Neighbourhood deprivation and small-for-gestational-age term births in the United States

The Contribution of Neighborhood Context to the Association of Race with Severe Maternal Morbidity

OBJECTIVE

Severe maternal morbidity (SMM) has disproportionate frequencies among racial minorities and those of socioeconomic disadvantage, with people of Black race consistently having the highest proportion. Neighborhood level deprivation has been associated with maternal morbidity and mortality, including adverse pregnancy outcomes. We sought to explore the relationship between neighborhood socioeconomic disadvantage and SMM and describe how neighborhood context impacts the relationship between race and SMM.

STUDY DESIGN

We performed a retrospective cohort analysis of all delivery admissions in a single health care network from 2015 to 2019. Area deprivation index (ADI) was used to represent neighborhood socioeconomic disadvantage and is a composite index of neighborhood that spans income, education, household characteristics, and housing. The index ranges from 1 to 100 with higher values indicating higher disadvantage. Logistic regression assessed the relationship between ADI and SMM and estimated the effect that ADI has on the relationship between race and SMM.

RESULTS

Of the 63,208 birthing persons in our cohort, the unadjusted incidence of SMM was 2.2%. ADI was significantly associated with SMM, with higher values conferring higher risk for SMM (p < 0.001). The absolute risk of SMM increased roughly by 1.0% from the lowest to highest ADI value. Those of Black race had the highest unadjusted incidence of SMM compared with the referent group (3.4 vs. 2.0%) and highest median ADI (92; interquartile range [IQR]: 20). In the multivariable model, in which the primary exposure was race and ADI was adjusted for, Black race had a 1.7 times odds SMM when compared with White race (95% confidence interval [CI]: 1.5-1.9). This association was attenuated to 1.5 adjusted odds when controlling for ADI (95% CI: 1.3-1.7). Risk attenuation for SMM was not seen in other race categories.

CONCLUSION

Neighborhood context contributes to SMM but does not explain the majority of racial disparities.

KEY POINTS

· Neighborhood context is associated with SMM, with higher disadvantage conferring higher risk.. · Compared with White race, all other races had higher rates of SMM, with Black race having the highest.. · Accounting for neighborhood modestly attenuates the magnitude of association of Black race with SMM.. · Neighborhood context contributes to health outcomes but does not explain the majority of disparities..

Neighborhood Socioeconomic Disadvantage and Abnormal Birth Weight

OBJECTIVE

To examine whether exposure to community or neighborhood socioeconomic disadvantage as measured by the ADI (Area Deprivation Index) is associated with risk of abnormal birth weight among nulliparous individuals with singleton gestations.

METHODS

This was a secondary analysis from the prospective cohort NuMoM2b study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be). Participant addresses at cohort enrollment between 6 and 13 weeks of gestation were geocoded at the Census tract level and linked to the 2015 ADI. The ADI, which incorporates the domains of income, education, employment, and housing quality into a composite national ranking of neighborhood socioeconomic disadvantage, was categorized by quartiles (quartile 1, least disadvantaged, reference; quartile 4, most disadvantaged). Outcomes were large for gestational age (LGA; birth weight at or above the 90th percentile) and small for gestational age (SGA; birth weight below the 10th percentile) compared with appropriate for gestational age (AGA; birth weight 10th-90th percentile) as determined with the 2017 U.S. natality reference data, standardized for fetal sex. Multinomial logistic regression models were adjusted for potential confounding variables.

RESULTS

Of 8,983 assessed deliveries in the analytic population, 12.7% (n=1,143) were SGA, 8.2% (n=738) were LGA, and 79.1% (n=7,102) were AGA. Pregnant individuals living in the highest ADI quartile (quartile 4, 17.8%) had an increased odds of delivering an SGA neonate compared with those in the lowest referent quartile (quartile 1, 12.4%) (adjusted odds ratio [aOR] 1.32, 95% CI 1.09-1.55). Pregnant individuals living in higher ADI quartiles (quartile 2, 10.3%; quartile 3, 10.7%; quartile 4, 9.2%) had an increased odds of delivering an LGA neonate compared with those in the lowest referent quartile (quartile 1, 8.2%) (aOR: quartile 2, 1.40, 95% CI 1.19-1.61; quartile 3, 1.35, 95% CI 1.09-1.61; quartile 4, 1.47, 95% CI 1.20-1.74).

CONCLUSION

Neonates of nulliparous pregnant individuals living in U.S. neighborhoods with higher area deprivation were more likely to have abnormal birth weights at both extremes.

Neighborhood Deprivation and Neural Tube Defects

BACKGROUND

Individual measures of socioeconomic status (SES) have been associated with an increased risk of neural tube defects (NTDs); however, the association between neighborhood SES and NTD risk is unknown. Using data from the National Birth Defects Prevention Study (NBDPS) from 1997 to 2011, we investigated the association between measures of census tract SES and NTD risk.

METHODS

The study population included 10,028 controls and 1829 NTD cases. We linked maternal addresses to census tract SES measures and used these measures to calculate the neighborhood deprivation index. We used generalized estimating equations to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) estimating the impact of quartiles of census tract deprivation on NTDs adjusting for maternal race-ethnicity, maternal education, and maternal age at delivery.

RESULTS

Quartiles of higher neighborhood deprivation were associated with NTDs when compared with the least deprived quartile (Q2: aOR = 1.2; 95% CI = 1.0, 1.4; Q3: aOR = 1.3, 95% CI = 1.1, 1.5; Q4 (highest): aOR = 1.2; 95% CI = 1.0, 1.4). Results for spina bifida were similar; however, estimates for anencephaly and encephalocele were attenuated. Associations differed by maternal race-ethnicity.

CONCLUSIONS

Our findings suggest that residing in a census tract with more socioeconomic deprivation is associated with an increased risk for NTDs, specifically spina bifida.

Explaining the Link Between Paternal Socioeconomic Position and Small for Gestational Age Birth: The Effect of Maternal Unhealthy Behaviors

OBJECTIVE

To determine the proportion of small for gestational age (weight < 10th percentile, SGA) births among fathers with lifelong low (compared to high) socioeconomic position (SEP) attributable to white and African-American women's unhealthy pregnancy-related behaviors.

METHODS

Oaxaca-Blinder decomposition methods were conducted on the Illinois transgenerational dataset of infants (1989-1991) and their Chicago-born parents (1956-1976) with appended US census income data. The neighborhood income of father's residence at the time of his birth and at the time of his infant's birth were used to estimate his lifetime SEP. Maternal unhealthy pregnancy-related behaviors were defined as cigarette smoking, inadequate prenatal care, and/or low weight gain during pregnancy.

RESULTS

Among African-American women, births (n = 4426) to fathers with lifetime low SEP had an SGA rate of 14.8% compared to 12.1% for those (n = 365) born to fathers with lifetime high SEP (p < 0.0001). Among white women, births (n = 1430) to fathers with lifetime low SEP had an SGA rate of 9.8% compared to 6.2% for those (n = 9141) born to fathers with lifetime high SEP (p < 0.0001). Adjusting for maternal age, marital status, education, and parity, African-American and white women's unhealthy pregnancy behaviors accounted for 25% and 33%, respectively, of the disparity in SGA rates among infants of lifetime low (compared to high) SEP fathers.

CONCLUSION

A significant proportion of the disparity in SGA rates between fathers with lifelong low (compared to high) SEP is explained in both races by maternal unhealthy pregnancy behaviors.

Are individual-level risk factors for gastroschisis modified by neighborhood-level socioeconomic factors?

BACKGROUND

Two strong risk factors for gastroschisis are young maternal age (<20 years) and low/normal pre-pregnancy body mass index (BMI), yet the reasons remain unknown. We explored whether neighborhood-level socioeconomic position (nSEP) during pregnancy modified these associations.

METHODS

We analyzed data from 1269 gastroschisis cases and 10,217 controls in the National Birth Defects Prevention Study (1997-2011). To characterize nSEP, we applied the neighborhood deprivation index and used generalized estimating equations to calculate odds ratios and relative excess risk due to interaction.

RESULTS

Elevated odds of gastroschisis were consistently associated with young maternal age and low/normal BMI, regardless of nSEP. High-deprivation neighborhoods modified the association with young maternal age. Infants of young mothers in high-deprivation areas had lower odds of gastroschisis (adjusted odds ratio [aOR]: 3.1, 95% confidence interval [CI]: 2.6, 3.8) than young mothers in low-deprivation areas (aOR: 6.6; 95% CI: 4.6, 9.4). Mothers of low/normal BMI had approximately twice the odds of having an infant with gastroschisis compared to mothers with overweight/obese BMI, regardless of nSEP (aOR range: 1.5-2.3).

