The association between neighbourhoods and adverse birth outcomes: a systematic review and meta-analysis of multi-level studies

Contributions of neighborhood physical and social environments to racial and ethnic disparities in birth outcomes in California: A mediation analysis

BACKGROUND

Racially minoritized populations experience higher rates of adverse birth outcomes than White populations in the U.S. We estimated the mediating effect of neighborhood social and physical environments on disparities in adverse birth outcomes in California.

METHOD

We used birthing parent's residential address for California live birth records from 2019 to estimate census block group Area Deprivation Index and census tract level measures of ambient fine particulate matter (PM2.5), drinking water contamination, tree canopy coverage, as a measure of greenspace, potential heat vulnerability, and noise. We performed mediation analysis to assess whether neighborhood factors explain racial/ethnic disparities in preterm birth (PTB) and term-birth low birth weight (TLBW) comparing Black, Latinx, and Asian with White births after controlling for individual-level factors.

RESULTS

Black, Latinx, and Asian parents had PTB rates that were 67%, 36%, and 11% higher, and TLBW rates that were 150%, 38%, and 81% higher than Whites. Neighborhood deprivation contributed 7% (95% CI: 3%, 11%) to the Black-White and 9% (95% CI: 6%, 12%) to the Latinx-White disparity in PTB, and 8% (95% CI: 3%, 12%) of the Black-White and 9% (95% CI: 5%, 15%) of the Latinx-White disparity in TLBW. Drinking water contamination contributed 2% (95% CI: 1%, 4%) to the Latinx-White disparity in PTB. Lack of greenspace accounted for 7% (95% CI: 2%, 10%) of the Latinx-White PTB disparity and 7% (95% CI: 3%, 12%) of the Asian-White PTB disparity. PM2.5 contributed 11% (95% CI: 5%, 18%), drinking water contamination contributed 3% (95% CI: 1%, 7%), and potential heat vulnerability contributed 2% (95% CI: 1%, 3%) to the Latinx-White TLBW disparity. Lack of green space contributed 3% (95% CI: 1%, 6%) to the Asian-White TLBW disparity.

CONCLUSIONS

Our study suggests social environments explain portions of Black/Latinx-White disparities while physical environments explain Latinx/Asian-White disparities in PTB and TLBW.

The Influence of Gentrification on Adverse Birth Outcomes in California

Evidence has documented the effects of place on perinatal outcomes, but less is known about the sociopolitical mechanisms, such as gentrification, that shape neighborhood context and produce spatialized inequities in adverse birth outcomes. Leveraging a diverse sample in California, we assessed the associations between gentrification and birth outcomes: preterm birth, small-for-gestational-age, and low birth weight. Gentrification was measured using the Freeman method and the Displacement and Gentrification Typology. Descriptive analysis assessed outcome prevalence and race and ethnicity distribution by exposure and participant characteristics. Overall and race and ethnicity-stratified mixed effects logistic models examined associations between gentrification and birth outcomes, sequentially adjusting for sociodemographic status and pregnancy factors, with a random intercept to account for clustering by census tract. In a sample of 5,116,131 births, outcome prevalence ranged from 1.0% for very preterm birth, 5.0% for low birth weight, 7.9% for preterm birth, and 9.4% for small-for-gestational-age. Adjusting for individual-level factors, gentrification was associated with increased odds of preterm birth (Freeman OR = 1.09, 95% CI 1.07-1.10; Displacement and Gentrification Typology OR = 1.11, 95% CI 1.09-1.13). While Displacement and Gentrification Typology-measured gentrification was consistently associated with greater odds of adverse outcomes, Freeman-measured gentrification was associated with slightly lower odds of small-for-gestational-age and low birth weight. Furthermore, gentrification was associated with birth outcome odds across multiple racial and ethnic groups, but the directions and magnitudes of the associations varied depending on the gentrification assessment methodology and the outcome assessed. Results demonstrate that gentrification plays a role in shaping adverse birth outcomes in California.

Indirect Effects of Neighbourhood Socioeconomic Status on Preterm Birth Risk in an Argentine Population

BACKGROUND

Preterm birth (PTB) is the main condition related to perinatal morbimortality worldwide. The aim of this study was to determine the indirect effects of neighbourhood socioeconomic status (NSES) on the risk of spontaneous PTB.

METHODS

We carried out a retrospective case-control study including sociodemographic and obstetric data of multigravid women who gave birth at a maternity hospital in Tucumán, Argentina, between 2005 and 2010: 949 women without previous PTB nor pregnancy loss who delivered at term and 552 who had spontaneous PTB. NSES was estimated from the Unsatisfied Basic Needs index of census data. Variables selected through penalised regressions were used to create a data-driven Bayesian network; then, pathways were identified and mediation analyses performed.

RESULTS

Maternal age less than 20 years mediated part of the protective effect of high NSES on spontaneous PTB [natural indirect effect (NIE) -0.0125, 95% confidence interval (CI) (-0.0208, -0.0041)] and on few prenatal visits (< 5) [NIE - 0.0095, 95% CI (-0.0166, -0.0025)]. These pathways showed greater sensitivity to unobserved confounders that affect the variables mediator-outcome in the same direction, and exposure-mediator in the opposite direction. They did not show sensitivity to observed potential confounders, nor to the parameterization used to define NSES. Meanwhile, urinary tract infections showed a trend in mediating the effect of low NSES on spontaneous PTB [NIE 0.0044, 95% CI (-0.0006, 0.0093), P 0.0834].

CONCLUSIONS

High NSES has protective indirect effects on spontaneous PTB risk, mainly associated with a lower frequency of teenage pregnancy.

Neighborhood mobility and racial disparities in preterm birth: A sibling study in California

Recent work finds that upward neighborhood mobility-defined as reductions in neighborhood socioeconomic disadvantage due to moving-may improve birth outcomes. Less work, however, explores whether changes in socioeconomic context differentially impact birth outcomes by maternal race and ethnicity. In the US, mothers of minoritized racial and ethnic identity often experience worse neighborhood conditions and pregnancy outcomes than White mothers. Using a sibling-linked dataset, we examined whether neighborhood mobility corresponds with changes in preterm birth risk among Asian (N = 130,079), Black (N = 50,149), Hispanic (N = 429,938), and White (N = 233,428) mothers who delivered multiple live births in California between 2005 and 2015. We linked residential addresses at each birth to census-derived indices of neighborhood disadvantage and defined levels of neighborhood mobility as moving-induced changes in disadvantage between pregnancies. We mapped neighborhood mobility patterns and fit conditional logistic regression models estimating the odds of preterm birth in the sibling delivered after moving, controlling for the risk of preterm birth in the sibling delivered before moving, by maternal race and ethnicity. Dot density maps highlight racialized patterns of neighborhood mobility and segregation between Black and White mothers. Regression results show that Black and, in some cases, Asian and Hispanic mothers who experienced upward mobility (moves away from neighborhood disadvantage) exhibited reduced odds of preterm birth in the second delivery. Upward mobility did not reduce the odds of preterm birth among White mothers. Findings suggest that policies and programs that enable opportunities for neighborhood mobility may reduce persistent racial and ethnic disparities in adverse birth outcomes.

Area-Level Social Vulnerability and Severe COVID-19: A Case-Control Study Using Electronic Health Records from Multiple Health Systems in the Southeastern Pennsylvania Region

Knowledge about neighborhood characteristics that predict disease burden can be used to guide equity-based public health interventions or targeted social services. We used a case-control design to examine the association between area-level social vulnerability and severe COVID-19 using electronic health records (EHR) from a regional health information hub in the greater Philadelphia region. Severe COVID-19 cases (n = 15,464 unique patients) were defined as those with an inpatient admission and a diagnosis of COVID-19 in 2020. Controls (n = 78,600; 5:1 control-case ratio) were a random sample of individuals who did not have a COVID-19 diagnosis from the same geographic area. Retrospective data on comorbidities and demographic variables were extracted from EHR and linked to area-level social vulnerability index (SVI) data using ZIP codes. Models adjusted for different sets of covariates showed incidence rate ratios (IRR) ranging from 1.15 (95% CI, 1.13-1.17) in the model adjusted for individual-level age, sex, and marital status to 1.09 (95% CI, 1.08-1.11) in the fully adjusted model, which included individual-level comorbidities and race/ethnicity. The fully adjusted model indicates that a 10% higher area-level SVI was associated with a 9% higher risk of severe COVID-19. Individuals in neighborhoods with high social vulnerability were more likely to have severe COVID-19 after accounting for comorbidities and demographic characteristics. Our findings support initiatives incorporating neighborhood-level social determinants of health when planning interventions and allocating resources to mitigate epidemic respiratory diseases, including other coronavirus or influenza viruses.

Neighborhood Deprivation and Severe Maternal Morbidity in a Medicaid Population

INTRODUCTION

Few studies have examined whether neighborhood deprivation is associated with severe maternal morbidity (SMM) in already socioeconomically disadvantaged populations. Little is known about to what extent neighborhood deprivation accounts for Black-White disparities in SMM. This study investigated these questions among a statewide Medicaid-insured population, a low-income population with heightened risk of SMM.

METHODS

Data were from Michigan statewide linked birth records and Medicaid claims between 01/01/2016 and 12/31/2019, and were analyzed between 2022 and 2023. Neighborhood deprivation was measured with the Area Deprivation Index at census block group and categorized as low, medium, or high deprivation. Multilevel logistic models were used to examine the association between neighborhood deprivation and SMM. Fairlie nonlinear decomposition was conducted to quantify the contribution of neighborhood deprivation to SMM racial disparity.

RESULTS

People in the most deprived neighborhoods had higher odds of SMM than those in the least deprived neighborhoods (aOR [95% CI]: 1.27 [1.15, 1.40]). Such association was observed in Black (aOR [95% CI]: 1.34 [1.07, 1.67]) and White (aOR [95% CI]: 1.26 [1.12, 1.42]) racial subgroups. Decomposition showed that of 57.5 (cases per 10,000) explained disparity in SMM, neighborhood deprivation accounted for 23.1 (cases per 10,000; 95% CI: 16.3, 30.0) or two-fifths (40.2%) of the Black-White disparity. Analysis on SMM excluding blood transfusion showed consistent but weaker results.

