Associations of neighborhood-level racial residential segregation with adverse pregnancy outcomes

Published:February 04, 2018DOI:


      Previous analyses utilizing birth certificate data have shown environmental factors such as racial residential segregation may contribute to disparities in adverse pregnancy outcomes. However, birth certificate data are ill equipped to reliably differentiate among small for gestational age, spontaneous preterm birth, and medically indicated preterm birth.


      We sought to utilize data from electronic medical records to determine whether residential segregation among Black women is associated with an increased risk of adverse pregnancy outcomes.

      Study Design

      The study population was composed of 4770 non-Hispanic Black women who delivered during the years 2009 through 2013 at a single urban medical center. Addresses were geocoded at the level of census tract, and this tract was used to determine the degree of residential segregation for an individual’s neighborhood. Residential segregation was measured using the Gi* statistic, a z-score that measures the extent to which the neighborhood racial composition deviates from the composition of the larger surrounding area. The Gi* statistic z-scores were categorized as follows: low (z < 0), medium (z = 0-1.96), and high (z > 1.96). Adverse pregnancy outcomes included overall preterm birth, spontaneous preterm birth, medically indicated preterm birth, and small for gestational age. Hierarchical logistic regression models accounting for clustering by census tract and repeated births among mothers were used to estimate odds ratios of adverse pregnancy outcomes associated with segregation.


      In high segregation areas, the prevalence of overall preterm birth was significantly higher than that in low segregation areas (15.5% vs 10.7%, respectively; P < .001). Likewise, the prevalence of spontaneous preterm birth and medically indicated preterm birth were higher in high (9.5% and 6.0%) vs low (6.2% and 4.6%) segregation neighborhoods (P < .001 and P = .046, respectively). The associations of high segregation with overall preterm birth (odds ratio, 1.31; 95% confidence interval, 1.02–1.69) and spontaneous preterm birth (odds ratio, 1.37; 95% confidence interval, 1.02–1.85) remained significant with adjustment for neighborhood poverty, insurance status, parity, and maternal medical conditions.


      Among non-Hispanic Black women in an urban area, high levels of segregation were independently associated with the higher odds of spontaneous preterm birth. These findings highlight one aspect of social determinants (ie, segregation) through which adverse pregnancy outcomes may be influenced and points to a potential target for intervention.