CONCLUSION

Our findings suggest nSEP modified the association between gastroschisis and maternal age, but not BMI. Further research could clarify whether the modification is due to unidentified biologic and/or non-biologic factors.

Maternal exposure to childhood maltreatment and adverse birth outcomes

Exposure to traumatic events during pregnancy may influence pregnancy and birth outcomes. Growing evidence suggests that exposure to traumatic events well before pregnancy, such as childhood maltreatment (CM), also may influence the course of pregnancy and risk of adverse birth outcomes. We aimed to estimate associations between maternal CM exposure and small-for-gestational-age birth (SGA) and preterm birth (PTB) in a diverse US sample, and to examine whether common CM-associated health and behavioral sequelae either moderate or mediate these associations. The Measurement of Maternal Stress (MOMS) Study was a prospective cohort study that enrolled 744 healthy English-speaking participants ≥ 18 years with a singleton pregnancy, who were < 21 weeks at enrollment, between 2013 and 2015. CM was measured via the Childhood Trauma Questionnaire (CTQ) and participants above the moderate/severe cut-off for any of the five childhood abuse and neglect scales were assigned to the CM-exposed group. Common CM-associated health (obesity, depressive symptoms, hypertensive disorders) and behavioral (substance use) sequelae were obtained from standardized questionnaires and medical records. The main outcomes included PTB (gestational age < 37 weeks at birth) and SGA (birthweight < 10%ile for gestational age) abstracted from the medical record. Multivariable logisitic regression was used to test associations between CM, sequeale, and birth outcomes, and both moderation and mediation by CM-related sequelae were tested. Data were available for 657/744 participants. Any CM exposure was reported by 32% of participants. Risk for SGA birth was 61% higher among those in the CM group compared to the non-CM group (14.1% vs. 7.6%), and each subsequent form of CM that an individual was exposed to corresponded with a 27% increased risk for SGA (aOR 1.27, 95% CI 1.05, 1.53). There was no significant association between CM and PTB (9.3% vs. 13.0%, aOR 1.07, 95% CI 0.58, 1.97). Of these sequelae only hypertensive disorders were associated with both CM and SGA and hypertensive disorders of pregnancy did not mediate the association between CM and SGA. Our findings indicate that maternal CM exposure is associated with increased risk for SGA birth and highlight the importance of investigating the mechanisms whereby childhood adversity sets the trajectory for long-term and intergenerational health issues.

Assessing community-level exposure to social vulnerability and isolation: spatial patterning and urban-rural differences

BACKGROUND

Environmental health disparity research involves the use of metrics to assess exposure to community-level vulnerabilities or inequities. While numerous vulnerability indices have been developed, there is no agreement on standardization or appropriate use, they have largely been applied in urban areas, and their interpretation and utility likely vary across different geographies.

OBJECTIVE

We evaluated the spatial distribution, variability, and relationships among different metrics of social vulnerability and isolation across urban and rural settings to inform interpretation and selection of metrics for environmental disparity research.

METHODS

For all census tracts in North Carolina, we conducted a principal components analysis using 23 socioeconomic/demographic variables from the 2010 United States Census and American Community Survey. We calculated or obtained the neighborhood deprivation index (NDI), residential racial isolation index (RI), educational isolation index (EI), Gini coefficient, and social vulnerability index (SVI). Statistical analyses included Moran's I for spatial clustering, t-tests for urban-rural differences, Pearson correlation coefficients, and changes in ranking of tracts across metrics.

RESULTS

Social vulnerability metrics exhibited clear spatial patterning (Moran's I ≥ 0.30, p < 0.01). Greater educational isolation and more intense neighborhood deprivation was observed in rural areas and greater racial isolation in urban areas. Single-domain metrics were not highly correlated with each other (rho ≤ 0.36), while composite metrics (i.e., NDI, SVI, principal components analysis) were highly correlated (rho > 0.80). Composite metrics were more highly correlated with the racial isolation metric in urban (rho: 0.54-0.64) versus rural tracts (rho: 0.36-0.48). Census tract rankings changed considerably based on which metric was being applied.

SIGNIFICANCE

High correlations between composite metrics within urban and rural tracts suggests they could be used interchangeably; single domain metrics cannot. Composite metrics capture different facets of vulnerabilities in urban and rural settings, and these complexities should be examined by researchers applying metrics to areas of diverse urban and rural forms.

A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms

Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.

The intersection of race and socioeconomic status is associated with inflammation patterns during pregnancy and adverse pregnancy outcomes

BACKGROUND

Preterm birth rates are higher among individuals of lower socioeconomic status and non-White race, which is possibly related to life-course stressors. It is important to better understand the underlying mechanisms of these health disparities, and inflammation is a possible pathway to explain the disparities in birth outcomes.

OBJECTIVE

In this study, we aimed to determine whether patterns of inflammation differed by maternal race and socioeconomic status.

STUDY DESIGN

744 participants in a multi-site, prospective study of pregnancy and birth outcomes provided biological and psychological data between 12'0-20'6 weeks gestation. Participants with recent infection, fever, antibiotics or steroid treatment were excluded. Cytokines including INFɣ, IL-10, IL-13, IL-6, IL-8, and TNFα, and the acute phase protein CRP were measured in serum and values and were log-transformed for normality when appropriate and a non-orthogonal rotation (Oblimid) was performed to allow the extracted factor to inter-correlate. IFNγ, IL-8, IL-10, IL-6, TNF-a, and IL-13 loaded onto Inflammatory Factor 1 (IF-1), while CRP and IL-6 loaded onto Inflammatory Factor 2 (IF-2). Race and education were collected via self-report during an in-person study visit. Multivariable models were used to determine the association of race and SES with IF-1 and IF-2 during the second trimester, and a mediation model to examine if inflammation is on the causal pathway. Models were adjusted for study site, prenatal age, pre-pregnancy BMI, smoking during pregnancy, and gestational age at the time of blood collection.

RESULTS

605 participants were included in our final analysis, with 61.2 % of low or moderate SES, and 35.5% identifying as a person of color (POC). Identifying as a POC, being of low and moderate SES, and being both low-SES and POC or Moderate-SES and POC were associated with higher odds of preterm birth and lower birth weight percentile infants. Low SES POC participants had significantly higher IF-1 and IF-2 scores when compared to high-SES White participants. Additionally, higher IF-1and IF-2 were associated with shorter gestation. In the mediation analysis, we observed a significant direct effect of race/SES on preterm birth, however the results did not support an indirect pathway where IF-1 or IF-2 acted as mediators.

CONCLUSION

Maternal race and SES are significantly associated with inflammatory biomarkers during pregnancy, and when race and SES are considered in combination, they are stronger predictors of adverse pregnancy outcomes than when evaluated separately. This article is protected by copyright. All rights reserved.

Using principal component analysis to examine associations of early pregnancy inflammatory biomarker profiles and adverse birth outcomes

OBJECTIVE

Inflammation as a risk factor for preterm birth is well-established. The primary objective of this analysis was to examine whether individual cytokines versus a composite indicator of mid-pregnancy inflammation are significantly associated with risk for adverse birth outcomes.

STUDY DESIGN

A multi-site prospective study was conducted in a socio-demographically diverse cohort of 610 pregnant participants. At a study visit between 12 and 20 6/7 weeks' gestation, low-grade inflammation was measured via log-transformed serum concentrations of the biomarkers IFN-γ, IL-10, IL-13, IL-6, IL-8, TNF-α, and CRP. Principal component analysis (PCA) was used to identify underlying dimensions of inflammatory activity from the seven biomarkers measured. Gestational age and birth weight at delivery were obtained from medical chart review. The associations between inflammatory profiles and birth outcomes were assessed via linear and logistic regression models. Results were compared with those from individual inflammatory biomarkers, and model fit was assessed using Akaike's Information Criterion (AIC).

RESULTS

Principal component analysis analysis yielded a two-factor solution, with the first factor (IF1) composed of IL-8, IL-10, IL-13, IFN-ɣ, and TNF-α, and the second factor (IF2) containing IL-6 and CRP. When adjusted for race, education, BMI, smoking status, gestational age at time of blood draw, and study site, a one standard deviation (SD) increase in IF1 remained significantly associated with a decrease in standardized gestational age (β = -.13, 95% CI: -.21, -.05) and an increase in odds of preterm delivery (OR = 1.46, 95% CI: 1.13, 1.88) (Table 3). A one SD increase in IF2 was similarly associated with a decrease in standardized gestational age at delivery (β = -.13, 95% CI: -.23, -.04) and an increase in odds of preterm delivery (OR: 1.46, 95% CI: 1.04, 2.05). Neither IF1 nor IF2 was associated with measures of fetal growth. AIC identified that IL-6 was a slightly better fit for length of gestation compared to either composite measure, though all performed similarly.