CONCLUSIONS

Neighborhood deprivation may be used as an effective tool to identify at-risk individuals within a low-income population. Community-engaged interventions aiming at improving neighborhood conditions may be helpful to reduce both SMM prevalence and racial inequity in SMM.

Community Health Workers: Improving Home Visiting Engagement of High-Risk Birthing People in Segregated Neighborhoods

CONTEXT

Racial and ethnic disparities in perinatal health remain a public health crisis. Despite improved outcomes from home visiting (HV) participation during pregnancy, most eligible individuals of color do not engage. Neighborhood segregation, a manifestation of structural racism, may impose constraints on engaging eligible individuals in HV.

OBJECTIVE

To examine whether race, ethnicity, and/or language-concordant community health workers (CHWs) increased HV engagement for birthing people in segregated neighborhoods.

DESIGN

Program evaluation using administrative linked data from birth records, Medicaid claims, and HV program participation. Strong Beginnings (SB), a program with HV provided by CHWs working with nurses and social workers, was compared with the Maternal Infant Health Program (MIHP), a state Medicaid-sponsored HV program without CHW involvement. Data were analyzed using χ 2 tests and Poisson regressions.

PARTICIPANTS

A total of 4560 individuals with a Medicaid-eligible birth between 2016 and 2019, including 1172 from SB and 3388 from the MIHP.

MAIN OUTCOME MEASURES

Penetration (percentage of participants in HV among all Medicaid-eligible individuals across quintiles of neighborhood segregation) and dosage (the total number of home visits from both CHWs and nurses/social workers, and then restricted to those from nurses/social workers).

RESULTS

SB penetrated more segregated neighborhoods than the MIHP (58.4% vs 48.3%; P < .001). SB participants received a higher dosage of home visits (mean [SD]: 11.9 [6.1]) than MIHP participants (mean [SD]: 4.4 [2.8], P < .001). Importantly, CHWs did not replace but moderately increased home visits from nurses and social workers (51.1% vs 35.2% with ≥5 intervention visits, P < .001), especially in more segregated neighborhoods.

POLICY IMPLICATION

Community-informed HV models intentionally designed for people facing disparities may help facilitate program outreach to segregated neighborhoods with concentrated deprivation and reduce racial and ethnic disparities.

CONCLUSIONS

An HV program provided by CHWs working with nurses and social workers was associated with an increase in penetration and dosage in segregated neighborhoods, compared with HV without CHW involvement. This underscores the value of CHWs partnering with licensed professional workers in improving HV engagement in disadvantaged communities.

The Maternal and Infant Environmental Health Riskscape study of perinatal disparities in greater Houston: rationale, study design and participant profiles

Introduction

The Maternal and Infant Environmental Health Riskscape (MIEHR) Center was established to address the interplay among chemical and non-chemical stressors in the biological, physical, social, and built environments that disproportionately impact perinatal health among Black pregnant people in a large and diverse urban area with documented disparities in the U.S.

Methods

The MIEHR cohort is recruiting non-Hispanic Black and non-Hispanic white pregnant people who deliver their infants at major obstetric hospitals in Houston, Texas. At enrollment, all participants are asked to provide urine samples for chemical [metals, cotinine, and polycyclic aromatic hydrocarbons (PAHs)] analyses and blood samples. A subset of the cohort is asked to provide oral and vaginal swabs, and fecal samples. Questionnaire and electronic health record data gather information about residential address history during pregnancy, pregnancy history and prenatal care, sociodemographic and lifestyle factors, experiences of discrimination and stress, and sources of social support. Using information on where a participant lived during their pregnancy, features of their neighborhood environment are characterized. We provide summaries of key individual- and neighborhood-level features of the entire cohort, as well as for Black and white participants separately.

Results

Between April 2021 and February 2023, 1,244 pregnant people were recruited. Nearly all participants provided urine samples and slightly less than half provided blood samples. PAH exposure patterns as assessed on 47% of participants thus far showed varying levels depending on metabolite as compared to previous studies. Additionally, analyses suggest differences between Black and white pregnant people in experiences of discrimination, stress, and levels of social support, as well as in neighborhood characteristics.

Discussion

Our findings to date highlight racial differences in experiences of discrimination, stress, and levels of support, as well as neighborhood characteristics. Recruitment of the cohort is ongoing and additional neighborhood metrics are being constructed. Biospecimens will be analyzed for metals and PAH metabolites (urine samples), miRNAs (plasma samples) and the microbiome (oral swabs). Once enrollment ends, formal assessments are planned to elucidate individual- and neighborhood-level features in the environmental riskscape that contribute to Black-White disparities in perinatal health.

Stimulating Preconception Care Uptake by Women With a Vulnerable Health Status Through a Mobile Health App (Pregnant Faster): Pilot Feasibility Study

BACKGROUND

A low socioeconomic status is associated with a vulnerable health status (VHS) through the accumulation of health-related risk factors, such as poor lifestyle behaviors (eg, inadequate nutrition, chronic stress, and impaired health literacy). For pregnant women, a VHS translates into a high incidence of adverse pregnancy outcomes and therefore pregnancy-related inequity. We hypothesize that stimulating adequate pregnancy preparation, targeting lifestyle behaviors and preconception care (PCC) uptake, can reduce these inequities and improve the pregnancy outcomes of women with a VHS. A nudge is a behavioral intervention aimed at making healthy choices easier and more attractive and may therefore be a feasible way to stimulate engagement in pregnancy preparation and PCC uptake, especially in women with a VHS. To support adequate pregnancy preparation, we designed a mobile health (mHealth) app, Pregnant Faster, that fits the preferences of women with a VHS and uses nudging to encourage PCC consultation visits and engagement in education on healthy lifestyle behaviors.

OBJECTIVE

This study aimed to test the feasibility of Pregnant Faster by determining usability and user satisfaction, the number of visited PCC consultations, and the course of practical study conduction.

METHODS

Women aged 18-45 years, with low-to-intermediate educational attainment, who were trying to become pregnant within 12 months were included in this open cohort. Recruitment took place through social media, health care professionals, and distribution of flyers and posters from September 2021 until June 2022. Participants used Pregnant Faster daily for 4 weeks, earning coins by reading blogs on pregnancy preparation, filling out a daily questionnaire on healthy lifestyle choices, and registering for a PCC consultation with a midwife. Earned coins could be spent on rewards, such as fruit, mascara, and baby products. Evaluation took place through the mHealth App Usability Questionnaire (MAUQ), an additional interview or questionnaire, and assessment of overall study conduction.

RESULTS

Due to limited inclusions, the inclusion criterion "living in a deprived neighborhood" was dropped. This resulted in the inclusion of 47 women, of whom 39 (83%) completed the intervention. In total, 16 (41%) of 39 participants visited a PCC consultation, with their main motivation being obtaining personalized information. The majority of participants agreed with 16 (88.9%) of 18 statements of the MAUQ, indicating high user satisfaction. The mean rating was 7.7 (SD 1.0) out of 10. Points of improvement included recruitment of the target group, simplification of the log-in system, and automation of manual tasks.

CONCLUSIONS

Nudging women through Pregnant Faster to stimulate pregnancy preparation and PCC uptake has proven feasible, but the inclusion criteria must be revised. A substantial number of PCC consultations were conducted, and this study will therefore be continued with an open cohort of 400 women, aiming to establish the (cost-)effectiveness of an updated version, named Pregnant Faster 2.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/45293.

Women's preconception psychological stress and birth outcomes in a fertility clinic: the EARTH study

Background

The epidemiologic literature on women's perceived stress in relation to perinatal outcomes has been inconclusive and does not consider the preconception window of exposure.

Objective

To evaluate whether women's preconception perceived stress is related to live birth, gestational age, and birthweight in a cohort receiving fertility treatment.

Methods

This observational study included women seeking fertility care at the Massachusetts General Hospital (2004-2019). During preconception, women provided information on their psychological stress using the short version of the validated Perceived Stress Scale 4 (PSS-4). We used regression models to evaluate the associations of stress with live birth (N = 768 attempting to conceive) and perinatal outcomes (N = 413 live births) while adjusting for confounders. Stratified analyses by mode of conception [natural, intrauterine insemination (IUI), and IVF (in vitro fertilization)] and selected socioeconomic factors (race, education, and income) were also conducted.

Results

Higher psychological stress was negatively associated with the overall probability of live birth (adjusted RR = 0.95, 95% CI: 0.92, 0.98), particularly among women conceiving using IVF. However, we found no association between women's psychological stress and gestational age and birth weight in the overall analyses and also stratified by mode of conception. Similarly, we observed no differences in women's psychological stress with any of the measured outcomes by socioeconomic factors.

Discussion

These results highlight the importance of considering the preconception window and mode of conception when evaluating the relationship between women's preconception stress and live birth.

Current preconception care practice in the Netherlands - An evaluation study among birth care professionals

OBJECTIVE

To evaluate the current practice of preconception care in the Netherlands and the perceptions of birth care professionals concerning preconception care.

METHODS

We have developed a digital questionnaire and conducted a cross-sectional study by distributing the questionnaire among 102 organisations: 90 primary care midwifery practices and obstetric departments of 12 hospitals in the Southwest region of the Netherlands between December 2020 and March 2021. One birth care professional per organization was asked to complete the questionnaire. Descriptive statistics were used to present the results.

FINDINGS

Respondents of eighty-three organisations (81.4 %) filled in the questionnaire, of whom 74 respondents were independent primary care midwives and 9 respondents were obstetricians. Preconception care mostly consisted of an individual consultation in which personalized health and lifestyle advice was given. Among the respondents, 44.4 % reported that the organization had a preconception care protocol. The way in which the consultation was carried out, as well as the health and lifestyle related questions asked, differed between respondents. More than 85 % of the respondents inquire about the following possible risk factors for complications: maternal illnesses, obstetric history, folic acid supplement intake, alcohol intake, smoking, substance abuse, hereditary disease, prescription medication, dietary habits, overweight, and birth defects in the family. The respondents acknowledged that preconception care should be offered to all couples who wish to become pregnant, as opposed to offering preconception care only to those with an increased risk of complications. Still, respondents do not receive many questions regarding the preconception period or requests for preconception care consultations.