      Key words

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        • Matthews T.J.
        • MacDorman M.F.
        • Thoma M.E.
        Infant mortality statistics from the 2013 period linked birth/infant death data set.
        Natl Vital Stat Rep. 2015; 64: 1-30
        • Collins Jr., J.W.
        • David R.J.
        Racial disparity in low birth weight and infant mortality.
        Clin Perinatol. 2009; 36: 63-73
        • El-Sayed A.M.
        • Paczkowski M.
        • Rutherford C.G.
        • Keyes K.M.
        • Galea S.
        Social environments, genetics, and black-white disparities in infant mortality.
        Paediatr Perinat Epidemiol. 2015; 29: 546-551
        • Willis E.
        • McManus P.
        • Magallanes N.
        • Johnson S.
        • Majnik A.
        Conquering racial disparities in perinatal outcomes.
        Clin Perinatol. 2014; 41: 847-875
        • White K.
        • Borrell L.N.
        Racial/ethnic residential segregation: framing the context of health risk and health disparities.
        Health Place. 2011; 17: 438-448
        • Masi C.M.
        • Hawkley L.C.
        • Piotrowski Z.H.
        • Pickett K.E.
        Neighborhood economic disadvantage, violent crime, group density, and pregnancy outcomes in a diverse, urban population.
        Soc Sci Med. 2007; 65: 2440-2457
        • Ncube C.N.
        • Enquobahrie D.A.
        • Albert S.M.
        • Herrick A.L.
        • Burke J.G.
        Association of neighborhood context with offspring risk of preterm birth and low birthweight: a systematic review and meta-analysis of population-based studies.
        Soc Sci Med. 2016; 153: 156-164
        • Debbink M.P.
        • Bader M.D.
        Racial residential segregation and low birth weight in Michigan’s metropolitan areas.
        Am J Public Health. 2011; 101: 1714-1720
        • Mason S.M.
        • Messer L.C.
        • Laraia B.A.
        • Mendola P.
        Segregation and preterm birth: the effects of neighborhood racial composition in North Carolina.
        Health Place. 2009; 15: 1-9
        • Grady S.C.
        Racial disparities in low birthweight and the contribution of residential segregation: a multilevel analysis.
        Soc Sci Med. 2006; 63: 3013-3029
        • Culhane J.F.
        • Elo I.T.
        Neighborhood context and reproductive health.
        Am J Obstet Gynecol. 2005; 192: S22-S29
        • Wilcox A.J.
        On the importance–and the unimportance–of birthweight.
        Int J Epidemiol. 2001; 30: 1233-1241
        • Duryea E.L.
        • Hawkins J.S.
        • McIntire D.D.
        • Casey B.M.
        • Leveno K.J.
        A revised birth weight reference for the United States.
        Obstet Gynecol. 2014; 124: 16-22
        • Clausson B.
        • Cnattingius S.
        • Axelsson O.
        Preterm and term births of small for gestational age infants: a population-based study of risk factors among nulliparous women.
        Br J Obstet Gynaecol. 1998; 105: 1011-1017
        • Acevedo-Garcia D.
        • Osypuk T.L.
        Invited commentary: residential segregation and health–the complexity of modeling separate social contexts.
        Am J Epidemiol. 2008; 168: 1255-1258
        • Osypuk T.L.
        • Acevedo-Garcia D.
        Beyond individual neighborhoods: a geography of opportunity perspective for understanding racial/ethnic health disparities.
        Health Place. 2010; 16: 1113-1123
        • Getis A.
        • Ord J.K.
        The analysis of spatial association by use of distance statistics.
        Geogr Anal. 1992; 24: 189-206
        • Kershaw K.N.
        • Robinson W.R.
        • Gordon-Larsen P.
        • et al.
        Association of changes in neighborhood-level racial residential segregation with changes in blood pressure among black adults: the CARDIA study.
        JAMA Intern Med. 2017; 177: 996-1002
        • Behrman R.E.
        • Butler A.S.
        Preterm birth: causes, consequences, and prevention. Institute of Medicine (US) committee on understanding premature birth and assuring healthy outcomes.
        National Academies Collection: reports funded by National Institutes of Health, Washington (DC)2007
        • Premkumar A.
        • Henry D.E.
        • Moghadassi M.
        • Nakagawa S.
        • Norton M.E.
        The interaction between maternal race/ethnicity and chronic hypertension on preterm birth.
        Am J Obstet Gynecol. 2016; 215: 787.e1-787.e8
        • Sibai B.M.
        • Caritis S.N.
        • Hauth J.C.
        • et al.