CONCLUSION

Independent of known sociodemographic risk factors, an elevated mid-pregnancy inflammatory profile was associated with a nearly 50% increase in odds of preterm delivery. The composite performed similarly to IL-6. These results suggest that maternal low-grade inflammation is a risk factor for preterm delivery, and that mid-pregnancy inflammatory biomarkers may be useful in predicting risk for preterm delivery.

Non-Hispanic White Women's Exposure to Decreased Neighborhood Income and Small for Gestational Age Births: A Population-Based Study

BACKGROUND

The relationship between non-Hispanic White (NHW) women's decreased neighborhood income between early-life and adulthood, individual risk-status at delivery, and small for gestational age (weight for gestation < 10th percentile, SGA) rates is unknown.

OBJECTIVE

To determine the extent to which NHW women's exposure to decreased neighborhood income is a risk factor for SGA births, and whether their own birth weight modifies this relationship.

METHODS

Stratified and multilevel logistic regression analyses were executed on the Illinois transgenerational dataset of mothers (born 1956-1976) and their infants (born 1989-1991) with appended U.S. census income information. Only NHW women with an early-life residence in top income quartile Chicago neighborhoods were studied.

RESULTS

NHW women (n = 4889) unexposed to decreased neighborhood income between early-life and adulthood had an SGA rate of 7.1%. In contrast, NHW women exposed to slightly (n = 5112), modestly (n = 2158), or severely (n = 339) decreased neighborhood income by the time of delivery had SGA rates of 8.2%, 10.8%, and 10.8%, respectively; RR (95% CI) equaled 1.2 (1.0-1.3), 1.5 (1.3-1.8) and 1.5 (1.1-2.1), respectively. The relationship between maternal exposure to modestly decreased neighborhood income and SGA rates was present only among former non-low birth weight (> 2500 g, non-LBW) mothers. In multilevel logistic regression models, the adjusted (controlling for age, parity, prenatal care usage, and cigarette smoking) OR of SGA birth for former low birth weight (< 2500 g, LBW) and non-LBW NHW women exposed to modestly (compared to no) decreased neighborhood income equaled 0.7 (0.4, 1.4) and 1.3 (1.1-1.6), respectively.

CONCLUSIONS FOR PRACTICE

NHW women's exposure to modestly decreased neighborhood income is associated with an increased risk of SGA birth; this phenomenon is absent among former low birth weight women.

Longitudinal measures of neighborhood poverty and income inequality are associated with adverse birth outcomes in Texas

BACKGROUND

Inequity in adverse birth outcomes between black and white women in the U.S. is persistent, despite decades of research and prevention efforts. Neighborhood environments are plausibly related to pre-pregnancy health and other risk factors for adverse birth outcomes and may help explain black/white inequities. Despite the fact that neighborhoods change over time, most prior work has relied upon cross-sectional measures of neighborhood economic contexts.

METHODS

We used birth certificates for non-Hispanic black and white women in Texas (2009-2011, N = 470,896) to examine whether longitudinal measures of neighborhood economic context (poverty and income inequality, based on census tract data from 1990 to 2010) were associated with preterm birth, low birthweight and small-for-gestational-age (SGA) with hierarchical generalized linear models. We also tested whether (1) the longitudinal measures explained black/white inequities or (2) moderated the effect of race on the birth outcomes. Finally, we compared the models with longitudinal measures to models with cross-sectional measures of neighborhood economic context.

RESULTS

Longitudinal measures of neighborhood economic context were associated with all three birth outcomes, but did not explain racial inequities. Except for income inequality and SGA, there was no evidence of moderation by race. Substituting cross-sectional measures of economic context for longitudinal ones resulted in similar findings.

CONCLUSION

Policies that either address structural neighborhood-level economic disadvantage or mitigate the effects of such disadvantage are warranted to improve the health of mothers and prevent adverse birth outcomes.

Air pollution, neighborhood deprivation, and autism spectrum disorder in the Study to Explore Early Development

Background

To examine whether neighborhood deprivation modifies the association between early life air pollution exposure and autism spectrum disorder (ASD), we used resources from a multisite case-control study, the Study to Explore Early Development.

Methods

Cases were 674 children with confirmed ASD born in 2003-2006; controls were 855 randomly sampled children born during the same time period and residents of the same geographic areas as cases. Air pollution was assessed by roadway proximity and particulate matter <2.5 μm (PM_2.5) exposure during pregnancy and first year of life. To characterize neighborhood deprivation, an index was created based on eight census tract-level socioeconomic status-related parameters. The continuous index was categorized into tertiles, representing low, moderate, and high deprivation. Logistic regression was used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs).

Results

Neighborhood deprivation modified (P _{for interaction} = 0.08) the association between PM_2.5 exposure during the first year of life and ASD, with a stronger association for those living in high (OR = 2.42, 95% CI = 1.20, 4.86) rather than moderate (OR=1.21, 95% CI = 0.67, 2.17) or low (OR=1.46, 95% CI = 0.80, 2.65) deprivation neighborhoods. Departure from additivity or multiplicativity was not observed for roadway proximity or exposures during pregnancy.

Conclusion

These results provide suggestive evidence of interaction between neighborhood deprivation and PM_2.5 exposure during the first year of life in association with ASD.

Economic Downturns and Inequities in Birth Outcomes: Evidence From 149 Million US Births

Using birth certificate data for nearly all registered US births from 1976 to 2016 and monthly data on state unemployment rates, we reexamined the link between macroeconomic variation and birth outcomes. We hypothesized that economic downturns reduce exposure to work-related stressors and pollution while increasing exposure to socioeconomic stressors like job loss. Because of preexisting inequalities in health and other resources, we expected that less-educated mothers and black mothers would be more exposed to macroeconomic variation. Using fixed-effect regression models, we found that a 1-percentage-point increase in state unemployment during the first trimester of pregnancy increased the probability of preterm birth by 0.1 percentage points, while increases in the state unemployment rate during the second/third trimester reduced the probability of preterm birth by 0.06 percentage points. During the period encompassing the Great Recession, the magnitude of these associations doubled in size. We found substantial variation in the impact of economic conditions across different groups, with highly educated white women least affected and less-educated black women most affected. The results highlight the increased relevance of economic conditions for birth outcomes and population health as well as continuing, large inequities in the exposure and impact of macroeconomic fluctuations on birth outcomes.

Personal Versus Group Experiences of Racism and Risk of Delivering a Small-for-Gestational Age Infant in African American Women: a Life Course Perspective

The majority of studies investigating the relationship between racism/racial discrimination and birth outcomes have focused on perceived experiences of racism/racial discrimination directed at oneself (personal racism). However, evidence suggests individuals report with greater frequency racism/racial discrimination directed at friends, family members, or other members of their racial/ethnic group (group racism). We examined how much African American (AA) women report lifetime experiences of perceived racism or racial discrimination, both personal and group, varied by maternal age. We also investigated whether reports of personal and group racism/racial discrimination were associated with the risk of delivering a small-for-gestational age (SGA) infant and how much maternal age in relation to developmental life stages (adolescence [≤ 18 years], emerging adulthood [19-24 years], and adulthood [≥ 25 years]) moderated the relationship. Data stem from the Baltimore Preterm Birth Study, a hybrid prospective/retrospective cohort study that enrolled 872 women between March 2000 and July 2004 (analyzed in 2016-2017). Spline regression analyses demonstrated a statistically significant (p value for overall association < 0.001) and non-linear (p value = 0.044) relationship between maternal age and the overall racism index. Stratified analysis showed experiences of racism overall was associated with a higher odds ratio of delivering an SGA infant among AA women aged ≥ 25 years (OR = 1.45, 95% CI 1.02-2.08). The overall racism index was not associated with the SGA infant odds ratio for emerging adults (OR = 0.86, 95% CI 0.69-1.06) or adolescents (OR = 0.92, 95% CI 0.66-1.28). Multiple aspects of racism and the intersection between racism and other contextual factors need to be considered.

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.