KEY CONCLUSION

Birth care professionals acknowledge the need for preconception care for all couples. In the Netherlands, preconception care consists mostly of an individual consultation with recommendations for health and lifestyle advice. However, the identification of risk factors varies between birth care professionals and less than half of the respondents indicate that they have a protocol available in their practice. Furthermore, the demand of parents-to-be for preconception care is low. More research, that includes more obstetricians, is necessary to investigate if there is a difference between the care provided by primary care midwives and obstetricians.

IMPLICATIONS FOR PRACTICE

To increase the awareness and uptake of preconception care, it would be prudent to emphasize its importance to parents-to-be and professionals, and actively promote the use of widespread, standardized protocols for birth care professionals.

Place-Based Developmental Research: Conceptual and Methodological Advances in Studying Youth Development in Context

Scientists have, for some time, recognized that development unfolds in numerous settings, including families, schools, neighborhoods, and organized and unorganized activity settings. Since the turn of the 20th century, the body of mainstream neighborhood effects scholarship draws heavily from the early 20th century Chicago School of Sociology frameworks and have been situating development in neighborhood contexts and working to identify the structures and processes via which neighborhoods matter for a range of developmental outcomes, especially achievement, behavioral and emotional problems, and sexual activity. From this body of work, two new areas of developmental scholarship are emerging. Both areas are promising for advancing an understanding of child development in context. First, cultural-developmental neighborhood researchers are advancing neighborhood effects research that explicitly recognizes the ways that racial, ethnic, cultural, and immigrant social positions matter for neighborhood environments and for youths' developmental demands, affordances, experiences, and competencies. This body of work substantially expands the range of developmental outcomes examined in neighborhood effects scholarship to recognize normative physical, emotional, cognitive, behavioral, social, and cultural competencies that have largely been overlooked in neighborhood effects scholarship that espoused a more color-blind developmental approach. Second, activity space neighborhood researchers are recognizing that residential neighborhoods have important implications for broader activity spaces-or the set of locations and settings to which youth are regularly exposed, including, for example, schools, work, organized activities, and hang-outs. They are using newer technologies and geographic frameworks to assess exposure to residential neighborhood and extra-neighborhood environments. These perspectives recognize that time (i.e., from microtime to mesotime) and place are critically bound and that exposures can be operationalized at numerous levels of the ecological system (i.e., from microsystems to macrosystems). These frameworks address important limitations of prior development in context scholarship by addressing selection and exposure. Addressing selection involves recognizing that families have some degree of choice when selecting into settings and variables that predict families' choices (e.g., income) also predict development. Considering exposure involves recognizing that different participants or residents experience different amounts of shared and nonshared exposures, resulting in both under-and over-estimation of contextual effects. Activity space scholars incorporate exposure to the residential neighborhood environments, but also to other locations and settings to which youth are regularly exposed, like schools, after-school settings, work, and hang-outs. Unfortunately, the cultural-development and activity space streams, which have both emerged from early 20th century work on neighborhood effects on development, have been advancing largely independently. Thus, the overarching aim of this monograph is to integrate scholarship on residential neighborhoods, cultural development, and activity spaces to advance a framework that can support a better understanding of development in context for diverse groups. In Chapters I and II we present the historical context of the three streams of theoretical, conceptual, and methodological research. We also advance a comprehensive cultural-developmental activity space framework for studying development in context among children, youth, and families that are ethnically, racially, and culturally heterogeneous. This framework actively recognized diversity in ethnic, racial, immigrant, and socioeconomic social positions. In Chapters III-V we advance specific features of the framework, focusing on: (1) the different levels of nested and nonnested ecological systems that can be captured and operationalized with activity space methods, (2) the different dimensions of time and exposures or experiences that can be captured and operationalized by activity space methods, and (3) the importance of settings structures and social processes for identifying underlying mechanisms of contextual effects on development. Structures are setting features related to the composition and spatial arrangement of people and institutions (e.g., socioeconomic disadvantage, ethnic/racial compositions). Social processes represent the collective social dynamics that take place in settings, like social interactions, group activities, experiences with local institutions, mechanisms of social control, or shared beliefs. In Chapter VI, we highlight a range of methodological and empirical exemplars from the United States that are informed by our comprehensive cultural-developmental activity space framework. These exemplars feature both quantitative and qualitative methods, including method mixing. These exemplars feature both quantitative and qualitative methods, including method mixing. The exemplars also highlight the application of the framework across four different samples from populations that vary in terms of race, ethnicity, gender, age, socioeconomic status (SES), geographic region, and urbanicity. They capture activity space characteristics and features in a variety of ways, in addition to incorporating family shared and nonshared activity space exposures. Finally, in Chapter VII we summarize the contributions of the framework for advancing a more comprehensive science of development in context, one that better realizes major developmental theories emphasizing persons, processes, contexts, and time. Additionally, we offer a place-based, culturally informed developmental research agenda to meet the needs of an increasingly diverse population.

Neighborhood gentrification, displacement, and severe maternal morbidity in California

Gentrification, a racialized and profit-driven process in which historically disinvested neighborhoods experience an influx of development that contributes to the improvement of physical amenities, increasing housing costs, and the dispossession and displacement of existing communities, may influence the risk of severe maternal morbidity (SMM). Leveraging a racially diverse population-based sample of all live hospital births in California between 2006 and 2017, we examined associations between neighborhood-level gentrification and SMM. SMM was defined as having one of 21 procedures and diagnoses, as described in the SMM index developed by Centers for Disease Control and Prevention. We compared three gentrification measures to determine which operationalization best captures aspects of gentrification most salient to SMM: Freeman, Landis 3-D, and Urban Displacement Project Gentrification and Displacement Typology. Descriptive analysis assessed bivariate associations between gentrification and birthing people's characteristics. Overall and race and ethnicity-stratified mixed-effects logistic models assessed associations between gentrification and SMM, adjusting for individual sociodemographic and pregnancy factors while accounting for clustering by census tract. The study sample included 5,256,905 births, with 72,718 cases of SMM (1.4%). The percentage of individuals living in a gentrifying neighborhood ranged from 5.7% to 11.7% across exposure assessment methods. Net of individual and pregnancy-related factors, neighborhood-level gentrification, as measured by the Freeman method, was protective against SMM (OR = 0.89, 95% CI: 0.86-0.93); in comparison, gentrification, as measured by the Gentrification and Displacement Typology, was associated with greater risk of SMM (OR = 1.18, 95% CI: 1.14-1.23). These associations were significant among non-Hispanic White, non-Hispanic Black, and Hispanic individuals. Findings demonstrate that gentrification plays a role in shaping the risk of SMM among birthing people in California. Differences in how gentrification is conceptualized and measured, such as an emphasis on housing affordability compared to a broader characterization of gentrification's multiple aspects, may explain the heterogeneity in the directions of observed associations.

Stimulating the Uptake of Preconception Care by Women With a Vulnerable Health Status Through mHealth App-Based Nudging (Pregnant Faster): Cocreation Design and Protocol for a Cohort Study

BACKGROUND

Women with a low socioeconomic status often have a vulnerable health status due to an accumulation of health-deteriorating factors such as poor lifestyle behaviors, including inadequate nutrition, mental stressors, and impaired health literacy and agency, which puts them at an unnecessary high risk of adverse pregnancy outcomes. Adequately preparing for pregnancy through preconception care (PCC) uptake and lifestyle improvement can improve these outcomes. We hypothesize that nudging is a successful way of encouraging engagement in PCC. A nudge is a behavioral intervention that changes choice behavior through influencing incentives. The mobile health (mHealth) app-based loyalty program Pregnant Faster aims to reward women in an ethically justified way and nudges to engage in pregnancy preparation by visiting a PCC consultation.

OBJECTIVE

Here, we first describe the process of the cocreation of the mHealth app Pregnant Faster that aims to increase engagement in pregnancy preparation by women with a vulnerable health status. Second, we describe the cohort study design to assess the feasibility of Pregnant Faster.

METHODS

The content of the app is based on the eHealth lifestyle coaching program Smarter Pregnancy, which has proven to be effective in ameliorating preconceptional lifestyle behaviors (folic acid, vegetables, fruits, smoking, and alcohol) and an interview study pertaining to the preferences of the target group with regard to an mHealth app stimulating PCC uptake. For moral guidance on the design, an ethical framework was developed based on the bioethical principles of Beauchamp and Childress. The app was further developed through iterative cocreation with the target group and health care providers. For 4 weeks, participants will engage with Pregnant Faster, during which opportunities will arise to earn coins such as reading informative blogs and registering for a PCC consultation. Coins can be spent on small fun rewards, such as folic acid, fruits, and mascara. Pregnant Faster's feasibility will be tested in a study including 40 women aged 18 to 45 years, who are preconceptional or <8 weeks pregnant, with a low educational level, and living in a deprived neighborhood. The latter 2 factors will serve as a proxy of a low socioeconomic status. Recruitment will take place through flyers, social media, and health care practices. After finalization, participants will evaluate the app through the "mHealth App Usability Questionnaire" and additional interviews or questionnaires.

RESULTS

Results are expected to be published by December 2023.

CONCLUSIONS

Pregnant Faster has been designed through iterative cocreation with the target group and health care professionals. With the designed study, we will test Pregnant Faster's feasibility. If overall user satisfaction and PCC uptake is achieved, the app will be further developed and the cohort will be continued with an additional 400 inclusions to establish effectiveness.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45293.

Do prenatal factors shape the risk for dementia?: A systematic review of the epidemiological evidence for the prenatal origins of dementia

PURPOSE

Prenatal factors such as maternal stress, infection and nutrition affect fetal brain development and may also influence later risk for dementia. The purpose of this systematic review was to provide an overview of all studies which investigated the association between prenatal factors and later risk for dementia.

METHODS

We systematically searched MEDLINE and Embase for original human studies reporting on associations between prenatal factors and dementia from inception to 23 November 2022. Prenatal factors could be any factor assessed during pregnancy, at birth or postnatally, provided they were indicative of a prenatal exposure. Risk of bias was assessed using the Newcastle Ottawa Scale. We followed PRISMA guidelines for reporting.