        Preterm delivery in women with pregestational diabetes mellitus or chronic hypertension relative to women with uncomplicated pregnancies. The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.
        Am J Obstet Gynecol. 2000; 183: 1520-1524
        • Dejmek J.
        • Solansky I.
        • Podrazilova K.
        • Sram R.J.
        The exposure of nonsmoking and smoking mothers to environmental tobacco smoke during different gestational phases and fetal growth.
        Environ Health Perspect. 2002; 110: 601-606
        • Ray J.G.
        • Park A.L.
        • Bartsch E.
        • Feig D.S.
        • Booth G.L.
        Preterm birth and small for gestational birthweight in relation to maternal relative hypoglycemia and chronic hypertension.
        Eur J Obstet Gynecol Reprod Biol. 2017; 211: 220-222
        • Grady S.C.
        • Ramirez I.J.
        Mediating medical risk factors in the residential segregation and low birthweight relationship by race in New York City.
        Health Place. 2008; 14: 661-677
        • Gaskin D.J.
        • Dinwiddie G.Y.
        • Chan K.S.
        • McCleary R.R.
        Residential segregation and the availability of primary care physicians.
        Health Serv Res. 2012; 47: 2353-2376
        • Bower K.M.
        • Thorpe Jr., R.J.
        • Rohde C.
        • Gaskin D.J.
        The intersection of neighborhood racial segregation, poverty, and urbanicity and its impact on food store availability in the United States.
        Prev Med. 2014; 58: 33-39
        • Krivo L.J.
        • Byron R.A.
        • Calder C.A.
        • et al.
        Patterns of local segregation: do they matter for neighborhood crime?.
        Soc Sci Res. 2015; 54: 303-318
        • Qato D.M.
        • Daviglus M.L.
        • Wilder J.
        • Lee T.
        • Qato D.
        • Lambert B.
        “Pharmacy deserts” are prevalent in Chicago’s predominantly minority communities, raising medication access concerns.
        Health Aff (Millwood). 2014; 33: 1958-1965
        • Crandall M.
        • Sharp D.
        • Unger E.
        • et al.
        Trauma deserts: distance from a trauma center, transport times, and mortality from gunshot wounds in Chicago.
        Am J Public Health. 2013; 103: 1103-1109
        • Rich-Edwards J.W.
        • Grizzard T.A.
        Psychosocial stress and neuroendocrine mechanisms in preterm delivery.
        Am J Obstet Gynecol. 2005; 192: S30-S35
        • Kramer M.S.
        • Lydon J.
        • Goulet L.
        • et al.
        Maternal stress/distress, hormonal pathways and spontaneous preterm birth.
        Paediatr Perinat Epidemiol. 2013; 27: 237-246
        • Hoffman M.C.
        • Mazzoni S.E.
        • Wagner B.D.
        • Laudenslager M.L.
        • Ross R.G.
        Measures of maternal stress and mood in relation to preterm birth.
        Obstet Gynecol. 2016; 127: 545-552
        • Nkansah-Amankra S.
        • Luchok K.J.
        • Hussey J.R.
        • Watkins K.
        • Liu X.
        Effects of maternal stress on low birth weight and preterm birth outcomes across neighborhoods of South Carolina, 2000-2003.
        Matern Child Health J. 2010; 14: 215-226
        • Silbergeld E.K.
        • Patrick T.E.
        Environmental exposures, toxicologic mechanisms, and adverse pregnancy outcomes.
        Am J Obstet Gynecol. 2005; 192: S11-S21
        • Davis H.T.
        • Aelion C.M.
        • Liu J.
        • et al.
        Potential sources and racial disparities in the residential distribution of soil arsenic and lead among pregnant women.
        Sci Total Environ. 2016; 551-2: 622-630
        • Ahamed M.
        • Mehrotra P.K.
        • Kumar P.
        • Siddiqui M.K.
        Placental lead-induced oxidative stress and preterm delivery.
        Environ Toxicol Pharmacol. 2009; 27: 70-74
        • Rabito F.A.
        • Kocak M.
        • Werthmann D.W.
        • Tylavsky F.A.
        • Palmer C.D.
        • Parsons P.J.
        Changes in low levels of lead over the course of pregnancy and the association with birth outcomes.
        Reprod Toxicol. 2014; 50: 138-144
        • Jelliffe-Pawlowski L.L.
        • Miles S.Q.
        • Courtney J.G.
        • Materna B.
        • Charlton V.
        Effect of magnitude and timing of maternal pregnancy blood lead (Pb) levels on birth outcomes.
        J Perinatol. 2006; 26: 154-162
        • Taylor C.M.
        • Tilling K.
        • Golding J.
        • Emond A.M.
        Low level lead exposure and pregnancy outcomes in an observational birth cohort study: dose-response relationships.
        BMC Res Notes. 2016; 9: 291