Mapping Geographic Variation in Infant Mortality and Related Black-White Disparities in the US

Building Collective Power to Advance Maternal and Child Health Equity: Lessons from the New Orleans Maternal and Child Health Coalition

OBJECTIVES

The New Orleans Maternal Child Health Coalition convenes to support and amplify the work of New Orleans-based individuals and organizations working to reduce disparities and protect the health of birthing families in the New Orleans area. The objectives of this qualitative study were to identify successes, challenges, and areas of growth for the Coalition and develop broadly generalizable recommendations for similar groups seeking to mobilize and advance health equity in their own communities.

METHODS

Using purposive sampling, we conducted semi-structured interviews with 12 key informants from within and outside of the Coalition. Interviews were transcribed verbatim, and data was analyzed using inductive and deductive coding approaches.

RESULTS

We identified themes relating to the barriers and facilitators to the maintenance of the Coalition, as well as opportunities to advance the mission of the Coalition. Some themes included structural- and systemic-level barriers to achieving the mission, varying perspectives on the effectiveness of the Coalition, opportunities to enhance the operations of the Coalition's work, and opportunities to involve other individuals, particularly those with lived experience, and non-MCH related sectors in Coalition's work.

CONCLUSIONS FOR PRACTICE

As the maternal health crisis continues, coalitions like the New Orleans MCH Coalition provide a vehicle to amplify the mission-driven work of people and organizations. Recommendations put forth by the Coalition can also be utilized by coalitions in other jurisdictions.

Geographic heterogeneity in Black-white infant mortality disparities

Despite recent decreases in Black infant mortality, racial disparities persist, motivating continued research into factors related to these inequalities. While the inverse association between education and infant mortality has been documented across races, less is known about its geographic heterogeneity. Using vital statistics from the National Center for Health Statistics, this study considers Black-white disparities in infant mortality for births occurring between 2011 and 2015 across regions and metropolitan status of maternal residence. With logistic regressions, we investigate heterogeneity in maternal educational gradients of infant mortality by geographic residence both within and between races. Beyond confirming the well-known relationship between education and infant mortality, our findings document a slight metropolitan advantage for infants born to white mothers as well as lower returns to education for infants born to Black mothers residing in nonmetropolitan counties. We observe a metropolitan advantage for infants born to Black mothers with at least a bachelor's degree, but a metropolitan disadvantage for infants born to Black mothers with less than a high school degree. The South is driving this divergence, pointing to particular mechanisms limiting returns to education for Southern Black mothers in nonmetropolitan areas. This paper's geographic perspective emphasizes that racial infant health disparities are not uniform across the country and cannot be fully understood through individual and household characteristics.

Does a Rising Median Income Lift All Birth Weights? County Median Income Changes and Low Birth Weight Rates Among Births to Black and White Mothers

Policy Points Policies that increase county income levels, particularly for middle-income households, may reduce low birth weight rates and shrink disparities between Black and White infants. Given the role of aggregate maternal characteristics in predicting low birth weight rates, policies that increase human capital investments (e.g., funding for higher education, job training) could lead to higher income levels while improving population birth outcomes. The association between county income levels and racial disparities in low birth weight is independent of disparities in maternal risks, and thus a broad set of policies aimed at increasing income levels (e.g., income supplements, labor protections) may be warranted.

CONTEXT

Low birth weight (LBW; <2,500 grams) and infant mortality rates vary among place and racial group in the United States, with economic resources being a likely fundamental contributor to these disparities. The goals of this study were to examine time-varying county median income as a predictor of LBW rates and Black-White LBW disparities and to test county prevalence and racial disparities in maternal sociodemographic and health risk factors as mediators.

METHODS

Using national birth records for 1992-2014 from the National Center for Health Statistics, a total of approximately 27.4 million singleton births to non-Hispanic Black and White mothers were included. Data were aggregated in three-year county-period observations for 868 US counties meeting eligibility requirements (n = 3,723 observations). Sociodemographic factors included rates of low maternal education, nonmarital childbearing, teenage pregnancy, and advanced-age pregnancy; and health factors included rates of smoking during pregnancy and inadequate prenatal care. Among other covariates, linear models included county and period fixed effects and unemployment, poverty, and income inequality.

FINDINGS

An increase of $10,000 in county median income was associated with 0.34 fewer LBW cases per 100 live births and smaller Black-White LBW disparities of 0.58 per 100 births. Time-varying county rates of maternal sociodemographic and health risks mediated the association between median income and LBW, accounting for 65% and 25% of this estimate, respectively, but racial disparities in risk factors did not mediate the income association with Black-White LBW disparities. Similarly, county median income was associated with very low birth weight rates and related Black-White disparities.

CONCLUSIONS

Efforts to increase income levels-for example, through investing in human capital, enacting labor union protections, or attracting well-paying employment-have broad potential to influence population reproductive health. Higher income levels may reduce LBW rates and lead to more equitable outcomes between Black and White mothers.

