child health in marginalized settings, especially as climate change continues to intensify.

The online version contains supplementary material available at 10.1186/s12978-025-02159-y.

This study looks at how disasters and broader social conditions have affected the health of pregnant people and newborns in Puerto Rico. The U.S. territory experienced several major events—including a hurricane, a series of earthquakes, and the COVID-19 pandemic—that caused widespread disruption. These events coincided with long-standing inequalities in health, infrastructure, and emergency support compared to U.S. states. We analyzed over 100,000 birth records from Puerto Rico that occurred between 2017 and 2021 and compared them with similar data from Florida and Texas. We looked at health conditions during pregnancy such as gestational diabetes, excessive weight gain, early births, and low birthweight, and how these varied based on the timing of the birth relative to disasters. Our findings showed that disaster periods were associated with higher rates of gestational diabetes and high blood pressure, but that the effects on newborns were less clear, partly because fewer people gave birth during disaster periods. We also found some differences depending on the region of Puerto Rico and when we compared Puerto Rico to U.S. states, with people living in Puerto Rico (vs. Texas and Florida) and people in more vulnerable parts of the island (vs. the capital) were more likely to experience poor maternal health. Our results suggest that repeated disasters, combined with social and political factors like colonialism, can harm maternal health. Understanding these effects can help inform better policies and support systems for future emergencies—especially for communities that face structural disadvantages.

The online version contains supplementary material available at 10.1186/s12978-025-02159-y.