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The immigrant birthweight paradox in an urban cohort: Role of immigrant enclaves and ambient air pollution

Authors:
Mydzung T. Chu at George Washington University
Mydzung T. Chu
Stephanie Ettinger de Cuba at Boston University
Stephanie Ettinger de Cuba
Patricia Fabian at Boston University
Patricia Fabian
Kevin James Lane
Kevin James Lane
Kevin James Lane
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Background Foreign-born Black and Latina women on average have higher birthweight infants than their US-born counterparts, despite generally worse socioeconomic indicators and prenatal care access, i.e., “immigrant birthweight paradox” (IBP). Residence in immigrant enclaves and associated social-cultural and economic benefits may be drivers of IBP. Yet, enclaves have been found to have higher air pollution, a risk factor for lower birthweight. Objective We investigated the association of immigrant enclaves and children’s birthweight accounting for prenatal ambient air pollution exposure. Methods In the Boston-based Children’s HealthWatch cohort of mother-child dyads, we obtained birthweight-for-gestational-age z-scores (BWGAZ) for US-born births, 2006–2015. We developed an immigrant enclave score based on census-tract percentages of foreign-born, non-citizen, and linguistically-isolated households statewide. We estimated trimester-specific PM2.5 concentrations and proximity to major roads based residential address at birth. We fit multivariable linear regressions of BWGAZ and examined effect modification by maternal nativity. Analyses were restricted to nonsmoking women and term births. Results Foreign-born women had children with 0.176 (95% CI: 0.092, 0.261) higher BWGAZ than US-born women, demonstrating the IBP in our cohort. Immigrant enclave score was not associated with BWGAZ, even after adjusting for air pollution exposures. However, this association was significantly modified by maternal nativity (pinteraction = 0.014), in which immigrant enclave score was positively associated with BWGAZ for only foreign-born women (0.090, 95% CI: 0.007, 0.172). Proximity to major roads was negatively associated with BWGAZ (−0.018 per 10 m, 95% CI: −0.032, −0.003) and positively correlated with immigrant enclave scores. Trimester-specific PM2.5 concentrations were not associated with BWGAZ. Significance Residence in immigrant enclaves was associated with higher birthweight children for foreign-born women, supporting the role of immigrant enclaves in the IBP. Future research of the IBP should account for immigrant enclaves and assess their spatial correlation with potential environmental risk factors and protective resources.
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ARTICLE
The immigrant birthweight paradox in an urban cohort: Role of
immigrant enclaves and ambient air pollution
MyDzung T. Chu
1,2,3
✉, Stephanie Ettinger de Cuba
4
, M. Patricia Fabian
5
, Kevin James Lane
5
, Tamarra James-Todd
1,6
,
David R. Williams
7,8
, Brent A. Coull
1,9
, Fei Carnes
5
, Marisa Massaro
10
, Jonathan I. Levy
5
, Francine Laden
1,6,11
, Megan Sandel
4
,
Gary Adamkiewicz
1,12
and Antonella Zanobetti
1,12
© The Author(s), under exclusive licence to Springer Nature America, Inc. 2021
BACKGROUND: Foreign-born Black and Latina women on average have higher birthweight infants than their US-born
counterparts, despite generally worse socioeconomic indicators and prenatal care access, i.e., “immigrant birthweight paradox”
(IBP). Residence in immigrant enclaves and associated social-cultural and economic benefits may be drivers of IBP. Yet, enclaves
have been found to have higher air pollution, a risk factor for lower birthweight.
OBJECTIVE: We investigated the association of immigrant enclaves and children’s birthweight accounting for prenatal ambient air
pollution exposure.