From convergence to divergence: Lifespan variation in US states, 1959-2017

BACKGROUND

Large disparities in life expectancy exist across US states and the gaps have been widening in recent decades. Less is known about the lifespan variability - a measure that can provide important insights into mortality inequalities both between and within states.

METHOD

Using yearly lifetables from the United States Mortality Database, we explore geographic and temporal patterns in lifespan variation (unconditional and conditional on survival to age 10, 35 and 65) across US states between 1959 and 2017. We also examine the contribution of state differences in life expectancy to overall lifespan variation using standard decomposition techniques.

RESULTS

Despite overall convergence in lifespan variation across states over the last six decades, in more recent years there has been notable divergence. Gender-specific analyses show that lifespan variation was generally greater among males than among females; but this pattern reverses for mortality past age 65. Much of the state disparities in lifespan variation, unconditional and conditional on survival to age 10 and 35, were due to mortality differences under the age 65. Decomposition analysis shows that while within-state variability remains the primary driver of overall lifespan variation, the contribution of cross-state differences in life expectancy is growing.

CONCLUSIONS

Variation in longevity is greater within US States than between them, yet cross-states disparities in mortality are increasing. This likely reflects the long-term consequences of rising social, economic, and political stratification for health inequalities both within and across states.

Maternal and Child Mortality: Analysis of Nurse Home Visiting in 3 RCTs

INTRODUCTION

The impact of intensive prenatal and infant/toddler nurse home visiting on low-income mothers' and children's survival was examined in 3 RCTs following participants over 2-decade periods after trial registration during pregnancy (data gathered between 1978 and 2015 and analyzed between 2016 and 2020).

METHODS

All-cause and external-cause maternal mortality and preventable-cause child mortality were examined using National Death Index data. Survival rates were calculated for all the 1,138 mothers randomized and 1,076 live-born children in the second RCT (conducted in Memphis, TN) and for all the 1,135 mothers randomized and 1,087 live-born children in the first and third RCTs combined (conducted in Elmira, NY and Denver, CO).

RESULTS

There were no significant nurse home visiting-control differences in maternal mortality in Memphis or Elmira and Denver. Posthoc analysis, combining all 3 trials, suggested a reduction in external-cause maternal mortality among nurse-visited mothers (p=0.054). There was a marginally significant nurse home visiting-control difference in preventable-cause child mortality (p=0.09) in Memphis.

CONCLUSIONS

These results support examining maternal and child mortality in additional nurse home visiting trials with larger samples living in disadvantaged contexts. Intensive prenatal and infant/toddler home visiting by nurses for mothers and children living in poverty may decrease premature death.

The geography of ethnoracial low birth weight inequalities in the United States

In this article, we describe, decompose, and examine correlates of the geography of ethnoracial inequalities in low birth weight (LBW) in the United States. Drawing on the population of singleton births to U.S.-born White, Black, Latinx, and Native American parents in the first decade of the twenty-first century (N = 28.2 million births), we calculate county-level LBW rates and rate ratios. Results demonstrate a stark racial hierarchy in which Black infants experience the most significant disadvantage, but we also document substantial local-level variation organized in what we call a regionalized patchwork of inequality, with high-disparity counties bordering low-disparity counties coupled with regional clustering. Examining the component parts of local disparities - the LBW rates for Whites and groups of color - we find strong evidence that spatial variation in ethnoracial LBW inequalities is driven by greater variation in infants of color's health across counties relative to Whites. Further, LBW rates for groups of color are only weakly to moderately correlated with Whites' LBW rates, indicating that the same contexts can produce racially divergent health outcomes. Examining contextual factors that predict LBW disparities, we find that more segregated, socioeconomically unequal, and urban counties have larger LBW disparities. We conclude by positing an approach to health disparities that conceptualizes ethnoracial differences in health as fundamentally relational and spatial phenomena produced by systems of White advantage.

Geographical variation in infant mortality due to congenital heart disease in the USA: a population-based cohort study

BACKGROUND

Little is known about geographical variation in infant mortality due to congenital heart disease (CHD) and the social determinants of health that might mediate such variation. We aimed to examine US county-level estimates of infant mortality due to CHD to understand geographical patterns and factors that might influence variation in mortality.

METHODS

This US population-based cohort study used linked livebirth-infant death cohort files from the US National Center for Health Statistics from Jan 1, 2006, to Dec 31, 2015. All deaths attributable to congenital heart disease in infants in a given year were included. We used hierarchical Bayesian models to estimate rates of infant mortality due to congenital heart disease for all US counties. We mapped model-based estimates to explore geographical patterns. Covariates included infant sex, gestational age, maternal race and ethnicity, percentage of the county population below the poverty level, and proximity of the county to a US News & World Report 2015 top-50 ranked paediatric cardiac centre.