African-American women's Upward Economic Mobility and Small for Gestational Age Births: A Population-Based Study

Background The relationship between African-American women's upward economic mobility and small for gestational age (weight for gestational < 10th percentile, SGA) rates is incompletely understood. Objective To ascertain the extent to which African-American women's upward economic mobility from early-life impoverishment is coupled with reduced SGA rates. Methods Stratified and multilevel logistic regression analyses were completed on the Illinois transgenerational dataset of African-American infants (1989-1991) and their Chicago-born mothers (1956-1976) with linked U.S. census income information. Results Impoverished-born (defined as lowest quartile of neighborhood income distribution) African-American women (n = 4891) who remained impoverished by the time of delivery had a SGA rate of 19.7%. Individuals who achieved low (n = 5827), modest (n = 2254), or high (n = 732) upward economic mobility by adulthood had lower SGA rates of 17.2, 14.8, and 13.7%, respectively; RR = 0.9 (0.8-0.9), 0.8 (0.7-0.8), and 0.7 (0.6-0.8), respectively. In adjusted (controlling for traditional individual-level risk factors) multilevel regression models, there was a decreasing linear trend in SGA rates with increasing levels of upward economic mobility; the adjusted RR of SGA birth for impoverished-born African-American women who experienced low, modest, of high (compared to no) upward mobility equaled 0.95 (0.91, 0.99), 0.90 (0.83, 0.98), and 0.86 (0.75, 0.98), respectively, p < 0.05. Conclusions African-American women's upward economic mobility from early-life residence in poor urban communities is associated with lower SGA rates independent of adulthood risk status.

Testing the Association Between Traditional and Novel Indicators of County-Level Structural Racism and Birth Outcomes among Black and White Women

Despite decreases in infants born premature and at low birth weight in the United States (U.S.), racial disparities between Black and White women continue. In response, the purpose of this analysis was to examine associations between both traditional and novel indicators of county-level structural racism and birth outcomes among Black and White women. We merged individual-level data from the California Birth Statistical Master Files 2009-2013 with county-level data from the United States (U.S.) Census American Community Survey. We used hierarchical linear modeling to examine Black-White differences among 531,170 primiparous women across 33 California counties. Traditional (e.g., dissimilarity index) and novel indicators (e.g., Black to White ratio in elected office) were associated with earlier gestational age and lower birth weight among Black and White women. A traditional indicator was more strongly associated with earlier gestational age for Black women than for White women. This was the first study to empirically demonstrate that structural racism, measured by both traditional and novel indicators, is associated with poor health and wellbeing of infants born to Black and White women. However, findings indicate traditional indicators of structural racism, rather than novel indicators, better explain racial disparities in birth outcomes. Results also suggest the need to develop more innovative approaches to: (1) measure structural racism at the county-level and (2) reform public policies to increase integration and access to resources.

Living in stressful neighbourhoods during pregnancy: an observational study of crime rates and birth outcomes

Background: Patterns of adverse birth outcomes vary spatially and there is evidence that this may relate to features of the physical environment such as air pollution. However, other social characteristics of the environment such as levels of crime are relatively understudied. This study examines the association between crime rates and birth weight and prematurity. Methods: Maternity inpatient data recorded at birth, including residential postcode, was linked to a representative 5% sample of Scottish Census data and small area crime rates from Scottish Police forces. Coefficients associated with crime were reported from crude and confounder adjusted models predicting low birth weight (< 2500 g), mean birthweight, small for gestational age and prematurity for all singleton live births. Results: Total crime rates were associated with strong and significant reductions in mean birth weight and increases in the risks of both a small for gestational age baby and premature birth. These effects, with the exception of prematurity, were robust to adjustment for individual characteristics including smoking, ethnicity and other socio-economic variables as well as area based confounders including air pollution. Mean birth weight was robust to additional adjustment for neighbourhood income deprivation. Conclusion: The level of crime in a mother’s area of residence, which may be a proxy for the degree of threat felt and therefore stress experienced, appears to be an important determinant of the risk of adverse birth outcomes.

A Multidimensional Approach to Characterizing Psychosocial Health During Pregnancy

Objectives Domains of psychosocial health have been separately connected to pregnancy outcomes. This study explores the relationship between five domains of psychosocial health and their joint association with prenatal health and pregnancy outcomes. Methods Women from a prospective cohort study in Durham, North Carolina were clustered based on measures of paternal support, perceived stress, social support, depression, and self-efficacy. Clusters were constructed using the K-means algorithm. We examined associations between psychosocial health and maternal health correlates, pregnancy intention, and pregnancy outcomes using Chi square tests and multivariable models. Results Three psychosocial health profiles were identified, with the first (Resilient; n = 509) characterized by low depression and perceived stress and high interpersonal support, paternal support, and self-efficacy. The second profile (Vulnerable; n = 278) was marked by high depression and perceived stress, and low interpersonal support, paternal support, and self-efficacy. The third profile (Moderate, n = 526) fell between the other profiles on all domains. Health correlates, pregnancy intention, and pregnancy outcomes varied significantly across profiles. Women with the vulnerable profile were more likely to have risky health correlates, have an unintended pregnancy, and deliver preterm. Women with the resilient profile had better birth outcomes and fewer deleterious health correlates, preconception and prenatally. Conclusions We posit that vulnerable psychosocial health, deleterious health correlates, and the stress which often accompanies pregnancy may interact to magnify risk during pregnancy. Identifying and intervening with women experiencing vulnerable psychosocial health may improve outcomes for women and their children.

Use of geographic indicators of healthcare, environment and socioeconomic factors to characterize environmental health disparities

BACKGROUND

An environmental health inequality is a major public health concern in Europe. However just few studies take into account a large set of characteristics to analyze this problematic. The aim of this study was to identify and describe how socioeconomic, health accessibility and exposure factors accumulate and interact in small areas in a French urban context, to assess environmental health inequalities related to infant and neonatal mortality.

METHODS

Environmental indicators on deprivation index, proximity to high-traffic roads, green space, and healthcare accessibility were created using the Geographical Information System. Cases were collected from death certificates in the city hall of each municipality in the Nice metropolitan area. Using the parental addresses, cases were geocoded to their census block of residence. A classification using a Multiple Component Analysis following by a Hierarchical Clustering allow us to characterize the census blocks in terms of level of socioeconomic, environmental and accessibility to healthcare, which are very diverse definition by nature. Relation between infant and neonatal mortality rate and the three environmental patterns which categorize the census blocks after the classification was performed using a standard Poisson regression model for count data after checking the assumption of dispersion.

RESULTS

Based on geographic indicators, three environmental patterns were identified. We found environmental inequalities and social health inequalities in Nice metropolitan area. Moreover these inequalities are counterbalance by the close proximity of deprived census blocks to healthcare facilities related to mother and newborn. So therefore we demonstrate no environmental health inequalities related to infant and neonatal mortality.

CONCLUSION

Examination of patterns of social, environmental and in relation with healthcare access is useful to identify census blocks with needs and their effects on health. Similar analyzes could be implemented and considered in other cities or related to other birth outcomes.

Neighborhood deprivation and maternal psychological distress during pregnancy: a multilevel analysis

Maternal psychosocial distress is conceptualized as an important factor underlying the association between neighborhood deprivation and pregnancy outcomes. However, empirical studies to examine effects of neighborhood deprivation on psychosocial distress during pregnancy are scant. Based on a large multicenter cohort of pregnant women in Montreal, we examined (1) the extent to which psychosocial distress is clustered at the neighborhood-level, (2) the extent to which the clustering is explained by neighborhood material or social deprivation, and (3) whether associations between neighborhood deprivation and psychosocial distress persist after accounting for neighborhood composition (individual-level characteristics) using multilevel analyses. For 5,218 women residing in 740 neighborhoods, a prenatal interview at 24-26 gestational weeks measured both general and pregnancy-related psychological distress using well-validated scales: perceived stress, social support, depressive symptoms, optimism, commitment to the pregnancy, pregnancy-related anxiety, and maternal locus-of-control. Neighborhood deprivation indices were linked to study participants by their residential postal code. Neighborhood-level clustering (intraclass correlation) ranged from 1 to 2 % for perceived stress (lowest), optimism, pregnancy-related anxiety, and commitment to pregnancy to 4-6 % for perceived social support, depressive symptoms, and maternal locus of control (highest). Neighborhood material deprivation explained far more of the clustering (23-75 %) than did social deprivation (no more than 4 %). Although both material and social deprivation were associated with psychological distress in unadjusted analyses, the associations disappeared after accounting for individual-level socioeconomic characteristics. Our results highlight the importance of accounting for individual-level socioeconomic characteristics in studies of potential neighborhood effects on maternal mental health.