METHODS: In the Boston-based Children’s HealthWatch cohort of mother-child dyads, we obtained birthweight-for-gestational-age
z-scores (BWGAZ) for US-born births, 2006–2015. We developed an immigrant enclave score based on census-tract percentages of
foreign-born, non-citizen, and linguistically-isolated households statewide. We estimated trimester-specificPM
2.5
concentrations
and proximity to major roads based residential address at birth. We fit multivariable linear regressions of BWGAZ and examined
effect modification by maternal nativity. Analyses were restricted to nonsmoking women and term births.
RESULTS: Foreign-born women had children with 0.176 (95% CI: 0.092, 0.261) higher BWGAZ than US-born women, demonstrating
the IBP in our cohort. Immigrant enclave score was not associated with BWGAZ, even after adjusting for air pollution exposures.
However, this association was significantly modified by maternal nativity (p
interaction
=0.014), in which immigrant enclave score was
positively associated with BWGAZ for only foreign-born women (0.090, 95% CI: 0.007, 0.172). Proximity to major roads was
negatively associated with BWGAZ (−0.018 per 10 m, 95% CI: −0.032, −0.003) and positively correlated with immigrant enclave
scores. Trimester-specificPM
2.5
concentrations were not associated with BWGAZ.
SIGNIFICANCE: Residence in immigrant enclaves was associated with higher birthweight children for foreign-born women,
supporting the role of immigrant enclaves in the IBP. Future research of the IBP should account for immigrant enclaves and assess
their spatial correlation with potential environmental risk factors and protective resources.
Keywords: Immigrants; Race and ethnicity; Maternal and child health; Health inequality; Air pollution; Immigrant enclaves;
Birthweight
Journal of Exposure Science & Environmental Epidemiology (2022) 32:571–582; https://doi.org/10.1038/s41370-021-00403-8
INTRODUCTION
Immigrants are a rapidly growing population in the United States
(US). By the year 2065, immigrants and subsequent generations
will account for 88% of the country’s growth or ~103 million
people [1]. As such, research that investigates drivers of perinatal
health outcomes among immigrants is critical for shaping the
health of future generations.
Low birthweight is a leading cause of infant mortality and
morbidity in the US and associated with learning, social, and
motor developmental delays and chronic diseases later in life [2].
Approximately 8.2% of babies in the US are low birthweight
(<2500 g) and 9.4% are preterm (<37 weeks) [2]. Racial/ethnic
disparities in low birthweight are well-documented, with Black
and Latina mothers having a higher risk of low birthweight
Received: 1 October 2020 Revised: 16 November 2021 Accepted: 17 November 2021
Published online: 4 January 2022
1
Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
2
Department of Environmental and Occupational Health, Milken Institute
School of Public Health, The George Washington University, Washington, DC, USA.
3
Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA,
USA.
4
Department of Pediatrics, School of Medicine, Boston University, Boston, MA, USA.
5
Department of Environmental Health, School of Public Health, Boston University,
Boston, MA, USA.
6
Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
7
Department of Social and Behavioral Sciences, Harvard T.H. Chan
School of Public Health, Boston, MA, USA.
8
Department of African and African American Studies, Harvard University, Cambridge, MA, USA.
9
Department of Biostatistics, Harvard T.
H. Chan School of Public Health, Boston, MA, USA.
10
Biostatistics and Epidemiology Data Analytics Center, School of Public Health, Boston University, Boston, MA, USA.
11
Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA.
12
These authors contributed
equally: Gary Adamkiewicz, Antonella Zanobetti. ✉email: mchu1@tuftsmedicalcenter.org
www.nature.com/jes
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... With respect to immigrant health, living in co-ethnic immigrant enclaves (areas with high concentrations of immigrants who share an ethnicity) may represent a form of structural resilience. Relevant to birth outcomes, there are data suggesting that residence in a co-ethnic enclave is associated with higher birthweights among immigrants of various backgrounds [8][9][10]. However, immigrant birth outcomes are also negatively affected by structural forms of discrimination that exist where a pregnant person lives, such as restrictive state policies regarding insurance eligibility [11,12]. ...