FINDINGS

From 2006 to 2015, 40 847 089 livebirths occurred, of which there were 13 988 infant deaths attributed to congenital heart disease, with an unadjusted infant mortality rate due to CHD of 0·34 per 1000 livebirths (95% CI 0·34-0·35). Kentucky and Mississippi had the greatest proportions of counties with a predicted rate of infant mortality due to CHD above the 95th percentile. All counties in Connecticut, Massachusetts, and Rhode Island had a predicted rate below the fifth percentile. In the model, lower mortality risk correlated with closer proximity to a top-50 ranked paediatric cardiac centre (odds ratio [OR] 0·890, 95% credible interval [CrI] 0·840-0·942), whereas higher mortality risk correlated with higher levels of poverty (OR 1·181, 95% CrI 1·125-1·239).

INTERPRETATION

Substantial geographical variation exists in infant mortality due to CHD in the USA, highlighting the potential importance of bolstering care delivery for infants from economically deprived communities and areas remote from top-performing paediatric cardiac centres.

FUNDING

None.

Disparities in infant mortality by payment source for delivery in the United States

In this study, we hypothesized that infant mortality varies among health insurance status. Furthermore, we examined whether there are racial and ethnic disparities in the association between infant death and payment source for delivery. Our study used US national linked birth and infant death data for 2013 and 2017 collected by the National Center for Health Statistics and included 3,311,504 and 3,218,168 live births for each year. The principal source of payment for delivery was classified into three groups: Medicaid, private insurance, and self-payment. The outcome measures were infant mortality, neonatal mortality, and postneonatal mortality. Subgroup analysis for race and ethnicity was also performed. Overall infant mortality was lower in mothers who paid with private insurance than in those who paid with Medicaid insurance (RR = 0.87, 95% CI 0.84-0.90 in 2013; RR = 0.91, 95% CI 0.87-0.94 in 2017), but it was higher in self-paid women than in Medicaid-insured women at delivery (RR = 1.25, 95% CI 1.17-1.33 in 2013; RR = 1.16, 95% CI 1.08-1.24 in 2017). Non-Hispanic black (RR = 1.67, 95% CI 1.47-1.90 in 2013; RR = 1.16, 95% CI 1.00-1.35 in 2017) and Hispanic (RR = 1.30, 95% CI 1.17-1.44 in 2013; RR = 1.22, 95% CI 1.09-1.36 in 2017) mothers with self-payment had a higher risk for infant mortality than those with Medicaid at delivery. Newborns whose mothers have no health insurance would be more vulnerable to infant mortality than Medicaid beneficiaries, and non-white ethnic groups with self-payment would have an elevated risk of infant mortality among other racial and ethnic groups.

Structural racism, racial inequities and urban-rural differences in infant mortality in the US

Background

While evidence shows considerable geographic variations in county-level racial inequities in infant mortality, the role of structural racism across urban–rural lines remains unexplored. The objective of this study was to examine the associations between county-level structural racism (racial inequity in educational attainment, median household income and jail incarceration) and infant mortality and heterogeneity between urban and rural areas.

Methods

Using linked live birth/infant death data provided by the National Center for Health Statistics, we calculated overall and race-specific 2013–2017 5-year infant mortality rates (IMRs) per 1000 live births in every county. Racially stratified and area-stratified negative binomial regression models estimated IMR ratios and 95% CIs associated with structural racism indicators, adjusting for county-level confounders. Adjusted linear regression models estimated associations between structural racism indicators and the absolute and relative racial inequity in IMR.

Results

In urban counties, structural racism indicators were associated with 7%–8% higher black IMR, and an overall structural racism score was associated with 9% greater black IMR; however, these findings became insignificant when adjusting for the region. In white population, structural racism indicators and the overall structural racism score were associated with a 6% decrease in urban white IMR. Both absolute and relative racial inequity in IMR were exacerbated in urban counties with greater levels of structural racism.

Conclusions

Our findings highlight the complex relationship between structural racism and population health across urban–rural lines and suggest its contribution to the maintenance of health inequities in urban settings.

Disparities in the usage of maternity leave according to occupation, race/ethnicity, and education

BACKGROUND

Unlike almost all other countries, the United States does not mandate paid maternity leave for mothers. Lack of access to maternity leave may be a risk factor for adverse maternal and child health outcomes. This study sought to assess disparities in the usage of maternity leave according to maternal occupation, race/ethnicity, and education, and to explore the relationships between these factors.

METHODS

We used data from the Pregnancy Risk Assessment Monitoring System from the years 2016 and 2017. We calculated the prevalence of usage of maternity leave and paid maternity leave according to the mother's age, race/ethnicity, education, state, and occupation. We constructed regression models to explore the bivariate and mutually adjusted associations between these factors and usage of maternal leave.

RESULTS

Usage of maternity leave and paid maternity leave were estimated at 89.3% and 49.0%, respectively. Usage of paid maternity leave was lower in younger mothers, in Black and Hispanic mothers, and in mothers with fewer years of education. Workers in several occupations, including building and grounds cleaning and maintenance, personal care, and food preparation and serving, used maternity leave at rates significantly lower than the average of all workers. Adjustment for education and occupation reduced, but did not obviate, racial/ethnic differentials in usage of paid maternity leave.