Preterm birth among the Hmong, other Asian subgroups and non-Hispanic whites in California

BACKGROUND

We investigated very preterm (VPTB) and preterm birth (PTB) risk among Hmong women relative to non-Hispanic whites and other Asian subgroups. We also examined the maternal education health gradient across subgroups.

METHODS

California birth record data (2002-2004) were used to analyze 568,652 singleton births to white and Asian women. Pearson Chi-square and logistic regression were used to assess variation in maternal characteristics and VPTB/PTB risk by subgroup.

RESULTS

White, Chinese, Japanese, Korean, Asian Indian, and Vietnamese women had 36-59% lower odds of VPTB and 30-56% lower odds of PTB than Hmong women. Controls for covariates did not substantially diminish these disparities. Cambodian, Filipino and Lao/Thai women's odds of VPTB were similar to that of Hmong women. But they had higher adjusted odds of PTB compared to the Hmong. There was heterogeneity in the educational gradient of PTB, with significant differences between the least and most educated women among whites, Chinese, Japanese, Asian Indians, Cambodians, and Laoians/Thais. Maternal education was not associated with PTB for Hmong, Vietnamese and Korean women, however.

CONCLUSIONS

Studies of Hmong infant health from the 1980s, the decade immediately following the group's mass migration to the US, found no significant differences in adverse birth outcomes between Hmong and white women. By the early 2000s, however, the disparities in VPTB and PTB between Hmong and white women, as well as between Hmong and other Asian women had become substantial. Moreover, despite gains in post-secondary education among childbearing-age Hmong women, the returns to education for the Hmong are negligible. Higher educational attainment does not confer the same health benefits for Hmong women as it does for whites and other Asian subgroups.

Perinatal Depression and Anxiety in Women with and without Human Immunodeficiency Virus Infection

BACKGROUND

Untreated depression and anxiety during the perinatal period have significant consequences on maternal and infant health; however, few studies have examined perinatal depression and perinatal anxiety in women with human immunodeficiency virus (HIV) infection. The current study prospectively examined the prevalence of prenatal and postpartum depression and anxiety, and emotional support from family and friends, as well as childhood sexual abuse in women with and without HIV infection.

METHODS

Between July 2009 and January 2013, 258 pregnant women receiving care in a Philadelphia hospital were enrolled, with 162 completing both the prenatal and postpartum portions of the study. The Center for Epidemiological Studies-Depression Scale (CES-D), and the State-Trait Anxiety Inventory for Adults were used to measure depression and anxiety symptoms, respectively. An independent samples t test and multiple linear regressions were used to determine associations among depression, anxiety, and pregnancy-related variables.

RESULTS

Forty-nine participants (30%) were living with HIV; 113 (70%) were HIV negative. CES-D scores did not differ prenatally (p = .131) or postpartum (p = .156) between women with and without HIV. Prenatal state anxiety scores were higher in women with HIV (p = .02) but there were no differences postpartum (p = .432). In a multiple linear regression, trait anxiety predicted postpartum anxiety in the full sample (p < .001) and childhood sexual abuse predicted postpartum depression among women with HIV (p = .021).

CONCLUSIONS

These findings highlight the importance of identifying and treating perinatal depression and anxiety early in the prenatal period. Results also emphasize the need for providers to be aware of childhood sexual abuse as a potential correlate for depression in women with HIV.

Joint Effects of Structural Racism and Income Inequality on Small-for-Gestational-Age Birth

OBJECTIVES

We examined potential synergistic effects of racial and socioeconomic inequality associated with small-for-gestational-age (SGA) birth.

METHODS

Electronic medical records from singleton births to White and Black women in 10 US states and the District of Columbia (n = 121 758) were linked to state-level indicators of structural racism, including the ratios of Blacks to Whites who were employed, were incarcerated, and had a bachelor's or higher degree. We used state-level Gini coefficients to assess income inequality. Generalized estimating equations models were used to quantify the adjusted odds of SGA birth associated with each indicator and the joint effects of structural racism and income inequality.

RESULTS

Structural racism indicators were associated with higher odds of SGA birth, and similar effects were observed for both races. The joint effects of racial and income inequality were significantly associated with SGA birth only when levels of both were high; in areas with high inequality levels, adjusted odds ratios ranged from 1.81 to 2.11 for the 3 structural racism indicators.

CONCLUSIONS

High levels of racial inequality and socioeconomic inequality appear to increase the risk of SGA birth, particularly when they co-occur.

Neighborhood disadvantage, preconception stressful life events, and infant birth weight

OBJECTIVES

We sought to determine whether the effects of preconception stressful life events (PSLEs) on birth weight differed by neighborhood disadvantage.

METHODS

We drew our data from the Early Childhood Longitudinal Study, Birth Cohort (2001-2002; n = 9300). We created a neighborhood disadvantage index (NDI) using county-level data from the 2000 US Census. We grouped the NDI into tertiles that represented advantaged, middle advantaged, and disadvantaged neighborhoods. Stratified multinomial logistic regressions estimated the effect of PSLEs on birth weight, controlling for confounders.

RESULTS

We found a gradient in the relationship between women's exposure to PSLEs and having a very low birth weight (VLBW) infant by NDI tertile; the association was strongest in disadvantaged neighborhoods (adjusted odd ratio [AOR] = 1.62; 95% confidence interval [CI] = 1.04, 2.53), followed by middle (AOR = 1.39; 95% CI = 1.00, 1.93) and advantaged (AOR = 1.29; 95% CI = 0.91, 1.82) neighborhoods. We observed a similar gradient for women with chronic conditions and among minority mothers.

CONCLUSIONS

Women who experienced PSLEs, who had chronic conditions, or were racial/ethnic minorities had the greatest risk of having VLBW infants if they lived in disadvantaged neighborhoods; this suggests exacerbation of risk within disadvantaged environments. Interventions to reduce rates of VLBW should focus on reducing the deleterious effects of stressors and on improving neighborhood conditions.

Neighborhood socioeconomic disadvantage and gestational weight gain and loss

We explored the relationship between neighborhood socioeconomic disadvantage (NSED) and gestational weight gain and loss and if the association differed by race. A census tract level NSED index (categorized as low, mid-low, mid-high, and high) was generated from 12 measures from the 2000 US Census data. Gestational weight gain and other individual-level characteristics were derived from vital birth records for Allegheny County, PA for 2003-2010 (n = 55,608). Crude and adjusted relative risks were estimated using modified multilevel Poisson regression models to estimate the association between NSED and excessive and inadequate gestational weight gain (GWG) and weight loss (versus adequate GWG). Black women lived in neighborhoods that were more likely to be socioeconomically disadvantaged compared to white women. Almost 55% of women gained an excessive amount of weight during pregnancy, and 2% lost weight during pregnancy. Black women were more likely than white women to have inadequate weight gain or weight loss. Mid-high (aRR = 1.3, 95% CI 1.2, 1.3) and high (aRR = 1.5, 95% CI 1.5, 1.6) NSED compared to low NSED was associated with inadequate weight gain while NSED was not associated with excessive weight gain. Among black women, high versus low NSED was associated with weight loss during pregnancy (RR = 1.6, 95% CI 1.1, 2.5). Among white women, each level of NSED compared to low NSED was associated with weight loss during pregnancy. This study demonstrates how neighborhood socioeconomic characteristics can contribute to our understanding of inadequate weight gain and weight loss during pregnancy, having implications for future research and interventions designed to advance pregnancy outcomes.

Variation in birth outcomes by mother's country of birth among non-Hispanic black women in the United States

Rates of prematurity (PTB) and small-for-gestational age (SGA) were compared between US-born and foreign-born non-Hispanic black women. Comparisons were also made between Sub-Saharan African-born and Caribbean-born black women and by maternal country of birth within the two regions. Comparisons were adjusted for sociodemographic, health behavioral and medical risk factors available on the birth record. Birth record data (2008) from all states (n = 27) where mother's country of birth was recorded were used. These data comprised 58 % of all singleton births to non-Hispanic black women in that year. Pearson Chi square and logistic regression were used to investigate variation in the rates of PTB and SGA by maternal nativity. Foreign-born non-Hispanic black women had significantly lower rates of PTB (OR 0.727; CI 0. 726, 0.727) and SGA (OR 0.742; CI 0.739-0.745) compared to US-born non-Hispanic black women in a fully adjusted model. Sub-Saharan African-born black women compared to Caribbean-born black women had significantly lower rates of PTB and SGA. Within each region, the rates of PTB and SGA varied by mother's country of birth. These differences could not be explained by adjustment for known risk factors obtained from vital records. Considerable heterogeneity in rates of PTB and SGA among non-Hispanic black women in the US by maternal nativity was documented and remained unexplained after adjustment for known risk factors.