RESULTS

A total of 68 studies met eligibility criteria (including millions of individuals), assessing maternal age (N = 30), paternal age (N = 22), birth order (N = 15), season of birth (N = 16), place of birth (N = 13), prenatal influenza pandemic (N = 1) or Chinese famine exposure (N = 1), birth characteristics (N = 3) and prenatal hormone exposure (N = 4). We observed consistent results for birth in a generally less optimal environment (e.g. high infant mortality area) being associated with higher dementia risk. Lower and higher birth weight and prenatal famine exposure were associated with higher dementia risk. The studies on season of birth, digit ratio, prenatal influenza pandemic exposure, parental age and birth order showed inconsistent results and were hampered by relatively high risk of bias.

CONCLUSION

Our findings suggest that some prenatal factors, especially those related to a suboptimal prenatal environment, are associated with an increased dementia risk. As these associations may be confounded by factors such as parental socioeconomic status, more research is needed to examine the potential causal role of the prenatal environment in dementia.

Elective induction of labour and expectant management in late-term pregnancy: A prospective cohort study alongside the INDEX randomised controlled trial

Objective

To assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy.

Design

Multicentre prospective cohort study alongside RCT.

Setting

90 midwifery practices and 12 hospitals in the Netherlands.

Population

3642 low-risk women with uncomplicated singleton late-term pregnancy.

Main outcome measures

Composite adverse outcome (perinatal death, Apgar score 5' < 7, NICU admission, meconium aspiration syndrome), composite severe adverse perinatal outcome (all above with Apgar score 5' < 4 instead of < 7) and caesarean section.

Results

From 2012-2016, 3642 women out of 6088 eligible women for the INDEX RCT, participated in the cohort study for observational data collection (induction of labour n = 372; expectant management n = 2174; unknown preference/management strategy n = 1096).Adverse perinatal outcome occurred in 1.1 % (4/372) in the induction group versus 1.9 % (42/2174) in the expectant group (adjRR 0.56; 95 %CI: 0.17-1.79), with severe adverse perinatal outcome occurring in 0.3 % (1/372) versus 1.0 % (22/2174), respectively (adjRR 0.39; 95 % CI: 0.05-2.88). There were no stillbirths among all 3642 women; one neonatal death occurred in the unknown preference/management group. Caesarean section rates were 10.5 % (39/372) after induction and 8.9 % (193/2174) after expectant management (adjRR 1.32; 95 % CI: 0.95-1.84).A higher incidence of adverse perinatal outcome was observed in nulliparous compared to multiparous women. Nulliparous 1.8 % (3/170) in the induction group versus 2.6 % (30/1134) in the expectant management group (adjRR 0.58; 95 % CI 0.14-2.41), multiparous 0.5 % (1/201) versus 1.1 % (11/1039) (adjRR 0.54; 95 % CI 0.07-24.19). One maternal death due to amniotic fluid embolism occurred after elective induction at 41 weeks + 6 days.

Conclusion

In this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1 % versus 1.9 %) and severe adverse (0.3 % versus 1.0 %) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3642 women. Caesarean section rates were comparable.

Association between preterm births and socioeconomic development: analysis of national data

Background

The increasing prevalence of preterm birth, which is a global phenomenon, is attributable to the increased medical indications, artificial gestations, and some socioeconomic factors. This study was conducted to identify whether development and equality indices are associated with the incidence of preterm birth, specifically, spontaneous and elective preterm births.

Methods

This retrospective observational study comprised an analysis of data on live births from 2019 in Brazil and on socioeconomic indices that were derived from census information in 2017. Data were summarised using absolute and relative frequencies. Spearman’s correlation was used to determine the correlation between socioeconomic factors and the preterm birth rate. Multiple beta regression analysis was performed to determine the best model of socioeconomic covariates and preterm birth rate. The significance level was set at 5%.

Results

In 2019 in Brazil, the preterm birth rate was 11.03%, of which 58% and 42% were spontaneous and elective deliveries, respectively. For all preterm births, Spearman’s correlation varied from ρ = 0.4 for the Gini Index and ρ =  − 0.24 for illiteracy. The best fit modelled the spontaneous preterm birth fraction as a negative function of the Human Development Index (HDI). The best-fit model considered the expected elective preterm birth fraction as a positive function of the HDI and as a negative function of the Gini Index, which was used as a precision parameter.

Conclusions

We observed a reduction in the fraction of spontaneous preterm births; however, the distribution was not uniform in the territory: higher rates of spontaneous preterm birth were noticed in the north, northeast, and mid-west regions. Thus, areas with lower education levels and inequal income distribution have a higher proportion of spontaneous preterm birth. The fraction of elective preterm birth was positively associated with more advantaged indices of socioeconomic status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14376-2.

Determining Gentrification's Relationship to Birth Outcomes in Metropolitan California

There is inconsistent evidence as to whether gentrification, the increase of affluent residents into low-income neighborhoods, is detrimental to health. To date, there is no systematic evidence on how gentrification may matter for a range of birth outcomes across cities with varying characteristics. We utilize California's Birth Cohort File (2009-2012), Decennial Census data, and the American Community Survey (2008-2012) to investigate the relationship of gentrification to: preterm birth, low birthweight, and small-for-gestational-age across California. We find that socioeconomic gentrification is uniformly associated with better birth outcomes. Notably, however, we find that only places specifically experiencing increases in non-White gentrification had this positive impact. These associations vary somewhat by maternal characteristics and by type of gentrification measure utilized; discrepancies between alternative measurement strategies are explored. This study provides evidence that socioeconomic gentrification is positively related to birth outcomes and the race-ethnic character of gentrification matters, emphasizing the continued need to examine how gentrification may impact a range of health and social outcomes.

Experiences and needs of women in vulnerable situations receiving additional interventions in maternity care: a qualitative study

BACKGROUND

Tailoring an intervention to the needs and wishes of pregnant women in vulnerable situations (e.g., socioeconomic disadvantages) can reduce the risk of adverse outcomes and empower these women. A relatively high percentage of pregnant women in the North of the Netherlands are considered vulnerable to adverse pregnancy outcomes because of their low socioeconomic status and the intergenerational transmission of poverty. In order to improve perinatal and maternal health, next to standard prenatal care, various interventions for pregnant women in vulnerable situations have been developed. We do not know to what extent these additional interventions suit the needs of (pregnant) women. Therefore, the aim of this study is to gain insight into the experiences and needs of women in vulnerable situations who receive additional maternity care interventions in the Northern Netherlands.

METHODS

Qualitative research was performed. We used a phenomenological framework, which is geared towards understanding people's experiences in the context of their everyday lives. In-depth semi-structured interviews were conducted with 17 pregnant women in vulnerable situations living in the Northern Netherlands. A thematic analysis was carried out.

RESULTS

We found three themes that reflect the experiences and needs of pregnant women in vulnerable situations in relation to the intervention they receive. These themes relate to the care provided by health professionals, to the impact of being offered an intervention, and to practical issues related to receiving an additional intervention. We found that the needs of pregnant women in vulnerable situations who received an additional maternity care intervention varied. This variation in needs was mainly related to practical issues. Women also expressed common needs, namely the desire to have control over their situation, the wish to receive tailor-made information about the intervention, and the wish for the intervention to be specifically tailored to their circumstances.

CONCLUSIONS

Living in vulnerable situations and being offered additional care evoked diverse reactions and emotions from pregnant women. We recommend that health professionals ensure open and clear communication with women, that they ensure continuity of care and relationship-centered care, and that they become aware of the process of stigmatization of women in vulnerable situations.

Mediators of socioeconomic inequalities in preterm birth: a systematic review

BACKGROUND

Rates of preterm birth are substantial with significant inequalities. Understanding the role of risk factors on the pathway from maternal socioeconomic status (SES) to preterm birth can help inform interventions and policy. This study therefore aimed to identify mediators of the relationship between maternal SES and preterm birth, assess the strength of evidence, and evaluate the quality of methods used to assess mediation.

METHODS

Using Scopus, Medline OVID, "Medline In Process & Other Non-Indexed Citation", PsycINFO, and Social Science Citation Index (via Web of Science), search terms combined variations on mediation, socioeconomic status, and preterm birth. Citation and advanced Google searches supplemented this. Inclusion criteria guided screening and selection of observational studies Jan-2000 to July-2020. The metric extracted was the proportion of socioeconomic inequality in preterm birth explained by each mediator (e.g. 'proportion eliminated'). Included studies were narratively synthesised.

RESULTS

Of 22 studies included, over one-half used cohort design. Most studies had potential measurement bias for mediators, and only two studies fully adjusted for key confounders. Eighteen studies found significant socioeconomic inequalities in preterm birth. Studies assessed six groups of potential mediators: maternal smoking; maternal mental health; maternal physical health (including body mass index (BMI)); maternal lifestyle (including alcohol consumption); healthcare; and working and environmental conditions. There was high confidence of smoking during pregnancy (most frequently examined mediator) and maternal physical health mediating inequalities in preterm birth. Significant residual inequalities frequently remained. Difference-of-coefficients between models was the most common mediation analysis approach, only six studies assessed exposure-mediator interaction, and only two considered causal assumptions.

CONCLUSIONS

The substantial socioeconomic inequalities in preterm birth are only partly explained by six groups of mediators that have been studied, particularly maternal smoking in pregnancy. There is, however, a large residual direct effect of SES evident in most studies. Despite the mediation analysis approaches used limiting our ability to make causal inference, these findings highlight potential ways of intervening to reduce such inequalities. A focus on modifiable socioeconomic determinants, such as reducing poverty and educational inequality, is probably necessary to address inequalities in preterm birth, alongside action on mediating pathways.

Protective Places: the Relationship between Neighborhood Quality and Preterm Births to Black Women in Oakland, California (2007-2011)

Black women have the highest incidence of preterm birth (PTB). Upstream factors, including neighborhood context, may be key drivers of this increased risk. This study assessed the relationship between neighborhood quality, defined by the Healthy Places Index, and PTB among Black women who lived in Oakland, California, and gave birth between 2007 and 2011 (N = 5418 women, N = 107 census tracts). We found that, compared with those living in lower quality neighborhoods, women living in higher quality neighborhoods had 20-38% lower risk of PTB, independent of confounders. Findings have implications for place-based research and interventions to address racial inequities in PTB.