CONCLUSIONS

There are substantial differentials in usage of maternity leave. Further research could examine whether these differences contribute to disparities in maternal and child health outcomes.

Geographic Hotspots for Low Birthweight: An Analysis of Counties With Persistently High Rates

This study evaluated persistency in county-level rates of low birthweight outcomes to identify “hotspot counties” and their associated area-level characteristics. Administrative data from the National Center for Health Statistics Birth Data Files, years 2011 to 2016 were used to calculate annual county-level rates of low birthweight. Counties ranking in the worst quintile (Q5) for ≥3 years with a neighboring county in the worst quintile were identified as hotspot counties. Multivariate logistic regression was used to associate county-level characteristics with hotspot designation. Adverse birth outcomes were persistent in poor performing counties, with 52% of counties in Q5 for low birthweight in 2011 remaining in Q5 in 2016. The rate of low birthweight among low birthweight hotspot counties (n = 495) was 1.6 times the rate of low birthweight among non-hotspot counties (9.3% vs 5.8%). The rate of very low birthweight among very low birthweight hotspot counties (n = 387) was twice as high compared to non-hotspot counties (1.8% vs 0.9%). A one standard deviation (6.5%) increase in the percentage of adults with at least a high school degree decreased the probability of low birthweight hotspot designation by 1.7 percentage points (P = .006). A one standard deviation (20%) increase in the percentage of the population that was of minority race/ethnicity increased hotspot designation for low birthweight by 5.7 percentage points (P < .001). Given the association between low birthweight and chronic conditions, hotspot counties should be a focus for policy makers in order to improve health equity across the life course.

Regional variation in Black infant mortality: The contribution of contextual factors

BACKGROUND

Compared to other racial/ethnic groups, infant mortality rates (IMR) are persistently highestamong Black infants in the United States, yet there is considerable regional variation. We examined state and county-level contextual factors that may explain regional differences in Black IMR and identified potential strategies for improvement.

METHODS AND FINDINGS

Black infant mortality data are from the Linked Birth/Infant Death files for 2009-2011. State and county contextual factors within social, economic, environmental, and health domains were compiled from various Census databases, the Food Environment Atlas, and the Area Health Resource File. Region was defined by the nine Census Divisions. We examined contextual associations with Black IMR using aggregated county-level Poisson regression with standard errors adjusted for clustering by state. Overall, Black IMR varied 1.5-fold across regions, ranging from 8.78 per 1,000 in New England to 13.77 per 1,000 in the Midwest. In adjusted models, the following factors were protective for Black IMR: higher state-level Black-White marriage rate (rate ratio (RR) per standard deviation (SD) increase = 0.81, 95% confidence interval (CI):0.70-0.95), higher state maternal and child health budget per capita (RR per SD = 0.96, 95% CI:0.92-0.99), and higher county-level Black index of concentration at the extremes (RR per SD = 0.85, 95% CI:0.81-0.90). Modeled variables accounted for 35% of the regional variation in Black IMR.

CONCLUSIONS

These findings are broadly supportive of ongoing public policy efforts to enhance social integration across races, support health and social welfare program spending, and improve economic prosperity. Although contextual factors accounted for about a third of regional variation, further research is needed to more fully understand regional variation in Black IMR disparities.

Association of Low Socioeconomic Status With Premature Coronary Heart Disease in US Adults

Importance

Individuals with low socioeconomic status (SES) bear a disproportionate share of the coronary heart disease (CHD) burden, and CHD remains the leading cause of mortality in low-income US counties.

Objective

To estimate the excess CHD burden among individuals in the United States with low SES and the proportions attributable to traditional risk factors and to other factors associated with low SES.

Design, Setting, and Participants

This computer simulation study used the Cardiovascular Disease Policy Model, a model of CHD and stroke incidence, prevalence, and mortality among adults in the United States, to project the excess burden of early CHD. The proportion of this excess burden attributable to traditional CHD risk factors (smoking, high blood pressure, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, type 2 diabetes, and high body mass index) compared with the proportion attributable to other risk factors associated with low SES was estimated. Model inputs were derived from nationally representative US data and cohort studies of incident CHD. All US adults aged 35 to 64 years, stratified by SES, were included in the simulations.

Exposures

Low SES was defined as income below 150% of the federal poverty level or educational level less than a high school diploma.

Main Outcomes and Measures

Premature (before age 65 years) myocardial infarction (MI) rates and CHD deaths.

