Small and large size for gestational age and neighborhood deprivation measured within increasing proximity to homes

Impact of experiencing multiple vulnerabilities on fetal growth and complications in women with hyperglycemia in pregnancy

BACKGROUND

In women with hyperglycemia in pregnancy living in France, psychosocial deprivation is associated with both earlier and greater exposure to the condition, as well as poorer maternofetal prognosis. We explored the impact of this and two other socioeconomic vulnerability indicators-food insecurity and poor language proficiency-on adherence to prenatal care and maternal and fetal outcomes.

METHODS

In a socially deprived suburb of Paris, we selected women who delivered between 01/01/2012 and 31/12/2018 and received care (nurse, dietician, diabetologist evaluation, advice, regular follow-up to adjust insulin doses if requested) for hyperglycemia in pregnancy. We analyzed the associations between individual psychosocial deprivation, food insecurity, French language proficiency (variables assessed by individual questionnaires) and fetal growth (main outcome), as well as other core maternal and fetal outcomes.

RESULTS

Among the 1,168 women included (multiethnic cohort, 19.3% of whom were Europeans), 56%, 17.9%, and 27.5% had psychosocial deprivation, food insecurity, and poor French language proficiency, respectively. Forty-three percent were prescribed insulin therapy. Women with more than one vulnerability had more consultations for diabetes. The rates for small (SGA), appropriate (AGA), and large-for-gestational-age (LGA) infant were 11.4%, 76.5% and 12.2%, respectively. These rates were similar in women with and without psychosocial deprivation, and in those with and without food insecurity. Interestingly, women with poor French language proficiency had a higher odds ratio of delivering a small- or large-for-gestational age infant than those with good proficiency.

CONCLUSION

We found similar pregnancy outcomes for women with hyperglycemia in pregnancy living in France, irrespective of whether or not they had psychosocial deprivation or food insecurity. Optimized single-center care with specialized follow-up could contribute to reduce inequalities in maternal and fetal outcomes in women with hyperglycemia in pregnancy.

Neighborhood Food Environment and Birth Weight Outcomes in New York City

Importance

Infants born with unhealthy birth weight are at greater risk for long-term health complications, but little is known about how neighborhood characteristics (eg, walkability, food environment) may affect birth weight outcomes.

Objective

To assess whether neighborhood-level characteristics (poverty rate, food environment, and walkability) are associated with risk of unhealthy birth weight outcomes and to evaluate whether gestational weight gain mediated these associations.

Design, Setting, and Participants

The population-based cross-sectional study included births in the 2015 vital statistics records from the New York City Department of Health and Mental Hygiene. Only singleton births and observations with complete birth weight and covariate data were included. Analyses were performed from November 2021 to March 2022.

Exposures

Residential neighborhood-level characteristics, including poverty, food environment (healthy and unhealthy food retail establishments), and walkability (measured by both walkable destinations and a neighborhood walkability index combining walkability measures like street intersection and transit stop density). Neighborhood-level variables categorized into quartiles.

Main Outcomes and Measures

The main outcomes were birth certificate birth weight measures including small for gestational age (SGA), large for gestational age (LGA), and sex-specific birth weight for gestational age z-score. Generalized linear mixed-effects models and hierarchical linear models estimated risk ratios for associations between density of neighborhood-level characteristics within a 1-km buffer of residential census block centroid and birth weight outcomes.

Results

The study included 106 194 births in New York City. The mean (SD) age of pregnant individuals in the sample was 29.9 (6.1) years. Prevalence of SGA and LGA were 12.9% and 8.4%, respectively. Residence in the highest density quartile of healthy food retail establishments compared with the lowest quartile was associated with lower adjusted risk of SGA (with adjustment for individual covariates including gestational weight gain z-score: risk ratio [RR], 0.89; 95% CI 0.83-0.97). Higher neighborhood density of unhealthy food retail establishments was associated with higher adjusted risk of delivering an infant classified as SGA (fourth vs first quartile: RR, 1.12; 95% CI, 1.01-1.24). The RR for the association between density of unhealthy food retail establishments and risk of LGA was higher after adjustment for all covariates in each quartile compared with quartile 1 (second: RR, 1.12 [95% CI, 1.04-1.20]; third: RR, 1.18 [95% CI, 1.08-1.29]; fourth: RR, 1.16; [95% CI, 1.04-1.29]). There were no associations between neighborhood walkability and birth weight outcomes (SGA for fourth vs first quartile: RR, 1.01 [95% CI, 0.94-1.08]; LGA for fourth vs first quartile: RR, 1.06 [95% CI, 0.98-1.14]).

Conclusions and Relevance

In this population-based cross-sectional study, healthfulness of neighborhood food environments was associated with risk of SGA and LGA. The findings support use of urban design and planning guidelines to improve food environments to support healthy pregnancies and birth weight.