Unsupervised Learning Applied to the Stratification of Preterm Birth Risk in Brazil with Socioeconomic Data

Preterm birth (PTB) is a phenomenon that brings risks and challenges for the survival of the newborn child. Despite many advances in research, not all the causes of PTB are already clear. It is understood that PTB risk is multi-factorial and can also be associated with socioeconomic factors. Thereby, this article seeks to use unsupervised learning techniques to stratify PTB risk in Brazil using only socioeconomic data. Through the use of datasets made publicly available by the Federal Government of Brazil, a new dataset was generated with municipality-level socioeconomic data and a PTB occurrence rate. This dataset was processed using various unsupervised learning techniques, such as k-means, principal component analysis (PCA), and density-based spatial clustering of applications with noise (DBSCAN). After validation, four clusters with high levels of PTB occurrence were discovered, as well as three with low levels. The clusters with high PTB were comprised mostly of municipalities with lower levels of education, worse quality of public services-such as basic sanitation and garbage collection-and a less white population. The regional distribution of the clusters was also observed, with clusters of high PTB located mostly in the North and Northeast regions of Brazil. The results indicate a positive influence of the quality of life and the offer of public services on the reduction in PTB risk.

Neighborhood poverty, intergenerational mobility, and early developmental health in a population birth cohort

Living in a neighborhood with high levels of intergenerational mobility is associated with better childhood cognition and behavior as well as adult health. Nevertheless, it is unclear if such differences originate earlier, and thus if neighborhood intergenerational mobility is associated with health differences at birth. To address this question, we examined whether neighborhood intergenerational mobility, independent of neighborhood poverty, was associated with low birth weight (LBW) in a population-based cohort of singleton children born in California in 2017 (n = 426,873). Although increased neighborhood mobility was associated with a decreased likelihood of LBW, it was no longer associated with LBW (OR = 0.98, CI = 0.96, 1.00) after adjusting for neighborhood poverty. Meanwhile, neighborhood poverty was associated with LBW (OR = 1.04, CI = 1.02, 1.05) after accounting for mobility, with the odds of LBW 9.4% higher among children born where neighborhood poverty was in the 90th percentile compared with children born where neighborhood poverty was in the 10th percentile. Findings indicate that neighborhood poverty, but not intergenerational mobility, is a robust and independent correlate of increased LBW births, and thus early developmental health. These findings also suggest that the role of neighborhood intergenerational mobility in child and adult health outcomes may emerge later in development, independent of LBW, or that the role of neighborhood intergenerational mobility in LBW may be indirectly mediated through exposure to neighborhood poverty.

Assessing the relationship between adverse pregnancy outcomes and area-level deprivation in Wales 2014-2019: a national population-based cross-sectional study

OBJECTIVES

The aim of this study was to assess the relationship between deciles of area-level deprivation and seven adverse pregnancy outcomes in Wales.

DESIGN

Cross-sectional analysis.

SETTING

64 699 live births in Wales from 31 March 2014 to 16 September 2019.

PRIMARY OUTCOME VARIABLE

We examined each of the following seven adverse pregnancy outcomes: (1) small for gestational age (SGA); (2) large for gestational age; (3) preterm birth; (4) third-degree or fourth-degree perineal tear; (5) major postpartum haemorrhage (MPPH); (6) a lower Apgar score at 5 min and (7) emergency caesarean section.

RESULTS

There was no significant association between increasing aggregate measures of area-level deprivation and the adverse pregnancy outcomes we studied. Women living in an area with greater access to services are more likely to have a baby that is SGA (1.27, 95% CI 1.11 to 1.49), have a greater likelihood of a perineal tear (1.74, 95% CI 1.15 to 2.61), are significantly less likely to have MPPH (0.79, 95% CI 0.64 to 0.96), have a baby with an Apgar score of 0.26 higher (95% CI 0.22 to 0.29) and are significantly less likely to have an emergency caesarean section (0.81, 95% CI 0.73 to 0.88). Women living in areas with higher employment (0.26, 95% CI 0.19 to 0.36) and better health (0.26, 95% CI 0.19 to 0.35) were less likely to experience perineal tear.

CONCLUSIONS

There was no clear social-spatial gradient in area-level deprivation and adverse pregnancy outcomes. We found a stronger association for individual-level behavioural risk factors than area-level factors. These findings support the benefits that accessible and holistic person-centred care may bring through addressing individual behavioural risk factors. There is a need for improved data completeness and further individual-level data on risk factors such as employment and income to better understand the role which may be played by population-level policies and their pathways to affecting outcomes.

Association of neighbourhood socioeconomic trajectories with preterm birth and small-for-gestational-age in the Netherlands: a nationwide population-based study

BACKGROUND

Adverse birth outcomes have serious health consequences, not only during infancy but throughout the entire life course. Most evidence linking neighbourhood socioeconomic status (SES) to birth outcomes is based on cross-sectional SES measures, which do not reflect neighbourhoods' dynamic nature. We investigated the association between neighbourhood SES trajectories and adverse birth outcomes, i.e. preterm birth and being small-for-gestational-age (SGA), for births occurring in the Netherlands between 2003 and 2017.

METHODS

We linked individual-level data from the Dutch perinatal registry to the Netherlands Institute for Social Research neighbourhood SES scores. Based on changes in their SES across four-year periods, neighbourhoods were categorised into seven trajectories. To investigate the association between neighbourhood SES trajectories and birth outcomes we used adjusted multilevel logistic regression models.

FINDINGS

Data on 2 334 036 singleton births were available for analysis. Women living in stable low-SES neighbourhoods had higher odds of preterm birth (OR[95%CI]= 1·12[1·07-1·17]) and SGA (OR[95%CI]= 1·19[1·15-1·23]), compared to those in high SES areas. Higher odds of preterm birth (OR[95%CI]= 1·12[1·05-1·20]) and SGA (OR[95%CI]=1·12[1·06-1·18]) were also observed for those living in areas declining to low SES. Women living in a neighbourhood where SES improved from low to medium showed higher odds of preterm birth (OR[95%CI]= 1·09[1·02-1·18]), but not of SGA (OR[95%CI]= 1·04[0.98-1·10]). The odds of preterm or SGA birth in other areas were comparable to those seen in high SES areas.

INTERPRETATION

In the Netherlands, disadvantaged neighbourhood SES trajectories were associated with higher odds of adverse birth outcomes. Longitudinal neighbourhood SES measures should also be taken into account when selecting a target population for public health interventions.

FUNDING

Erasmus Initiative Smarter Choices for Better Health.

Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association

The United States has the highest maternal mortality rates among developed countries, and cardiovascular disease is the leading cause. Therefore, the American Heart Association has a unique role in advocating for efforts to improve maternal health and to enhance access to and delivery of care before, during, and after pregnancy. Several initiatives have shaped the time course of major milestones in advancing maternal and reproductive health equity in the United States. There have been significant strides in improving the timeliness of data reporting in maternal mortality surveillance and epidemiological programs in maternal and child health, yet more policy reforms are necessary. To make a sustainable and systemic impact on maternal health, further efforts are necessary at the societal, institutional, stakeholder, and regulatory levels to address the racial and ethnic disparities in maternal health, to effectively reduce inequities in care, and to mitigate maternal morbidity and mortality. In alignment with American Heart Association's mission "to be a relentless force for longer, healthier lives," this policy statement outlines the inequities that influence disparities in maternal outcomes and current policy approaches to improving maternal health and suggests additional potentially impactful actions to improve maternal outcomes and ultimately save mothers' lives.

Social Determinants of Health and Adverse Outcomes in Adolescent Pregnancies

The association between adolescent childbearing and adverse maternal and birth outcomes has been well documented. Adverse adolescent pregnancy outcomes are associated with substantial risk of long-term morbidities for the young mother and their newborns. Multiple levels of social disadvantage have been related to adverse pregnancy outcomes among adolescent mothers. Patterns of cumulative social adversity define the most marginalized group of adolescents at the highest risk of experiencing adverse maternal and birth outcomes. Using a social determinants of health (SDOH) framework, we present an overview of the current scientific evidence on the influence of these conditions on adolescent pregnancy outcomes. Multiple SDOH such as residence in remote areas, low educational attainment, low socioeconomic status, and lack of family and community support have been linked with increased risk of adverse pregnancy outcomes among adolescents. Based on the PROGRESS-Plus equity framework, this review highlights some SDOH aspects that perinatal health researchers, clinicians, and policy makers should consider in the context of adolescent pregnancies. There is a need to acknowledge the intersectional nature of multiple SDOH when formulating clinical and societal interventions to address the needs of the most marginalized adolescent in this critical period of life.

Prenatal Exposure to Favorable Social and Environmental Neighborhood Conditions Is Associated with Healthy Pregnancy and Infant Outcomes

Neighborhood and individual level risks commonly co-occur for pregnant women and may cumulatively contribute to birth outcomes. Moreover, the relationship between favorable social and environmental neighborhood conditions and perinatal outcomes has been understudied. This study considered the accumulated impact of prenatal exposure to positive neighborhood social, environmental, and educational conditions in relation to maternal health during pregnancy and birth size outcomes. In a prospective study of a multi-ethnic and socioeconomically diverse cohort (n = 239) of pregnant women and their infants, neighborhoods were characterized by the Child Opportunity Index (COI), a census-tract composite indicator representing favorable social, environmental, and educational community conditions. Adjusted generalized estimating equations showed that favorable neighborhood conditions promoted the growth of longer and heavier infant bodies, and reduced the risk of intrauterine growth restriction. The associations were stronger for female versus male infants, though not significantly different. Moreover, COI was associated with better maternal mental health and diet during pregnancy; diet significantly mediated the association between COI and birth size outcomes. This study underscores the importance of considering the accumulated benefit of neighborhood assets for maternal and infant health. Interventions that capitalizes on the full range of contextual assets in which mothers live may promote pregnancy health and fetal growth.

Characteristics associated with downward residential mobility among birthing persons in California

BACKGROUND

Substantial research documents health consequences of neighborhood disadvantage. Patterns of residential mobility that differ by race/ethnicity and socioeconomic status (SES) may sort non-Hispanic (NH) Black and low-SES families into disadvantaged neighborhoods. In this study, we leverage a sibling-linked dataset to track residential mobility among birthing persons between pregnancies and investigate baseline characteristics associated with downward mobility, including race/ethnicity, SES, and pre-existing health conditions.