Results

Approximately 31.2 million US adults aged 35 to 64 years had low SES, of whom approximately 16 million (51.3%) were women. Compared with individuals with higher SES, both men and women in the low-SES group had double the rate of MIs (men: 34.8 [95% uncertainty interval (UI), 31.0-38.8] vs 17.6 [95% UI, 16.0-18.6]; women: 15.1 [95% UI, 13.4-16.9] vs 6.8 [95% UI, 6.3-7.4]) and CHD deaths (men: 14.3 [95% UI, 13.0-15.7] vs 7.6 [95% UI, 7.3-7.9]; women: 5.6 [95% UI, 5.0-6.2] vs 2.5 [95% UI, 2.3-2.6]) per 10 000 person-years. A higher burden of traditional CHD risk factors in adults with low SES explained 40% of these excess events; the remaining 60% of these events were attributable to other factors associated with low SES. Among a simulated cohort of 1.3 million adults with low SES who were 35 years old in 2015, the model projected that 250 000 individuals (19%) will develop CHD by age 65 years, with 119 000 (48%) of these CHD cases occurring in excess of those expected for individuals with higher SES.

Conclusions and Relevance

This study suggested that, for approximately one-quarter of US adults aged 35 to 64 years, low SES was substantially associated with early CHD burden. Although biomedical interventions to modify traditional risk factors may decrease the disease burden, disparities by SES may remain without addressing SES itself.

Visualizing Opportunity Index Data Using a Dashboard Application: A Tool to Communicate Infant Mortality-Based Area Deprivation Index Information

BACKGROUND

An area deprivation index (ADI) is a geographical measure that accounts for socioeconomic factors (e.g., crime, health, and education). The state of Ohio developed an ADI associated with infant mortality: Ohio Opportunity Index (OOI). However, a powerful tool to present this information effectively to stakeholders was needed.

OBJECTIVES

We present a real use-case by documenting the design, development, deployment, and training processes associated with a dashboard solution visualizing ADI data.

METHODS

The Opportunity Index Dashboard (OID) allows for interactive exploration of the OOI and its seven domains-transportation, education, employment, housing, health, access to services, and crime. We used a user-centered design approach involving feedback sessions with stakeholders, who included representatives from project sponsors and subject matter experts. We assessed the usability of the OID based on the effectiveness, efficiency, and satisfaction dimensions. The process of designing, developing, deploying, and training users in regard to the OID is described.

RESULTS

We report feedback provided by stakeholders for the OID categorized by function, content, and aesthetics. The OID has multiple, interactive components: choropleth map displaying OOI scores for a specific census tract, graphs presenting OOI or domain scores between tracts to compare relative positions for tracts, and a sortable table to visualize scores for specific county and census tracts. Changes based on parameter and filter selections are described using a general use-case. In the usability evaluation, the median task completion success rate was 83% and the median system usability score was 68.

CONCLUSION

The OID could assist health care leaders in making decisions that enhance care delivery and policy decision making regarding infant mortality. The dashboard helps communicate deprivation data across domains in a clear and concise manner. Our experience building this dashboard presents a template for developing dashboards that can address other health priorities.

Spatial Variation in Lung Cancer Mortality and Related Men-Women Disparities in Iran from 2011 to 2014

Purpose

Lung cancer is considered as a common cause of cancer mortality. The disease represents the second and third causes of deaths from cancer among Iranian women and men, respectively. The present study aimed to evaluate the spatial variations in relative risk of lung cancer mortality in Iran and its relation to common risk factors between men and women and specific risk factors among women.

Methods

In this ecological study, the lung cancer mortality data were analyzed in Iran during 2011–2014. Besag, York, and Mollie’s (BYM) model and shared component model (SCM) were used to compare the spatial variations of the relative risk of lung cancer mortality by applying OpenBUGS version 3.2.3 and R version 3.6.1.

Results

The median age for death due to lung cancer in Iran is 74 years. During 2011–2014, the age-standardized lung cancer mortality rates among men and women were 12 and 5 per 100,000 individuals, respectively. In addition, almost similar spatial patterns were observed for both men and women. Further, risk factors, which are shared between men and women, were considered as the main cause of variation of lung cancer mortality relative risk in the regions under study for both men and women. The highest impact of the women-specific risk factors was estimated in northeastern and southwestern of the country while the lowest was related to Gilan province in northern part of Iran.

Conclusion

Based on the spatial pattern, lung cancer risk factors are at relatively high levels in most parts of Iran, especially in the northwest of the country. Regarding the women, the high-risk regions were considerably extended. Further, the highest concentration of the specific risk factors among women was observed in the eastern, central, and southwestern parts. The smoking effect, and the second-smoking effect and environmental pollutions could play more significant roles for men and women, respectively.

Decomposition of the US black/white inequality in premature mortality, 2010-2015: an observational study

OBJECTIVE

Decompose the US black/white inequality in premature mortality into shared and group-specific risks to better inform health policy.

SETTING

All 50 US states and the District of Columbia, 2010 to 2015.

PARTICIPANTS

A total of 2.85 million non-Hispanic white and 762 639 non-Hispanic black US-resident decedents.

PRIMARY AND SECONDARY OUTCOME MEASURES

The race-specific county-level relative risks for US blacks and whites, separately, and the risk ratio between groups.