Associations between combined exposure to environmental hazards and social stressors at the neighborhood level and individual perinatal outcomes in the ECHO-wide cohort

Limited studies examine how prenatal environmental and social exposures jointly impact perinatal health. Here we investigated relationships between a neighborhood-level combined exposure (CE) index assessed during pregnancy and perinatal outcomes, including birthweight, gestational age, and preterm birth. Across all participants, higher CE index scores were associated with small decreases in birthweight and gestational age. We also observed effect modification by race; infants born to Black pregnant people had a greater risk of preterm birth for higher CE values compared to White infants. Overall, our results suggest that neighborhood social and environmental exposures have a small but measurable joint effect on neonatal indicators of health.

Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization

BACKGROUND

Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization.

METHODS

Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression.

RESULTS

Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients.

CONCLUSION

Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.

The role of neighbourhood socioeconomic status in large for gestational age

OBJECTIVE

To determine whether neighbourhood socioeconomic status (SES) was associated with large for gestational age (LGA) while considering key sociodemographic and clinical confounding factors.

SETTING AND PATIENT

All singleton infants whose parents were living in the city of Marseilles, France, between 2013 and 2016.

METHOD

Population-based study based on new-born hospital birth admission charts from the French National Uniform Hospital Discharge Data Set Database. LGA infants were compared to appropriate-for-gestational-age (AGA) infants. Multiple generalized logistic model analysis was used to examine factors associated with LGA.

RESULTS

A total of 43,309 singleton infants were included, and 4,747 (11%) were born LGA. LGA infants were more likely to have metabolic and respiratory diseases and to be admitted to the neonatal intensive care unit. Multiparity, advanced maternal age, obesity and diabetes were associated with an increased risk of LGA. Lower neighbourhood SES was associated with LGA (aOR = 1.24, 95% CI: 1.14; 1.36; p<0.0001) independent of age, diabetes, obesity, maternal smoking and multiparity. The strength of this association increased with maternal age, reaching an aOR of 1.50 (95% CI: 1.26; 1.78; p<0.0001) for women > 35 years old.

CONCLUSION

Neighbourhood SES could be considered an important factor for clinicians to better identify mothers at risk of having LGA births in addition to well-known risk factors such as maternal diabetes, obesity and age. The intensification of the association between SES and LGA with increasing maternal age suggests that neighbourhood disadvantage may act on LGA cumulatively over time.

Area-level deprivation and preterm birth: results from a national, commercially-insured population

BACKGROUND

Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psychosocial factors.

METHODS

We conducted a retrospective cohort study using national, commercial health insurance claims data from 2011, obtained from the Health Care Cost Institute. Area-level deprivation was derived from principal components methods using ZIP code-level data. Multilevel structural equation modeling was used to examine mediating effects.

RESULTS

In total, 138,487 women with a live singleton birth residing in 14,577 ZIP codes throughout the United States were included. Overall, 5.7% of women had a preterm birth. In fully adjusted generalized estimation equation models, compared to women in the lowest quartile of area-level deprivation, odds of preterm birth increased by 9.6% among women in the second highest quartile (odds ratio (OR) 1.096; 95% confidence interval (CI) 1.021, 1.176), by 11.3% in the third highest quartile (OR 1.113; 95% CI 1.035, 1.195), and by 24.9% in the highest quartile (OR 1.249; 95% CI 1.165, 1.339). Hypertension and infection moderately mediated this association.

CONCLUSIONS

Even among commercially-insured women, area-level deprivation was associated with increased risk of preterm birth. Similar to individual socioeconomic status, area-level deprivation does not have a threshold effect. Implementation of policies to reduce area-level deprivation, and the screening and treatment of maternal mediators may be associated with a lower risk of preterm birth.

Living in violence: Neighborhood domestic violence and small for gestational age births

OBJECTIVES

To determine the association between neighborhood domestic violence and small-for-gestational-age (SGA) birth and to examine if there is a differential impact of neighborhood domestic violence on SGA births by race in a high crime community.

METHODS

This analysis includes all birth records issued in New Orleans, Louisiana from 2011 to 2012 geocoded by census tract (N=177 census tracts, N=8322 women). Hierarchical modeling and ecologic spatial analysis were used to examine the area-effect of neighborhood domestic violence on SGA births, independent of individual-level predictors and accounting for the propensity to live in high domestic violence neighborhoods.

RESULTS

Tests for spatial autocorrelation reveled area-level clustering and overlap of SGA and domestic violent rates. Pregnant women living in high domestic violence areas were more likely to give birth to an SGA infant compared to women in low-domestic violence areas (OR=1.04, 95%CI: 1.01, 1.08), net of the effects of individual-level factors and propensity scores.

CONCLUSION

Neighborhood-level attributes including rates of domestic violence may increase women's risk for SGA birth, highlighting a policy-relevant and potentially amenable exposure.