METHODS

We used a probabilistic linkage strategy to identify births to the same person between 2007 and 2015 (n = 624,222) and categorized downward residential mobility by quartile-level increases in neighborhood disadvantage. We defined strong downward mobility as a move from a neighborhood with very low (quartile 1) to very high (quartile 4) disadvantage and estimated the logit (i.e., log-odds) of strong downward mobility as a function of racial/ethnic, sociodemographic, and health characteristics of the birthing person and their first birth. We further explored the role of neighborhood housing affordability by examining changes in affordability from first to second birth by race/ethnicity.

RESULTS

NH Black birthing persons show an over three-fold increased odds of strong downward mobility relative to NH white birthing persons (OR = 3.34, CI: 2.91, 3.84). To a lesser extent, Hispanic race/ethnicity, WIC receipt, low educational attainment, obesity, and infant preterm birth (PTB) also predict strong downward mobility. Examination of changes in neighborhood affordability indicate that over half of NH Black birthing persons move to a more affordable neighborhood, compared to less than a quarter of NH white birthing persons, before the birth of their second child. Results remain consistent across outcomes, measures of neighborhood SES, and modified log-Poisson models.

CONCLUSION

We find an elevated risk of strong downward mobility among NH Black and low-SES birthing persons. Future research may identify other factors (e.g., housing affordability) that generate downward residential mobility to identify interventions that promote neighborhood equity.

Association between gestational phthalate exposure and newborn head circumference; impacts by race and sex

Observational and experimental studies report associations between gestational phthalate exposure and fetal development, yet few data exist to characterize phthalate effects on head circumference (HC) or to estimate the impact of race or sex. To address this data gap, we enrolled 152 African American and 158 white mothers with uncomplicated singleton pregnancies from the Charleston, South Carolina (USA) metropolitan area in a prospective birth cohort. Study participants provided up to two urine specimens during mid and late gestation, completed a study questionnaire, and allowed access to hospital birth records. We measured eight phthalate monoester metabolites using liquid chromatography with tandem mass spectrometry, and calculated molar sums of phthalate parent diesters. After specific gravity correction, we tested for associations between phthalates and neonatal HC (cm) and cephalization index (cm/g) using multiple informant linear regression with inverse probability weighting to account for selection bias between repeated urine sampling, adjusted for maternal race, age, body mass index, education, and smoking. We explored interactions by maternal race and infant sex. A doubling of urinary monoethyl phthalate (MEP) concentration was associated with a -0.49% (95%CI: -0.95%, -0.02%) smaller head circumference, although seven other phthalate metabolites were null. There were no statistically significant associations with cephalization index. HC was larger for whites than African American newborns (p < 0.0001) but similar for males and females (p = 0.16). We detected interactions for maternal race with urinary monobutyl phthalate (MBP; p = 0.03), monobenzyl phthalate (MBzP; p = 0.01), monoethylhexyl phthalate (MEHP; p = 0.05), monomethyl phthalate (MMP; p = 0.02), and the sum of dibutyl phthalate metabolites (∑DBP; p = 0.05), in which reduced HC circumference associations were stronger among whites than African Americans, and interactions for sex with MBP (p = 0.08) and MiBP (p = 0.03), in which associations were stronger for females than males. Our results suggest that gestational phthalate exposure is associated with smaller neonatal HC and that white mothers and female newborns have greater susceptibility.

Examining longitudinal patterns of individual neighborhood deprivation trajectories in the province of Quebec: A sequence analysis application

Exposure to neighborhood deprivation has been associated with a number of health, behavioral and sociological outcomes. However, many negative outcomes associated with deprivation have a long latency and may be influenced by varying exposure to neighborhoods throughout time. Capturing the longitudinal exposure to neighborhood deprivation is methodologically complex when one wishes to include life course notions of order, duration and timing. In a sample of 60,555 participants, aged 12 years and older (representative of the population of the Province of Quebec in Canada) our objectives were to: 1) Create an indicator for neighborhood deprivation trajectories; 2) compare trajectories with cross-sectional and cumulative neighborhood deprivation; 3) identify individual socioeconomic determinants of membership to a trajectory cluster. Using sequence analysis based on optimal matching and clustering around theoretical types, we grouped sequences in nine neighborhood deprivation trajectory clusters. We found that half (50%) of the participants were in a stable trajectory and did not transition significantly from one deprivation tertile to another during their sequence. A comparison between a cross-sectional indicator of neighborhood deprivation and the trajectories showed that only 42.2% of the participants had a cross-sectional deprivation at the index date representative of their whole trajectory. We also found, using logistic regression (adjusted for age, sex, number of residential moves) that having no high school diploma, living in a rural area and being an immigrant was strongly associated with a deprived stable trajectory. Sequence analysis is an effective tool to describe neighborhood deprivation trajectories in a sample representative of the Quebec population. Trajectories are a useful addition to a better understanding of the distribution of health outcomes because they provide information about the order and accumulation of longitudinal exposures to neighborhood and seem to be associated with specific individual socioeconomic characteristics such as education, urbanity, and immigration status.

Association between maternal human immunodeficiency virus infection and preterm birth: A matched case-control study from a pregnancy outcome registry

This study aimed to evaluate the relationships between different types of antiretroviral therapy (ART) and preterm birth.Preterm birth was studied among all singleton pregnancies and compared between human immunodeficiency virus (HIV)-infected and uninfected women.We performed a matched case-control study from the pregnancy outcome registry of Cayenne Hospital. HIV-infected and uninfected women who delivered in the maternity ward of Cayenne Hospital from January 1, 2013 to December 31, 2015 were studied. We conducted an initial analysis to determine the risk factors for preterm birth among HIV-infected pregnant women. We also evaluated associations between exposure to antiretroviral therapy (ART) and preterm birth.There were 8682 deliveries; of these, 117 involved HIV-infected women, representing a prevalence of 1.34%. There were 470 controls. The sociodemographic characteristics were comparable. HIV-infected women were more likely to experience preterm birth (adjusted odds ratio [AOR] = 3.9, 95% confidence interval [CI] 1.5-9.9). Overall, 95.73% of the women received antiretroviral therapy before becoming pregnant, and they were in good clinical condition. The median CD4 count at the beginning of pregnancy was 500 cells/mm3 (357-722). Additionally, 53% of HIV-infected women had an undetectable viral load count (<20 copies/mL). Their median haemoglobin level was 120 g/L (100-120). There were 2 human immunodeficiency virus-infected babies. A higher rate of preterm birth was associated with protease inhibitor-based ART than a reverse transcriptase inhibitor-based ART regimen. The sample size being small this result would be considered with caution.The preterm birth rate among HIV-infected pregnant women was twice that of the general population; this trend was not explained by sociodemographic characteristics. Preterm birth was independently associated with combination ART, especially with ritonavir-boosted protease inhibitor therapy during pregnancy.

Maternal Morbidity and Mortality: Are We Getting to the "Heart" of the Matter?

Cardiovascular disease (CVD), including hypertensive disorders of pregnancy (HDP) and peripartum cardiomyopathy, is a leading cause of pregnancy-related death in the United States. Women who are African American or American Indian/Alaskan Native, have HDP, are medically underserved, are older, or are obese have a major risk for the onset and/or progression of CVD during and after pregnancy. Paradoxically, women with no preexisting chronic conditions or risk factors also experience significant pregnancy-related cardiovascular (CV) complications. The question remains whether substantial physiologic stress on the CV system during pregnancy reflected in hemodynamic, hematological, and metabolic changes uncovers subclinical prepregnancy CVD in these otherwise healthy women. Equally important and similarly understudied is the concept that women's long-term CV health could be detrimentally affected by adverse pregnancy outcomes, such as preeclampsia, gestational hypertension, and diabetes, and preterm birth. Thus, a critical life span perspective in the assessment of women's CV risk factors is needed to help women and health care providers recognize and appreciate not only optimal CV health but also risk factors present before, during, and after pregnancy. In this review article, we highlight new advancements in understanding adverse, pregnancy-related CV conditions and will discuss promising strategies or interventions for their prevention, diagnosis, and treatment.

Mental Health and Maternal Mortality-When New Life Doesn't Bring Joy

OBJECTIVE

To characterize the incidence and risk factors associated with maternal suicide during the peripartum period in an Alberta population. Our secondary objective was to characterize the incidence and risk factors associated with traumatic death in this same population.

METHODS

This is a retrospective cohort study compared all-cause mortality with death by trauma (suicide, homicide, MVA, drug toxicity) using data collected by the Alberta Perinatal Health Program from 1998 to 2015. Data were summarized using descriptive statistics. The maternal mortality rate was calculated, and χ² tests were used to determine between group differences with the statistical significance set at P < 0.05.

RESULTS

There were 206 perinatal maternal deaths in Alberta from 1998 to 2015; 68 (33%) were due to trauma, 17 (8%) were the result of suicide, 4 (2%) were the result of homicide, and 24 (12%) were related to drug toxicity. The pregnancy-related maternal mortality rate for suicide up to 365 days after birth was 2.05 deaths per 100 000 deliveries. Of these, 29.4% occurred during pregnancy and 70.6%, in the first year postpartum. For homicides, 62.5% of occurred in pregnancy and 37.5% occurred in the first year postpartum.

CONCLUSION

Close to 1 in 5 maternal deaths in Alberta is related to suicide or drug toxicity. We must escalate strategies to prevent deaths from suicide and drug toxicity, as well as increase funding for mental health and addictions screening and treatment.

