When President Trump banned travel from seven Muslim-majority countries as one of his first executive orders in 2017, fears of family separation and disrupted refugee resettlement were widespread. But few people were sounding the alarm about its potential impact on birth outcomes.

Now, research suggests that the stress associated with the travel ban increased preterm births for women from those seven countries. A study from the Columbia University’s Mailman School of Public Health found that women from the impacted countries living in the United States saw an almost 7 percent increase in their chances of delivering preterm from September 2017 to August 2018. White women born in the United States saw no change in their odds of having a preterm birth during the same period, which started eight months after the ban.

Trump’s policy, titled “Executive Order Protecting the Nation From Foreign Terrorist Entry Into the United States,” banned or put severe restrictions on travel to the United States for foreign nationals from Iran, Libya, Somalia, Sudan, Syria, Yemen and Iraq. While it has gone through three iterations, the ban remains relatively intact, now with slightly different countries being affected. It is estimated that tens of thousands of people have had their visa applications denied or stalled for months or years as a result; thousands more have experienced separation from family members.

Although President-elect Joe Biden has pledged to eliminate the ban, its effects are likely to last much longer. For women who were pregnant when the policy was put in place, those effects may be particularly detrimental.

“Structurally racist and xenophobic policies have real effects on people’s health and effects on birth outcomes,” said Goleen Samari, assistant professor of population and family health at Columbia’s Mailman School and principal investigator of the study. “Something like preterm birth is predictive of health over the entire lifetime, so the 2017 Muslim ban that affected these women’s birth outcomes could have lifelong detriments for all those births.”

She continued: “The magnitude of it is really important to think about.”

Preterm births occur when infants are born before 37 weeks of pregnancy. They are associated with a variety of health complications for infants, from higher death rates to learning disabilities to visual problems. In 2018, 17 percent of infant deaths were associated with preterm birth and low birth weight, according to the Centers for Disease Control and Prevention.

Given that the United States experiences some of the worst infant and maternal mortality rates in the developed world, better understanding preterm births could be a crucial intervention. But research and action has been sluggish — particularly for the most marginalized women who experience the worst outcomes.

“Infant mortality rates and maternal mortality rates are sentinel indicators about societal health, so you’d think we’d want to invest more in improving these unacceptably high levels of mortality,” said Alison Gemmill, an assistant professor at Johns Hopkins Bloomberg School of Public Health and a co-author of the study.

While recent years have seen a slow increase in media attention to the detrimental maternal inequities faced by Black women in America, who face maternal deaths at more than three times the rate of White women and preterm births about 50 percent higher, large gaps in understanding remain when it comes to the maternal and infant health of immigrants.

These knowledge gaps are even wider when it comes to the experiences of Muslim, Middle Eastern and North African immigrants, Samari said, as they are not typically reflected in existing racial and ethnic health demographic categories.

The link between stress and preterm birth is strong, with research showing everything from earthquakes to domestic violence can cause an increased likelihood of early birth. Samari’s research is part of a growing body of evidence that national policy and politics are also one of these stressful triggers.

“The weekend that the ban went into effect, the emotional impact was immediate, for me personally, but I also heard from dozens upon dozens of community members who were just really overwhelmed about what this meant for our communities,” said Azadeh Shahshahani, who is Iranian American and is the legal and advocacy director of Project South. “It appeared that being Iranian American, or Iraqi American, or Syrian American, is a crime in Trump’s America, very clearly so.”

These types of stresses are known to have consequences for pregnant women. A 2018 study found that fears about deportation increased risk of obesity and higher blood pressure among U.S. Latinos — both factors that can affect maternal health outcomes. A 2018 study also found that the stress of immigration raids significantly increased low birth weight in infants born to Latina mothers.

It is also possible that the policy increased women’s fear that they would face discrimination in health-care settings. A 2019 study found that anti-immigrant rhetoric in the United States was associated with delays in prenatal care and decreased prenatal visits, both of which strongly correlate with adverse health outcomes.

An acute example of this comes from February’s expanded public charge rule, which means that immigrants applying for permanent residency who used government benefits could have their application denied. Research from the Urban Institute found that 1 in 7 adults in immigrant families said they or a family member avoided government health, nutrition or housing benefits because they were afraid it would affect their future citizenship. Experts warn that the effects of forgoing medical care and nutrition assistance will be particularly devastating for pregnant and postpartum women and children.

The effects of racism and xenophobia on health are complicated, and pinpointing their origin to ameliorate them can be difficult.

“It’s not just that racism introduces stress into your physiology; it’s the social determinants of health that are shaped by racism,” Samari said. “You’re not getting physical activity, you’re not buying the food you might need, you’re not able to have access to equal education — there’s all these things that affect people’s health behavior and health outcomes.”

While this hasn’t yet been documented with immigrant women, there have also been studies showing that implicit bias among health-care providers has led to worse outcomes for Black women, a factor that Samari believes could also impact Muslim women.

Samari believes her study and the others are just the tip of the iceberg in terms of studying adverse birth outcomes for immigrants under the Trump administration.

The travel ban, after all, didn’t exist in a vacuum. Racism and xenophobia from the Trump administration ranged from Twitter vitriol, including tweeting that “the Squad” — four congresswomen of color — should “go back and help fix the totally broken and crime infested places from which they came” to his query about America’s acceptance of people from “shithole countries.”

“I think we’re going to start to see a lot of stuff come out not just in the maternal and infant health space, but a lot of things across different health outcomes for people based off of the stress and really structural racism and xenophobia of the last four years,” Samari said.

Research published last year by Gemmill, of Johns Hopkins, found that there was an increase in preterm births for Latina mothers in the United States in the nine months following Trump’s election. Given that there are a variety of Latina experiences under the Trump presidency (many Latinas don’t live in fear of deportation, for example), this suggests that the detrimental effects of a stressful event or policy might extend beyond those directly impacted.

“These stressors are felt diffusely across the population in ways we don’t fully understand,” Gemmill said.

Shahshahani, of Project South, put it like this: “All of it creates a ripple effect where I would say Muslim communities and especially those communities impacted by the ban are just constantly living in a state of fear of what could be coming next.”

Advocates like Shahshahani are hopeful Biden’s immigration policies will begin combating the effects of Trump’s. For many immigrant communities, however, dismantling the stress and fear of the past four years will be no easy task.

“You’re going to have to undo the damage that’s been done and that’s going to involve significant outreach and engaging with communities to gain back their trust,” Gemmill said.

This kind of work could involve increasing funding to clinics with close ties to immigrant communities, or implementing networks of doulas and community health-care workers, which have been shown to help with maternal outcomes within Black communities in the United States.

“Biden repealing the ban is great, but then what happens to the harm that our communities endured for four years?” Shahshahani asked. “The emotional, the mental, the separation, the financial, the pain, the discrimination, the feeling of not belonging; it was all extremely, extremely painful. Where does all that go?”