RESULTS

There is substantial geographic variation in premature mortality for both groups and the risk ratio between groups. After adjusting for median household income, county-level relative risks ranged from 0.46 to 2.04 (median: 1.03) for whites and from 0.31 to 3.28 (median: 1.15) for blacks. County-level risk ratios (black/white) ranged from 0.33 to 4.56 (median: 1.09). Half of the geographic variation in white premature mortality was shared with blacks, while only 15% of the geographic variation in black premature mortality was shared with whites. Non-Hispanic blacks experience substantial geographic variation in premature mortality that is not shared with whites. Moreover, black-specific geographic variation was not accounted for by median household income.

CONCLUSION

Understanding geographic variation in mortality is crucial to informing health policy; however, estimating mortality is difficult at small spatial scales or for small subpopulations. Bayesian joint spatial models ameliorate many of these issues and can provide a nuanced decomposition of risk. Using premature mortality as an example application, we show that Bayesian joint spatial models are a powerful tool as researchers grapple with disentangling neighbourhood contextual effects and sociodemographic compositional effects of an area when evaluating health outcomes. Further research is necessary in fully understanding when and how these models can be applied in an epidemiological setting.

Association of Revised WIC Food Package With Perinatal and Birth Outcomes: A Quasi-Experimental Study

IMPORTANCE

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves more than one-quarter of pregnant and postpartum women. In October 2009, the WIC food package underwent revisions to improve nutritional content. No studies have investigated the downstream effects of this revision on maternal and infant health.

OBJECTIVE

To investigate whether the revised WIC food package improved perinatal and birth outcomes among recipients.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a quasi-experimental difference-in-differences analysis, comparing WIC recipients (the treatment group) before and after the package revisions while accounting for temporal trends among nonrecipients (the control group). Multivariable linear regressions were adjusted for sociodemographic covariates. This study was conducted using linked birth certificate and hospital discharge data from California from January 2007 to December 2012. Analysis began July 2018.

EXPOSURES

Whether pregnant women received the revised WIC package, which included more whole grains, fruit, vegetables, and low-fat milk.

MAIN OUTCOMES AND MEASURES

Measures of maternal and infant health, including maternal preeclampsia, gestational diabetes, and gestational weight gain as well as infant gestational age, birth weight, and hospitalizations.

RESULTS

The sample included 2 897 537 infants born to 2 441 658 mothers. WIC recipients were more likely to be Hispanic, less educated, of greater parity, and younger than nonrecipients. The revised WIC food package was associated with reductions in maternal preeclampsia (-0.6% points; 95% CI, -0.8 to -0.4) and more than recommended gestational weight gain (-3.2% points; 95% CI, -3.6 to -2.7), increased likelihood of as recommended (2.3% points; 95% CI, 1.8 to 2.8) and less than recommended (0.9% points; 95% CI, 0.5 to 1.2) gestational weight gain, and longer gestational age (0.2 weeks; 95% CI, 0.001 to 0.034). Among infants, an increased likelihood of birth weight that was appropriate for gestational age was observed (0.9% points; 95% CI, 0.5 to 1.3). Although birth weight itself was reduced (-0.009 SDs; 95% CI, -0.016 to -0.001), this was accompanied by reductions in small for gestational age (-0.4% points; 95% CI, -0.7 to -0.1), large for gestational age (-0.5% points; 95% CI, -0.8 to -0.2), and low-birth-weight infants (-0.2% points; 95% CI, -0.4 to -0.004), suggesting that the revised food package improved distributions of birth weight.

CONCLUSIONS AND RELEVANCE

The revised WIC food package, intended to improve women's nutrition during pregnancy, was associated with beneficial impacts on maternal and child health. This suggests that WIC policy may be an important lever to reduce health disparities among high-risk women and children at a critical juncture in the life course.

Ecuadorian infant mortality linked to socioeconomic factors during the last 30 years

Abstract Objectives: to analyze the difference among geographical units and the evolution of infant mortality rate (IMR) based on Ecuadorian censuses (1990-2001-2010). Methods: artificial Neural Network analyzed the impact of sociodemographic factors over the variability of IMR. Poisson regression analyzed the variation of the standardized IMR (sIMR). Results: the decrease in the national IMR was 63.8%; however, 42.8% provinces showed an increase in 2001-2010. The variability was explained mainly by illiteracy decrease. The adjusted RR between provincial sIMR with illiteracy and poverty revealed a trend towards the unit. Conclusions: the variation of IMR reflects a complex interaction of the sociodemographic factors.