Neighborhood deprivation and preterm birth: an application of propensity score matching

PURPOSE

On the basis of a neighborhood deprivation index (NDI), this study aims to examine the association between neighborhood deprivation and preterm birth (PTB) by applying propensity score matching (PSM) methods.

METHODS

NDI was calculated for all census tracts in South Carolina based on the US Census data. Live births in South Carolina during 2008 to 2009 (n = 98,456) were assigned to an NDI quartile group based on residential addresses. PSM was used to create matched pairs by NDI quartiles to avoid any potential inference on imbalanced data. The differences of prevalence of PTB were calculated for exposed and reference deprivation groups.

RESULTS

Neighborhood deprivation was higher among blacks than whites. The overall prevalence of PTB was 8.5% for whites and 12.6% for blacks. Living in neighborhoods with higher deprivation was associated with increased risk of PTB among blacks compared with living in neighborhoods with lower deprivation among blacks. However, random-effect regression models showed that the most deprived whites experienced 1.13 times the odds of having PTB than the least deprived whites.

CONCLUSIONS

The racial disparities in adverse birth outcomes might be partially explained by neighborhood deprivation in South Carolina. PSM may be an appropriate approach to avoid imbalanced data inferences.

An ecological study to identify census blocks supporting a higher burden of disease: infant mortality in the lille metropolitan area, france

In France, reducing social health inequalities has become an explicit goal of health policies over the past few years, one of its objectives is specifically the reduction of the perinatal mortality rate. This study investigates the association between infant mortality and social deprivation categories at a small area level in the Lille metropolitan area, in the north of France, to identify census blocks where public authorities should prioritize appropriate preventive actions. We used census data to establish a neighbourhood deprivation index whose multiple dimensions encompass socioeconomic characteristics. Infant mortality data were obtained from the Lille metropolitan area municipalities to estimate a death rate at the census tract level. We used Bayesian hierarchical models in order to reduce the extra variability when computing relative risks (RR) and to assess the associations between infant mortality and deprivation. Between 2000 and 2009, 668 cases of infant death occurred in the Lille metropolitan area (4.2 per 1,000 live births). The socioeconomic status is associated with infant mortality, with a clear gradient of risk from the most privileged census blocks to the most deprived ones (RR = 2.62, 95 % confidence interval [1.87; 3.70]). The latter have 24.6 % of families who were single parents and 29.9 % of unemployed people in the labor force versus 8.5 % and 7.7 % in the former. Our study reveals socio-spatial disparities in infant mortality in the Lille metropolitan area and highlights the census blocks most affected by the inequalities. Fine spatial analysis may help inform the design of preventive policies tailored to the characteristics of the local communities.

Multi-factorial influences on sex ratio: a spatio-temporal investigation of endocrine disruptor pollution and neighborhood stress

Background:

It is suggested the declining male birth proportion in some industrialized countries is linked to ubiquitous endocrine disruptor exposure. Stress and advanced parental age are determinants which frequently present positive findings. Multi-factorial influences on population sex ratio are rarely explored or tested in research.

Objectives:

To test the hypothesis that dual factors of pollution and population stress affects sex proportion at birth through geographical analysis of Central Scotland.

Methods:

The study incorporates the use of Geographical Information Systems (GIS) tools to overlay modeled point source endocrine disruptor air emissions with “small-area” data on multiple deprivation (a proxy measurement of stress) and birth sex. Historical review of regional sex ratio trends presents additional data on sex ratio in Scotland to consider.

Results:

There was no overall concentration in Central Scotland of low sex ratio neighborhoods with areas where endocrine disruptor air pollution and deprivation or economic stress were high. Historical regional trends in Scotland (from 1973), however, do show significantly lower sex ratio values for populations where industrial air pollution is highest (i.e. Eastern Central Scotland).

Conclusions:

Use of small area data sets and pollution inventories is a potential new method of inquiry for reproductive environmental and health protection monitoring and has produced interesting findings.

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

Neighborhood deprivation is consistently associated with greater risk of low birthweight. However, large birth size is increasingly relevant but overlooked in neighborhood health research, and proximity within which neighborhood deprivation may affect birth outcomes is unknown. We estimated race/ethnic-specific effects of neighborhood deprivation index (NDI) within 1, 3, 5, and 8km buffers around Oregon Pregnancy Risk Assessment Monitoring System (n=3716; 2004-2007) respondents׳ homes on small and large for gestational age (SGA, LGA). NDI was positively associated with LGA and SGA in most race/ethnic groups. The results varied little across the four buffer sizes.

Neighborhood socioeconomic disadvantage and gestational weight gain and loss

We explored the relationship between neighborhood socioeconomic disadvantage (NSED) and gestational weight gain and loss and if the association differed by race. A census tract level NSED index (categorized as low, mid-low, mid-high, and high) was generated from 12 measures from the 2000 US Census data. Gestational weight gain and other individual-level characteristics were derived from vital birth records for Allegheny County, PA for 2003-2010 (n = 55,608). Crude and adjusted relative risks were estimated using modified multilevel Poisson regression models to estimate the association between NSED and excessive and inadequate gestational weight gain (GWG) and weight loss (versus adequate GWG). Black women lived in neighborhoods that were more likely to be socioeconomically disadvantaged compared to white women. Almost 55% of women gained an excessive amount of weight during pregnancy, and 2% lost weight during pregnancy. Black women were more likely than white women to have inadequate weight gain or weight loss. Mid-high (aRR = 1.3, 95% CI 1.2, 1.3) and high (aRR = 1.5, 95% CI 1.5, 1.6) NSED compared to low NSED was associated with inadequate weight gain while NSED was not associated with excessive weight gain. Among black women, high versus low NSED was associated with weight loss during pregnancy (RR = 1.6, 95% CI 1.1, 2.5). Among white women, each level of NSED compared to low NSED was associated with weight loss during pregnancy. This study demonstrates how neighborhood socioeconomic characteristics can contribute to our understanding of inadequate weight gain and weight loss during pregnancy, having implications for future research and interventions designed to advance pregnancy outcomes.

Neighborhood disadvantage, racial concentration and the birthweight of infants born to adolescent mothers

To study the relationship between neighborhood demographic characteristics (disadvantage, racial concentration) and the birthweight of infants born to adolescent mothers, potentially as mediated by smoking, prenatal care use, or perceptions of neighborhood safety. Data from Waves I and IV of the National Longitudinal Survey of Adolescent Health were analyzed. Birthweight (continuous) and low birthweight (<2.5 kg) of singleton infants born to non-Hispanic Black and non-Hispanic White adolescent mothers (<20 years) after Wave I were examined as outcomes. Neighborhood demographic characteristics included Census Block Group socioeconomic disadvantage and Black racial concentration. Possible mediators (smoking during pregnancy, early initiation of prenatal care, and perceptions of safety) were also examined. Controls for adolescent baseline age, age at pregnancy, body mass index (BMI) and parental education were included. Analyses were run stratified on race. Baseline continuous birthweight, BMI and neighborhood demographics varied significantly between non-Hispanic Black and White adolescent mothers, with Black adolescent mothers evidencing lower birthweight and higher BMI, neighborhood disadvantage and Black racial concentration. In multivariable analyses among Black adolescent mothers, Black racial concentration was positively associated with birthweight, and negatively associated with low birthweight; no mediators were supported. Neighborhood disadvantage and Black racial concentration were unassociated with birthweight outcomes among White adolescent mothers. Infants born to Black adolescent mothers evidenced higher birthweight with increasing Black neighborhood concentration. Further exploration of mechanisms by which Black racial concentration may positively impact birthweight is warranted.

Neighborhood Disadvantage, Preconception Health Behaviors and Infant Birthweight: A Preliminary Study

Prior studies have shown that neighborhood disadvantage and disorder are associated with birth outcomes. This study examined preconception diet and physical activity level, as well as body mass index, as mediators of the association between neighborhood conditions and birthweight. Secondary data analyses were conducted using data from the National Longitudinal Study of Adolescent Health (Add Health). The final analytic sample consisted of 523 adolescent and young adult mothers giving singleton live births between 1997 and 1998. In contrast to previous research, we found that neighborhood characteristics were unrelated to birthweight. Consistent with prior studies, compared to those who were White, on average, Blacks had birthweights that were 163.25 grams lighter. In addition, compared to mothers who were married or living with a partner, mothers who did not have a partner at the time of birth, on average, had offspring that were 127.20 grams lighter. No evidence was found for the mediation hypotheses as there were no associations between neighborhood characteristics and preconception diet or physical activity or between these behavioral variables and birthweight. To the authors' knowledge, this is the first study examining diet and physical activity as possible behavioral pathways between the neighborhood context and birthweight.