The role of neighbourhood socioeconomic status in large for gestational age

OBJECTIVE

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

SETTING AND PATIENT

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

METHOD

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

RESULTS

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

CONCLUSION

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

An Italian Network of Population-Based Birth Cohorts to Evaluate Social and Environmental Risk Factors on Pregnancy Outcomes: The LEAP Study

In Italy, few multicentre population-based studies on pregnancy outcomes are available. Therefore, we established a network of population-based birth cohorts in the cities of Turin, Reggio Emilia, Modena, Bologna, and Rome (northern and central Italy), to study the role of socioeconomic factors and air pollution exposure on term low birthweight, preterm births and the prevalence of small for gestational age. In this article, we will report the full methodology of the study and the first descriptive results. We linked 2007–2013 delivery certificates with municipal registry data and hospital records, and selected singleton livebirths from women who lived in the cities for the entire pregnancy, resulting in 211,853 births (63% from Rome, 21% from Turin and the remaining 16% from the three cities in Emilia-Romagna Region). We have observed that the association between socioeconomic characteristics and air pollution exposure varies by city and pollutant, suggesting a possible effect modification of both the city and the socioeconomic position on the impact of air pollution on pregnancy outcomes. This is the largest Italian population-based birth cohort, not distorted by selection mechanisms, which has also the advantage of being sustainable over time and easily transferable to other areas. Results from the ongoing multivariable analyses will provide more insight on the relative impact of different strands of risk factors and on their interaction, as well as on the modifying effect of the contextual characteristics. Useful recommendations for strategies to prevent adverse pregnancy outcomes may eventually derive from this study.

Socioeconomic Inequalities in Small-for-Gestational-Age Births Before and During the Economic Crisis: An Ecologic Study of Trends in 13 Spanish Cities

Economic recessions can increase socioeconomic inequalities in health. The objective of this study was to analyze socioeconomic inequalities in small-for-gestational-age (SGA) births before and during the Spanish economic crisis. We conducted an ecological study of trends based on 2 periods before the crisis (1999-2003 and 2004-2008) and another during the crisis (2009-2013). The study population was Spanish women resident in 13 cities who had given birth during 1999-2013. The prevalence of SGA was calculated for each census tract. A hierarchical Bayesian model was used to obtain the prevalence ratio (PR) and 95% credible intervals (CI). We analyzed the association between SGA and socioeconomic deprivation in each period for each city and for 3 age groups. The PR was above 1 and statistically significant for all 3 time periods in most of the 13 cities. The differences in PR between periods were only statistically significant for Madrid (PR = 1.56, 95% CI 1.48-1.65 for 1999-2003; PR = 1.28, 95% CI 1.19-1.38 for 2004-2008) and Barcelona (PR = 0.99, 95% CI 0.87-1.12 for 2004-2008; PR = 1.20, 95% CI 1.05-1.36 for 2009-2013). Socioeconomic inequalities in SGA births in small areas (census tracts) of most Spanish cities studied remained stable before and during the economic crisis.

Neighborhood Privilege, Preterm Delivery, and Related Racial/Ethnic Disparities: An Intergenerational Application of the Index of Concentration at the Extremes

We assessed whether early childhood and adulthood experiences of neighborhood privilege, measured by the Index of Concentration at the Extremes (ICE), were associated with preterm delivery and related racial/ethnic disparities using intergenerationally linked birth records of 379,794 California-born primiparous mothers (born 1982-1997) and their infants (born 1997-2011). ICE measures during early childhood and adulthood approximated racial/ethnic and economic dimensions of neighborhood privilege and disadvantage separately (ICE-income, ICE-race/ethnicity) and in combination (ICE-income + race/ethnicity). Results of our generalized estimating equation models with robust standard errors showed associations for ICE-income and ICE-income + race/ethnicity. For example, ICE-income + race/ethnicity was associated with preterm delivery in both early childhood (relative risk (RR) = 1.12, 95% confidence interval (CI): 1.08, 1.17) and adulthood (RR = 1.07, 95% CI: 1.03, 1.11). Non-Hispanic black and Hispanic women had higher risk of preterm delivery than white women (RR = 1.32, 95% CI: 1.28, 1.37; and RR = 1.11, 95% CI: 1.08, 1.14, respectively, adjusting for individual-level confounders). Adjustment for ICE-income + race/ethnicity at both time periods yielded the greatest declines in disparities (for non-Hispanic black women, RR = 1.23, 95% CI: 1.18, 1.28; for Hispanic women, RR = 1.05, 95% CI: 1.02, 1.09). Findings support independent effects of early childhood and adulthood neighborhood privilege on preterm delivery and related disparities.

Small-Area Factors and Their Impact on Low Birth Weight-Results of a Birth Cohort Study in Bielefeld, Germany

Introduction: The location of residence is a factor possibly contributing to social inequalities and emerging evidence indicates that it already affects perinatal development. The underlying pathways remain unknown; theory-based and hypothesis-driven analyses are lacking. To address these challenges, we aim to establish to what extent small-area characteristics contribute to low birth weight (LBW), independently of individual characteristics. First, we select small-area characteristics based on a conceptual model and measure them. Then, we empirically analyse the impact of these characteristics on LBW. Material and methods: Individual data were provided by the birth cohort study "Health of infants and children in Bielefeld/Germany." The sample consists of 892 eligible women and their infants distributed over 80 statistical districts in Bielefeld. Small-area data were obtained from local noise maps, emission inventory, Google Street View and civil registries. A linear multilevel analysis with a two-level structure (individuals nested within statistical districts) was conducted. Results: The effects of the selected small-area characteristics on LBW are small to non-existent, no significant effects are detected. The differences in proportion of LBW based on marginal effects are small, ranging from zero to 1.1%. Newborns from less aesthetic and subjectively perceived unsafe neighbourhoods tend to have higher proportions of LBW. Discussion: We could not find evidence for negative effects of small-area factors on LBW, but our study confirms that obtaining adequate sample size, reliable measure of exposure and using available data for operationalisation of the small-area context represent the core challenges in this field of research.

Violence As a Direct Cause of and Indirect Contributor to Maternal Death

Background: Death during pregnancy and postpartum in the United States is an issue of urgent and growing concern. Mortality from obstetric-related causes is on the rise, and pregnancy-associated homicide remains a leading cause of death. It is unknown how the context in which women live contributes to their risk of obstetric or violent death during pregnancy and the postpartum period. This study aimed to quantify incidence of mortality from obstetric-related causes and violent death during pregnancy and up to 1-year postpartum, and to identify associations between state-level violent crime rates and incidence of pregnancy-related mortality and pregnancy-associated homicide. Materials and Methods: We conducted a retrospective, ecologic analysis of all pregnancy-associated homicides in 17 states participating in the National Violent Death Reporting System from 2011 to 2015. Pregnancy-related mortality was identified by International Classification of Diseases-10 code for underlying cause of death in death records issued in the same states and years, data provided by the National Center for Health Statistics. We characterized decedents of both violent and nonviolent maternal death (n = 174 and 1,617, respectively). Five-year mortality ratios (deaths per 100,000 live births) were estimated for both pregnancy-related mortality and pregnancy-associated homicide in every state. Poisson regression models estimated associations between violent crime and maternal death, adjusting for area-level socioeconomic conditions. Results: Both pregnancy-related mortality and pregnancy-associated homicide ratios were higher in states with higher rates of violent crime (relative risk [RR] = 1.05, 95% confidence interval [CI] = 1.01-1.12; RR = 1.17, 95% CI = 1.01-1.34, respectively). Conclusion: Broad population-wide violence prevention efforts may help reduce incidence of maternal mortality from both obstetric and violent causes.

The impact of periconceptional maternal lifestyle on clinical features and biomarkers of placental development and function: a systematic review

BACKGROUND

Worldwide, placenta-related complications contribute to adverse pregnancy outcomes, such as pre-eclampsia, fetal growth restriction and preterm birth, with implications for the future health of mothers and offspring. The placenta develops in the periconception period and forms the interface between mother and embryo/fetus. An unhealthy periconceptional maternal lifestyle, such as smoking, alcohol and under- and over-nutrition, can detrimentally influence placental development and function.

OBJECTIVE AND RATIONALE

The impact of maternal lifestyle on placental health is largely unknown. Therefore, we aim to summarize the evidence of the impact of periconceptional maternal lifestyle on clinical features and biomarkers of placental development and function throughout pregnancy.

SEARCH METHODS

A comprehensive search in Medline, Embase, Pubmed, The Cochrane Library Web of Science and Google Scholar was conducted. The search strategy included keywords related to the maternal lifestyle, smoking, alcohol, caffeine, nutrition (including folic acid supplement intake) and body weight. For placental markers throughout pregnancy, keywords related to ultrasound imaging, serum biomarkers and histological characteristics were used. We included randomized controlled trials and observational studies published between January 2000 and March 2017 and restricted the analysis to singleton pregnancies and maternal periconceptional lifestyle. Methodological quality was scored using the ErasmusAGE tool. A protocol of this systematic review has been registered in PROSPERO International prospective register of systematic reviews (PROSPERO 2016:CRD42016045596).

OUTCOMES

Of 2593 unique citations found, 82 studies were included. The median quality score was 5 (range: 0-10). The findings revealed that maternal smoking was associated with lower first-trimester placental vascularization flow indices, higher second- and third-trimester resistance of the uterine and umbilical arteries and lower resistance of the middle cerebral artery. Although a negative impact of smoking on placental weight was expected, this was less clear. Alcohol use was associated with a lower placental weight. One study described higher second- and third-trimester placental growth factor (PlGF) levels after periconceptional alcohol use. None of the studies looked at caffeine intake. Adequate nutrition in the first trimester, periconceptional folic acid supplement intake and strong adherence to a Mediterranean diet, were all associated with a lower resistance of the uterine and umbilical arteries in the second and third trimester. A low caloric intake resulted in a lower placental weight, length, breadth, thickness, area and volume. Higher maternal body weight was associated with a larger placenta measured by ultrasound in the second and third trimester of pregnancy or weighed at birth. In addition, higher maternal body weight was associated with decreased PlGF-levels.

WIDER IMPLICATIONS

Evidence of the impact of periconceptional maternal lifestyle on placental health was demonstrated. However, due to poorly defined lifestyle exposures and time windows of investigation, unstandardized measurements of placenta-related outcomes and small sample sizes of the included studies, a cautious interpretation of the effect estimates is indicated. We suggest that future research should focus more on physiological consequences of unhealthy lifestyle during the critical periconception window. Moreover, we foresee that new evidence will support the development of lifestyle interventions to improve the health of mothers and their offspring from the earliest moment in life.