Greenspace and Infant Mortality in Philadelphia, PA

Despite mounting evidence that urban greenspace protects against mortality in adults, few studies have explored the relationship between greenspace and death among infants. Here, we describe results from an analysis of associations between greenness and infant mortality in Philadelphia, PA. We used images of the normalized difference vegetation index (NDVI), derived from processed satellite data, to estimate greenness density in each census tract. We linked these data with census tract level counts of total infant mortality cases (n = 963) and births (n = 113,610) in years 2010-2014, and used Bayesian spatial areal unit, conditional autoregressive models to estimate associations between greenness and infant mortality. The models included a set of random effects to account for spatial autocorrelation between neighboring census tracts. Infant mortality counts were modeled using a Poisson distribution, and the logarithm of total births in each census tract was specified as the offset term. The following variables were included as potential confounders and effect modifiers: percentage non-Hispanic black, percentage living below the poverty line, an indicator of housing quality, and population density. In adjusted models, the rate of infant mortality was 27% higher in less green compared to more green tracts (95% CI 1.02-1.59). These results contribute further evidence that greenspace may be a health promoting environmental asset.

Understanding, justifying, and optimizing radiation exposure for CT imaging in nephrourology

An estimated 4-5 million CT scans are performed in the USA every year to investigate nephrourological diseases such as urinary stones and renal masses. Despite the clinical benefits of CT imaging, concerns remain regarding the potential risks associated with exposure to ionizing radiation. To assess the potential risk of harmful biological effects from exposure to ionizing radiation, understanding the mechanisms by which radiation damage and repair occur is essential. Although radiation level and cancer risk follow a linear association at high doses, no strong relationship is apparent below 100 mSv, the doses used in diagnostic imaging. Furthermore, the small theoretical increase in risk of cancer incidence must be considered in the context of the clinical benefit derived from a medically indicated CT and the likelihood of cancer occurrence in the general population. Elimination of unnecessary imaging is the most important method to reduce imaging-related radiation; however, technical aspects of medically justified imaging should also be optimized, such that the required diagnostic information is retained while minimizing the dose of radiation. Despite intensive study, evidence to prove an increased cancer risk associated with radiation doses below ~100 mSv is lacking; however, concerns about ionizing radiation in medical imaging remain and can affect patient care. Overall, the principles of justification and optimization must remain the basis of clinical decision-making regarding the use of ionizing radiation in medicine.

Impacts of the Regional Greenhouse Gas Initiative (RGGI) on infant mortality: a quasi-experimental study in the USA, 2003-2014

OBJECTIVES

The Regional Greenhouse Gas Initiative (RGGI) is the first mandatory market-based regulatory programme to limit regional carbon dioxide (CO₂) emissions in the USA. Empirical evidence has shown that high concentrations of ambient air pollutants such as CO₂ have been positively associated with an increased risk of morbidity (eg, respiratory conditions including asthma and lung cancer) and premature mortality. The purpose of this study was to examine the impacts of RGGI on death rates in infancy.

DESIGN

A quasi-experimental difference-in-differences design.

SETTING AND PARTICIPANTS

We estimated the impacts of RGGI on infant mortality from 2003 through 2014 in the USA (6 years before and after RGGI implementation). Our analytic models included state- and year-fixed effects in addition to a number of covariates.

OUTCOME MEASURES

Death rates in infancy: neonatal mortality rates (NMRs), deaths under 28 days as well as infant mortality rates (IMRs), deaths under 1 year.

RESULTS

Implementation of RGGI was associated with significant decreases in overall NMRs (a reduction of 0.41/1000 live births) and male NMRs (a reduction of 0.43/1000 live births). However, RGGI did not have a significant effect on female NMRs. Similarly, overall IMRs and male IMRs decreased significantly by 0.37/1000 live births and 0.61/1000 live births, respectively, after implementation of RGGI while female IMRs were not significantly affected by RGGI.

CONCLUSIONS

RGGI was associated with decreases in overall infant mortality and boy mortality through reducing air pollutant concentrations. Of note, the impact of this environmental policy on infant girls was much smaller.

Psychosocial Adversity in Infancy and Mortality Rates in Childhood and Adolescence: A Birth Cohort Study of 1.5 Million Individuals

BACKGROUND

Childhood and adolescent mortality accounts for a substantial proportion of years lost prematurely. Reducing childhood and adolescent mortality relies on knowing characteristics of those at elevated risk of dying young. We therefore aimed to identify such characteristics; our main hypothesis is that psychosocial adversity in infancy is linked to increased mortality rates in childhood and adolescence.

METHODS

We conducted a register-based cohort study involving all 1,549,581 children born to Danish-born parents in Denmark between 1 January 1981 and 31 December 2010. For each infant, we extracted data relevant to Rutter's indicators of adversity (low social class, parents not cohabiting, large family size, paternal criminality, maternal mental disorder, and placement in out-of-home care). Follow-up began on the cohort member's first birthday. We estimated the association between adversity score (the number of Rutter's indicators of adversity present in infancy) and death via. Cox regression.

RESULTS

During follow-up (18,874,589 person-years), 2,081 boys and 1,420 girls died before or on their 18th birthday. The hazard ratios for death were 2.3 (95% CI = 1.9, 2.9) and 2.1 (95% CI = 1.6, 2.7) for boys and girls with adversity scores of 3-6 compared with those with a score of 0. These associations were driven by causes of death with known links to psychosocial adversity.