Maternal stressful life events prior to conception and the impact on infant birth weight in the United States

OBJECTIVES

We sought to determine if and to what extent a woman's exposure to stressful life events prior to conception (PSLEs) were associated with subsequent infant birth weight by using a nationally representative sample of US women.

METHODS

We examined 9350 mothers and infants participating in the first wave of the Early Childhood Longitudinal Study, Birth Cohort in 2001. Weighted regressions estimated the effect of exposure on very low and low birth weight, adjusting for maternal sociodemographic and health factors and stress during pregnancy.

RESULTS

Twenty percent of women experienced any PSLE. In adjusted analyses, exposed women were 38% more likely to have a very low birth weight infant than nonexposed women. Furthermore, the accumulation of PSLEs was associated with reduced infant birth weight.

CONCLUSIONS

This was the first nationally representative study to our knowledge to investigate the impact of PSLEs on very low and low birth weight in the United States. Interventions aimed to improve birth outcomes will need to shift the clinical practice paradigm upstream to the preconception period to reduce women's exposure to stress over the life course and improve the long-term health of children.

Preterm birth in the United States: the impact of stressful life events prior to conception and maternal age

OBJECTIVES

We determined whether and to what extent a woman's exposure to stressful life events prior to conception (PSLEs) was associated with preterm birth and whether maternal age modified this relationship.

METHODS

We examined 9350 mothers and infants participating in the first wave of the Early Childhood Longitudinal Study, Birth Cohort, a nationally representative sample of US women and children born in 2001, to investigate the impact of PSLEs on preterm birth in the United States. We estimated the effect of exposure on preterm birth with weighted logistic regression, adjusting for maternal sociodemographic and health factors and stress during pregnancy.

RESULTS

Of the women examined, 10.9% had a preterm birth. In adjusted analyses, women aged 15 to 19 years who experienced any PSLE had over a 4-fold increased risk for having a preterm birth. This association differed on the basis of the timing of the PSLE.

CONCLUSIONS

Findings suggest that adolescence may be a sensitive period for the risk of preterm birth among adolescents exposed to PSLEs. Clinical, programmatic, and policy interventions should address upstream PSLEs, especially for adolescents, to reduce the prevalence of preterm birth and improve maternal and child health.

Neighborhood context and breastfeeding behaviors among urban mothers

BACKGROUND

Research consistently shows that breastfeeding behaviors vary according to individual-level sociodemographic characteristics, yet few studies examine contextual variations in breastfeeding.

OBJECTIVE

The purpose of this study is to examine the association between neighborhood context and breastfeeding among a sample of predominately unmarried urban mothers, a group with relatively low rates of breastfeeding.

METHODS

This study combines census tract information with data from 2 waves of the Fragile Families and Child Wellbeing Study (n = 4228) to predict the odds of initiating and sustaining breastfeeding.

RESULTS

Findings indicate that neighborhood socioeconomic composition, rather than racial or ethnic concentration, is associated with breastfeeding behaviors. More specifically, living in a highly educated neighborhood is associated with higher odds of initiating and sustaining breastfeeding.

CONCLUSION

These results suggest that the breastfeeding behaviors of urban mothers vary according to neighborhood educational context. Understanding how breastfeeding behaviors are shaped by one's neighborhood environment will allow public health initiatives to more effectively target vulnerable populations.

Exploring the health consequences of majority-minority neighborhoods: minority diversity and birthweight among native-born and foreign-born blacks

We examined the association between neighborhood minority diversity and infant birthweight among non-Hispanic US-born black women and foreign-born black women from Sub-Saharan Africa and the non-Spanish speaking Caribbean using 2002-2006 vital statistics birth record data from the state of New Jersey (n = 73,907). We used a standardized entropy score to measure the degree of minority diversity (i.e., non-white multiethnic racial heterogeneity) for each census tract where women lived. We distinguished between four levels of minority diversity, with the highest level representing majority-minority neighborhoods. We estimated mean birthweight for singleton births over this 5-year period using linear regression with robust standard errors to correct for clustering of mothers within census tracts. We found significant differences in mean birthweight by mother's country of origin such that infants of US-born black mothers weighed significantly less than the infants of African and Caribbean immigrants (3130 g vs. 3299 g and 3212 g; p < 0.001). Adjustments for neighborhood deprivation, residential instability, individual-level sociodemographics, maternal health behaviors and conditions, and gestational age did not reduce these origin differences. Minority diversity had a protective effect on black infant health. Women living in low and moderately diverse tracts as well as those in majority-minority neighborhoods had heavier babies (β = 26.5, 29.8 and 61.2, respectively, p < 0.001) on average than women in the least diverse tracts. The results for majority-minority neighborhoods were robust when we controlled for neighborhood- and individual-level covariates.

Cluster analysis of social and environment inequalities of infant mortality. A spatial study in small areas revealed by local disease mapping in France

Mapping spatial distributions of disease occurrence can serve as a useful tool for identifying exposures of public health concern. Infant mortality is an important indicator of the health status of a population. Recent literature suggests that neighborhood deprivation status can modify the effect of air pollution on preterm delivery, a known risk factor for infant mortality. We investigated the effect of neighborhood social deprivation on the association between exposure to ambient air NO2 and infant mortality in the Lille and Lyon metropolitan areas, north and center of France, respectively, between 2002 and 2009. We conducted an ecological study using a neighborhood deprivation index estimated at the French census block from the 2006 census data. Infant mortality data were collected from local councils and geocoded using the address of residence. We generated maps using generalized additive models, smoothing on longitude and latitude while adjusting for covariates. We used permutation tests to examine the overall importance of location in the model and identify areas of increased and decreased risk. The average death rate was 4.2‰ and 4.6‰ live births for the Lille and Lyon metropolitan areas during the period. We found evidence of statistically significant precise clusters of elevated infant mortality for Lille and an east-west gradient of infant mortality risk for Lyon. Exposure to NO2 did not explain the spatial relationship. The Lille MA, socioeconomic deprivation index explained the spatial variation observed. These techniques provide evidence of clusters of significantly elevated infant mortality risk in relation with the neighborhood socioeconomic status. This method could be used for public policy management to determine priority areas for interventions. Moreover, taking into account the relationship between social and environmental exposure may help identify areas with cumulative inequalities.

Contribution of local area deprivation to cultural-linguistic inequalities in foetal growth restriction: trends over time in a Canadian metropolitan centre

This study investigated temporal trends in heterogeneity of foetal growth restriction across neighbourhood deprivation levels for two culturally distinct communities (Anglophones and Francophones) in a North American metropolitan centre. Inequalities in foetal growth restriction related to deprivation fell from 1989 to 2008 for Francophones, but initial improvements for Anglophones later reversed with a rise in poor foetal growth in the most materially disadvantaged and, unexpectedly, advantaged areas as well. Inequalities in foetal growth restriction related to neighbourhood material deprivation may be emerging in this minority Anglophone population. Potential mechanisms underlying these trends are discussed, as well as implications for perinatal health policy.

Social deprivation and adverse perinatal outcomes among Western and non-Western pregnant women in a Dutch urban population

Social deprivation is considered a key factor in adverse perinatal outcomes. Rotterdam, the second largest city in The Netherlands, has large inequalities in perinatal health and a high number of deprived neighbourhoods. Social deprivation is measured here through a composite variable: 'Social Index' (SI). We studied the impact of the SI (2008-2009; 5 categories) in terms of perinatal mortality, congenital anomalies, preterm birth, small for gestational age (SGA) and low 5-minute Apgar score as registered in The Netherlands Perinatal Registry (Rotterdam 2000-2007, n = 56,443 singleton pregnancies). We applied ethnic dichotomisation as Western (European/North-American/Australian) vs. Non-Western (all others) ethnicity was expected to interact with the impact of SI. Tests for trend and multilevel regression analysis were applied. Gradually decreasing prevalence of adverse perinatal outcomes was observed in Western women from the lowest SI category (low social quality) to the highest SI category (high social quality). In Western women the low-high SI gradient for prevalence of spontaneous preterm birth (per 1000) changed from 57.2 to 34.1, for iatrogenic preterm birth from 35.2 to 19.0, for SGA from 119.6 to 59.4, for low Apgar score from 10.9 to 8.2, and for perinatal mortality from 14.9 to 7.6. These trends were statistically confirmed by Chi2-tests for trend (p < 0.001). For non-Western women such trends were absent. These strong effects for Western women were confirmed by significant odds ratios for almost all adverse perinatal outcomes estimated from multilevel regression analysis. We conclude social deprivation to play a different role among Western vs. non-Western women. Our results suggest that improvements in social quality may improve perinatal outcomes in Western women, but alternative approaches may be necessary for non-Western groups. Suggested explanations for non-Western 'migrant' groups include the presence of 'protective' effects through knowledge systems or intrinsic resilience. Implications concern both general and targeted policies.