Socioeconomic gradients of adverse birth outcomes and related maternal factors in rural and urban Alberta, Canada: a concentration index approach

OBJECTIVE

Using a summary measure of health inequalities, this study evaluated the distribution of adverse birth outcomes (ABO) and related maternal risk factors across area-level socioeconomic status (SES) gradients in urban and rural Alberta, Canada.

DESIGN

Cross-sectional study using a validated perinatal clinical registry and an area-level SES.

SETTING

The study was conducted in Alberta, Canada. Data about ABO and related maternal risk factors were obtained from the Alberta Perinatal Health Program between 2006 and 2012. An area-level SES index derived from census data (2006) was linked to the postal code at delivery.

PARTICIPANTS

Women (n=3 30 957) having singleton live births with gestational age ≥22 weeks.

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated concentration indexes to assess inequalities across SES gradients in both rural and urban areas (CIdx_R and CIdx_U, respectively) for spontaneous preterm birth (PTB), small for gestational age (SGA), large for gestational age (LGA), gestational hypertension, gestational diabetes, smoking and substance use during pregnancy and pre-pregnancy weight >91 kg.

RESULTS

The highest health inequalities disfavouring low SES groups were identified for substance abuse and smoking in rural areas (CIdx_R-0.38 and -0.23, respectively). Medium inequalities were identified for LGA (CIdx_R-0.08), pre-pregnancy weight >91 kg (CIdx_R-0.07), substance use (CIdx_U-0.15), smoking (CIdx_U-0.14), gestational diabetes (CIdx_U-0.10) and SGA (CIdx_U-0.07). Low inequalities were identified for PTB (CIdx_R-0.05; CIdx_U-0.05) and gestational diabetes (CIdx_R-0.04). Inequalities disfavouring high SES groups were identified for gestational hypertension (CIdx_R+0.04), SGA (CIdx_R+0.03) and LGA (CIdx_U+0.03).

CONCLUSIONS

ABO and related maternal risk factors were unequally distributed across the socioeconomic gradient in urban-rural settings, with the greatest concentrations in lower SES groups of rural areas. Future research is needed on underlying mechanisms driving SES gradients in perinatal health across the rural-urban spectrum.

Neighborhood Gun Violence and Birth Outcomes in Chicago

OBJECTIVES

To examine the association between gun violence and birth outcomes among women in Chicago.

METHODS

Using a 5-year set of birth files (2011-2015) merged with census and police data, birth outcomes including low birth weight (LBW, BW < 2500 g), preterm birth (PTB, < 37 weeks gestation), and small-for-gestational-age (SGA, BW < 10th percentile) were examined among non-Hispanic (NH) white, NH black, and Hispanic women in Chicago. Gun violence rates were categorized into tertiles. Multilevel, multiple logistic regression examined the effects of gun violence and race/ethnicity on birth outcomes.

RESULTS

Of 175,065 births, 10.6% of LBW, 10.6% of PTB, and 9.1% of SGA occurred in high violence tertile. Using white women in low violence tertile as reference, the OR for LBW among black women ranged 1.9-2.1 across all tertiles, and 0.8-1.2 among Hispanic women. OR for PTB for black women were 1.6-1.7 and 1.0-1.2 for Hispanic women, and OR for SGA for black women were 1.6-1.7 and for Hispanic women 0.9-1.0.

CONCLUSIONS FOR PRACTICE

In Chicago, race/ethnicity was associated with birth outcomes, regardless of the level of exposure to gun violence, in 2011-2015. The differences in racial/ethnic composition across the violence exposure levels suggest that, rather than gun violence alone, residential segregation and the geographic inequities likely contribute to disparate birth outcomes.

A review of maternal prenatal exposures to environmental chemicals and psychosocial stressors-implications for research on perinatal outcomes in the ECHO program

Exposures to environmental chemicals and psychosocial stressors during pregnancy have been individually associated with adverse perinatal outcomes related to birthweight and gestational age, but are not often considered in combination. We review types of psychosocial stressors and instruments used to assess them and classes of environmental chemical exposures that are known to adversely impact perinatal outcomes, and identify studies relevant studies. We discuss the National Institutes of Health's Environmental influences on Child Health Outcomes (ECHO) program that has combined existing longitudinal cohorts that include more than 50,000 children across the U.S. We describe future opportunities for investigators to use this important new resource for addressing relevant and critical research questions to maternal health. Of the 84 cohorts in ECHO, 38 collected data on environmental chemicals and psychosocial stressors and perinatal outcomes. The diverse ECHO pregnancy cohorts provide capacity to compare regions with distinct place-based environmental and social stressors.

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.

Pregnancy vulnerability in urban areas: a pragmatic approach combining behavioral, medico-obstetrical, socio-economic and environmental factors

Multiple risk factors are associated with adverse pregnancy outcomes (APO), but how all these different factors combine and accumulate remains unknown. The objective of this observational retrospective study was to describe the accumulation of multiple vulnerability markers in pregnant women living in an urban area. Women living in Besançon (France) who delivered between 2005 and 2009 were included. Individual data were collected from the obstetrical records while environmental exposures were collected using environmental prediction models. The accumulation of 15 vulnerability markers, grouped into six dimensions (maternal age, smoking, body mass index (BMI), socio-economic, medico-obstetrical and environmental vulnerabilities) was described and analyzed in comparison with four APO. Among the 3686 included women, 20.8% were aged under 20 or over 34 and 21.9% had an extreme pre-pregnancy BMI. 18.8% declared smoking during pregnancy. Women exposed to socio-economic, medico-obstetrical or environmental vulnerability were 14.2%, 31.6% and 42.4% respectively. While 20.6% were not exposed to any marker, 18.8% accumulated three or more dimensions. The risk of APO increased significantly with the cumulative number of vulnerabilities. Define and validate a vulnerability score could be useful to identify vulnerable women, adapt their pregnancy monitoring and help policy makers to implement appropriate education or health promotion programs.

Neighborhood Physical Disorder and Adverse Pregnancy Outcomes among Women in Chicago: a Cross-Sectional Analysis of Electronic Health Record Data

Adverse pregnancy outcomes increase infants' risk for mortality and future health problems. Neighborhood physical disorder may contribute to adverse pregnancy outcomes by increasing maternal chronic stress. Google Street View technology presents a novel method for assessing neighborhood physical disorder but has not been previously examined in the context of birth outcomes. In this cross-sectional study, trained raters used Google's Street View imagery to virtually audit a randomly sampled block within each Chicago census tract (n = 809) for nine indicators of physical disorder. We used an item-response theory model and spatial interpolation to calculate tract-level neighborhood physical disorder scores across Chicago. We linked these data with geocoded electronic health record data from a large, academic women's hospital in Chicago (2015-2017, n = 14,309 births). We used three-level hierarchical Poisson regression to estimate prevalence ratios for the associations of neighborhood physical disorder with preterm birth (overall and spontaneous), small for gestational age (SGA), and hypertensive disorder of pregnancy (HDP). After adjustment for maternal sociodemographics, multiparity, and season of birth, living in a neighborhood with high physical disorder was associated with higher prevalence of PTB, SGA, and HDP (prevalence ratios and 95% confidence intervals 1.21 (1.06, 1.39) for PTB, 1.13 (1.01, 1.37) for SGA, and 1.23 (1.07, 1.42) for HDP). Adjustment for neighborhood poverty and maternal health conditions (e.g., hypertension, diabetes, asthma, substance use) attenuated associations. Results suggest that an adverse neighborhood physical environment may contribute to adverse pregnancy outcomes. However, future work is needed to disentangle the unique contribution of physical disorder from other characteristics of disadvantaged neighborhoods.

The influence of socioeconomic status on gestational weight gain: a systematic review

Background

Despite a large number of publications regarding the association between socioeconomic status (SES) and gestational weight gain (GWG), the literature is inconsistent. We conducted a systematic review of current evidence relating to the association between SES and GWG, according to the Institute of Medicine (IOM) 2009 guidelines.

Methods

Six electronic databases were searched, with the final search run on first July 2016. The PRISMA Statement guidelines were followed and a modified version of the RTI Item Bank was used to assess risk of bias within studies. The primary outcome was inadequate, adequate or excessive GWG, as per the IOM guidelines.

Results

Sixteen studies were included. There was a positive skew in the number of studies that indicated that those who are less well educated are most at risk of gaining weight outside of the recommendations. Other measures of SES were not significantly associated with GWG.

Conclusions

Low educational attainment is likely to be associated with women gaining outside the IOM recommendations for GWG. Healthcare providers should provide additional support to pregnant women who are most at risk of gaining outside the recommendations, thus reducing the gap in health inequalities between those of high and low SES.

Neighbourhood Income and Risk of Having an Infant With Concomitant Preterm Birth and Severe Small for Gestational Age Birth Weight

OBJECTIVE

Socioeconomic position gradients have been individually demonstrated for preterm birth (PTB) at <37 weeks gestation and severe small for gestational age birth weight at <5th percentile (SGA). It is not known how neighbourhood income is related to the combination of PTB and severe SGA, a state reflective of greater placental dysfunction and higher risk of neonatal morbidity and mortality than PTB or severe SGA alone.

METHODS

This population-based study comprised all 1 367 656 singleton live births in Ontario from 2002 to 2011. Multinomial logistic regression was used to estimate the odds of PTB with severe SGA, PTB without severe SGA, and severe SGA without PTB, compared with neither PTB nor severe SGA, in relation to neighbourhood income quintile (Q). The highest income quintile, Q5, served as the exposure referent. Adjusted odds ratios (aORs) were adjusted for maternal age at delivery, parity, marital status, and world region of birth (Canadian Task Force Classification II-2).

RESULTS

Relative to women residing in Q5 (2.3 per 1000), the rate of PTB with severe SGA was highest among those in Q1 (3.6 per 1000), with an aOR of 1.34 (95% confidence interval [CI] 1.20-1.50). The corresponding aORs were 1.23 (95% CI 1.09-1.37) for Q2, 1.14 (95% CI 1.02-1.28) for Q3, and 1.06 (95% CI 0.95-1.20) for Q4. Less pronounced aORs were seen for each individual outcome of PTB and severe SGA.

CONCLUSION

Women residing in the lowest-income areas are at highest risk of having a fetus born too small and too soon. Future research should focus on identifying those women most predisposed to combined PTB and severe SGA.