CONCLUSION

While absolute mortality rates were low, infants with adversity scores of 3-6 were approximately twice as likely to die prematurely compared with infants with adversity scores of 0. Whether these associations generalize to other countries should be subjected to further study.

Pockets of progress amidst persistent racial disparities in low birthweight rates

Racial disparities persist in adverse perinatal outcomes such as preterm birth, low birthweight (LBW), and infant mortality across the U.S. Although pervasive, these disparities are not universal. Some communities have experienced significant improvements in black (or African American) birth outcomes, both in absolute rates and in rate ratios relative to whites. This study assessed county-level progress on trends in black and white LBW rates as an indicator of progress toward more equal birth outcomes for black infants. County-level LBW data were obtained from the 2003 to 2013 U.S. Natality files. Black LBW rates, black-white rate ratios and percent differences over time were calculated. Trend lines were first assessed for significant differences in slope (i.e., converging, diverging, or parallel trend lines). For counties with parallel trend lines, intercepts were tested for statistically significant differences (sustained equality vs. persistent disparities). To assess progress, black LBW rates were compared to white LBW rates, and the trend lines were tested for significant decline. Each county's progress toward black-white equality was ultimately categorized into five possible trend patterns (n = 408): (1) converging LBW rates with reductions in the black LBW rate (decreasing disparities, n = 4, 1%); (2) converging LBW rates due to worsening white LBW rates (n = 5, 1%); (3) diverging LBW rates (increasing disparities, n = 9, 2%); (4) parallel LBW rates (persistent disparities, n = 373, 91%); and (5) overlapping trend lines (sustained equality, n = 18, 4%). Only four counties demonstrated improvement toward equality with decreasing black LBW rates. There is significant county-level variation in progress toward racial equality in adverse birth outcomes such as low birthweight. Still, some communities are demonstrating that more equitable outcomes are possible. Further research is needed in these positive exemplar communities to identify what works in accelerating progress toward more equal birth outcomes.

Mapping integration of midwives across the United States: Impact on access, equity, and outcomes

METHODS

Our multidisciplinary team examined published regulatory data to inform a 50-state database describing the environment for midwifery practice and interprofessional collaboration. Items (110) detailed differences across jurisdictions in scope of practice, autonomy, governance, and prescriptive authority; as well as restrictions that can affect patient safety, quality, and access to maternity providers across birth settings. A nationwide survey of state regulatory experts (n = 92) verified the 'on the ground' relevance, importance, and realities of local interpretation of these state laws. Using a modified Delphi process, we selected 50/110 key items to include in a weighted, composite Midwifery Integration Scoring (MISS) system. Higher scores indicate greater integration of midwives across all settings. We ranked states by MISS scores; and, using reliable indicators in the CDC-Vital Statistics Database, we calculated correlation coefficients between MISS scores and maternal-newborn outcomes by state, as well as state density of midwives and place of birth. We conducted hierarchical linear regression analysis to control for confounding effects of race.

RESULTS

MISS scores ranged from lowest at 17 (North Carolina) to highest at 61 (Washington), out of 100 points. Higher MISS scores were associated with significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean, and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. MISS scores also correlated with density of midwives and access to care across birth settings. Significant differences in newborn outcomes accounted for by MISS scores persisted after controlling for proportion of African American births in each state.

CONCLUSION

The MISS scoring system assesses the level of integration of midwives and evaluates regional access to high quality maternity care. In the United States, higher MISS Scores were associated with significantly higher rates of physiologic birth, less obstetric interventions, and fewer adverse neonatal outcomes.

State-Level Progress in Reducing the Black-White Infant Mortality Gap, United States, 1999-2013

OBJECTIVES

To assess state-level progress on eliminating racial disparities in infant mortality.

METHODS

Using linked infant birth-death files from 1999 to 2013, we calculated state-level 3-year rolling average infant mortality rates (IMRs) and Black-White IMR ratios. We also calculated percentage improvement and a projected year for achieving equality if current trend lines are sustained.

RESULTS

We found substantial state-level variation in Black IMRs (range = 6.6-13.8) and Black-White rate ratios (1.5-2.7), and also in percentage relative improvement in IMR (range = 2.7% to 36.5% improvement) and in Black-White rate ratios (from 11.7% relative worsening to 24.0% improvement). Thirteen states achieved statistically significant reductions in Black-White IMR disparities. Eliminating the Black-White IMR gap would have saved 64 876 babies during these 15 years. Eighteen states would achieve IMR racial equality by the year 2050 if current trends are sustained.

CONCLUSIONS

States are achieving varying levels of progress in reducing Black infant mortality and Black-White IMR disparities. Public Health Implications. Racial equality in infant survival is achievable, but will require shifting our focus to determinants of progress and strategies for success.