Absence of protective ethnic density effect on Ecuadorian migrants' mental health in a recent migration setting: a multilevel analysis

PURPOSE

We aimed to study the association between the Ecuadorians' ethnic density (EED) of the areas of residence (AR) with the mental health of Ecuadorians in Spain.

METHODS

Multilevel study of 568 Ecuadorian adults in 33 AR randomly selected from civil registries and interviewed at home. Possible psychiatric case (PPC) was measured by scoring ≥5 in General Health Questionnaire-28. Ecuadorians' ethnic density was dichotomized in high and low EED (<6 %). Multilevel logistic regression was used to estimate odds ratios (OR) and 95 % confidence intervals (CI).

RESULTS

Prevalence of PPC, 24 % (95 %CI 20-28 %), varied by area of residence. Ecuadorians' ethnic density varied by area of residence ranging from 0.9 to 19.5 %. PPC prevalence in High Ecuadorians' ethnic density AR was 29.5 and 20.4 % in low EED AR (p 0.013). Ecuadorians from High EED AR had higher odds of PPC than those from Low EED AR (OR 1.65 95 %CI 1.01-2.72). Adjusting for individual confounders (largely self-perceived discrimination), OR decreased to 1.48 (95 %CI 0.87-2.55). The final model, adjusted by area of residence and educational level, yielded an OR 1.37 (95 %CI 0.78-2.40).

CONCLUSIONS

No protective association between the Ecuadorians' ethnic density of the Area of residence and Ecuadorian migrants' mental health was found. Mechanisms underlying beneficial ethnic density effects may be absent in recent migration settings.

Pregnancy intention and contraceptive use at six months postpartum among women with recent preterm delivery

OBJECTIVE

To describe pregnancy intention and contraceptive use among women with a recent delivery that occurred at 35 weeks gestation or fewer and who were enrolled in a large-scale randomized control trial.

DESIGN

In this descriptive study we used data from assessments conducted at 6 months postpartum as part of a randomized controlled clinical trial, the Philadelphia Collaborative Preterm Prevention Project (PCPPP).

PARTICIPANTS AND SETTING

Participants were recruited following a preterm birth (PTB) in one of the 12 urban birth hospitals. All women enrolled in PCPPP, who completed their 6-month postpartum assessment, and who were sexually active at the time of that assessment (n = 566), were included in the analysis.

METHODS

Data were collected during face-to-face interviews. Study questionnaires included questions about participants' plans for the timing of subsequent pregnancies, contraceptive behaviors, and other health variables.

RESULTS

Nearly all of the participants (90.1%, n = 509) reported they did not want to get pregnant within one year of the index PTB. However, more than one half of these women (54.6%) reported contraceptive practices of low or moderate effectiveness. Most predictive of intending another pregnancy within the year was the death of the index PTB infant (odds ratio [OR]= 18.2,95% confidence interval [CI] [8.9, 37.0]).

CONCLUSIONS

Discordant pregnancy intention and contraceptive use were reported among this group of mothers of PTB infants who are at particularly high risk for a poor outcome of any subsequent pregnancy. The findings highlight the need for further investigation of the causes, correlates, and consequences of discordant pregnancy intentions and contraceptive practices.

Independent risk factors for infants who are small for gestational age by customised birthweight centiles in a multi-ethnic New Zealand population

BACKGROUND

Infants born small for gestational age (SGA) by customised birthweight centiles are at increased risk of adverse outcomes compared with those SGA by population centiles. Risk factors for customised SGA have not previously been described in a general obstetric population.

AIM

To determine independent risk factors for customised SGA in a multi-ethnic New Zealand population.

METHODS

We performed a retrospective cohort analysis of prospectively recorded maternity data from 2006 to 2009 at National Women's Health, Auckland, New Zealand. After exclusion of infants with congenital anomalies and missing data, our final study population was 26,254 singleton pregnancies. Multivariable logistic regression analysis adjusted for ethnicity, body mass index, maternal age, parity, smoking status, social deprivation, hypertensive disease, antepartum haemorrhage (APH), diabetes and relevant pre-existing medical conditions.

RESULTS

Independent risk factors for SGA included obesity (adjusted odds ratio 1.24 [95% CI 1.11-1.39] relative to normal weight), maternal age ≥ 35 years (1.16 [1.05-1.30] relative to 20-29 years), nulliparity (1.13 [1.04-1.24] relative to parity 1), cigarette smoking (2.01 [1.79-2.27]), gestational hypertension (1.46 [1.21-1.75]), pre-eclampsia (2.94 [2.49-3.48]), chronic hypertension (1.68 [1.34-2.09]), placental abruption (2.57 [1.74-3.78]) and APH of unknown origin (1.71 [1.45-2.00]). Gestational diabetes (0.80 [0.67-0.96]) and type 1 diabetes (0.26 [0.11-0.64]) were associated with reduced risk.

CONCLUSIONS

We report independent pregnancy risk factors for customised SGA in a general obstetric population. In contrast to population SGA, obesity is associated with increased risk. Our findings may help identify pregnancies that require increased fetal growth surveillance.

Residential segregation and the health of African-American infants: does the effect vary by prevalence?

Segregation effects may vary between areas (e.g., counties) of low and high low birth weight (LBW; <2,500 g) and preterm birth (PTB; <37 weeks of gestation) rates due to interactions with area differences in risks and resources. We assess whether the effects of residential segregation on county-level LBW and PTB rates for African-American infants vary by the prevalence of these conditions. The study sample includes 368 counties of 100,000 or more residents and at least 50 African-American live births in 2000. Residentially segregated counties are identified alternatively by county-level dissimilarity and isolation indices. Quantile regression is used to assess how residential segregation affects the entire distributions of county-level LBW and PTB rates (i.e. by prevalence). Residential segregation increases LBW and PTB rates significantly in areas of low prevalence, but has no such effects for areas of high prevalence. As a sensitivity analysis, we use metropolitan statistical area level data and obtain similar results. Our findings suggest that residential segregation has adverse effects mainly in areas of low prevalence of LBW and preterm birth, which are expected overall to have fewer risk factors and more resources for infant health, but not in high prevalence areas, which are expected to have more risk factors and fewer resources. Residential policies aimed at area resource improvements may be more effective.

Socioeconomic inequalities in the rate of stillbirths by cause: a population-based study

OBJECTIVE

To assess time trends in socioeconomic inequalities in overall and cause-specific stillbirth rates in England.

DESIGN

Population-based retrospective study.

SETTING

England.

PARTICIPANTS

Stillbirths occurring among singleton infants born between 1 January 2000 and 31 December 2007.

MAIN OUTCOME MEASURE

Cause-specific stillbirth rate per 10 000 births by deprivation tenth and year of birth. Deprivation measured using the UK index of multiple deprivation at Super Output Area level.

METHODS

Poisson regression models were used to estimate the relative deprivation gap (comparing the most and least deprived tenths) in rates of stillbirths (overall and cause-specific). Excess mortality was calculated by applying the rates seen in the least deprived tenth to the entire population at risk. Discussions with our local NHS multicentre ethics committee deemed that this analysis of national non-identifiable data did not require separate ethics approval.

RESULTS

There were 44 stillbirths per 10 000 births, with no evidence of a change in rates over time. Rates were twice as high in the most deprived tenth compared with the least (rate ratio (RR) 2.1, 95% CI 2.0 to 2.2) with no evidence of a change over time. There was a significant deprivation gap for all specific causes except mechanical events (RR 1.2, 95% CI 0.9 to 1.5). The widest gap was seen for stillbirths due to antepartum haemorrhages (RR 3.1, 95% CI 2.8 to 3.5). No evidence of a change in the rate of stillbirth or deprivation gap over time was seen for any specific cause.

CONCLUSION

A wide deprivation gap exists in stillbirth rates for most causes and is not diminishing. Unexplained antepartum stillbirths accounted for 50% of the deprivation gap, and a better understanding of these stillbirths is necessary to reduce socioeconomic inequalities.