National Variation in Black Immigrant Preterm Births and the Role of County-Level Social Factors
Article
Full-text available
  • Oct 2024
Preterm birth rates among Black individuals continue to be inequitably high in the USA. Black immigrants appear to have a preterm birth advantage over US-born counterparts. This national cross-sectional study of singleton non-Hispanic Black individuals in the USA from 2011 to 2018 aimed to investigate if the Black immigrant preterm birth advantage varied geographically and how this advantage associated with county-level social drivers of health. Generalized linear mixed models explored the odds of preterm birth (< 37 weeks) by birthing person’s nativity, defined as US- versus foreign-born. In county-level analyses, five measures were explored as possible sources of structural risk for or resilience against preterm birth: percent of residents in poverty, percent uninsured, percent with more than a high school education, percent foreign-born, and racial polarization. County-level immigrant advantage among foreign-born compared to US-born Black individuals was defined by a disparity rate ratio (RR); RR < 1 indicated a county-level immigrant preterm birth advantage. Linear regression models at the level of counties quantified associations between county-level factors and disparity RRs. Among 4,072,326 non-Hispanic Black birthing individuals, immigrants had 24% lower adjusted odds of preterm birth compared to US-born Black individuals (aOR 0.77, 95% CI 0.76–0.78). In county-level analyses, the immigrant advantage varied across counties; disparity RRs ranged from 0.13 to 2.82. County-level lack of health insurance and education greater than high school were both associated with immigrant preterm birth advantage. Future research should explore policies within counties that impact risk of preterm birth for both US-born and immigrant Black individuals.
View
... No study to our knowledge has considered racial or ethnic disparities in regard to air pollution exposure critical windows for birth weight. One possible explanation for the limited effect of PM 2 .5 on birth weight for Hispanics in our study is the immigrant birth weight paradox (Chu et al., 2022), where foreign-born women have higher birth weight children despite lower socioeconomic indicators and less prenatal care. All of the aforementioned studies used only a few predefined subgroups that were hypothesized by the researchers to show effect heterogeneity. ...
View
... No study to our knowledge has considered racial or ethnic disparities in regard to air pollution exposure critical windows for birth weight. One possible explanation for the limited effect of PM 2.5 on birth weight for Hispanics in our study is the immigrant birth weight paradox (Chu et al. 2022), where foreign-born women have higher birth weight children despite lower socioeconomic indicators and less prenatal care. All of the aforementioned studies used only a few predefined subgroups that were hypothesized by the researchers to show effect heterogeneity. ...
Heterogeneous Distributed Lag Models to Estimate Personalized Effects of Maternal Exposures to Air Pollution
Preprint
  • Sep 2021
Children's health studies support an association between maternal environmental exposures and children's birth and health outcomes. A common goal in such studies is to identify critical windows of susceptibility -- periods during gestation with increased association between maternal exposures and a future outcome. The associations and timings of critical windows are likely heterogeneous across different levels of individual, family, and neighborhood characteristics. However, the few studies that have considered effect modification were limited to a few pre-specified subgroups. We propose a statistical learning method to estimate critical windows at the individual level and identify important characteristics that induce heterogeneity. The proposed approach uses distributed lag models (DLMs) modified by Bayesian additive regression trees to account for effect heterogeneity based on a potentially high-dimensional set of modifying factors. We show in a simulation study that our model can identify both critical windows and modifiers responsible for DLM heterogeneity. We estimate the relationship between weekly exposures to fine particulate matter during gestation and birth weight in an administrative Colorado birth cohort. We identify maternal body mass index (BMI), age, Hispanic designation, and education as modifiers of the distributed lag effects and find non-Hispanics with increased BMI to be a susceptible population.
View
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Penalized distributed lag interaction model: Air pollution, birth weight, and neighborhood vulnerability
Article
  • Feb 2024
Maternal exposure to air pollution during pregnancy has a substantial public health impact. Epidemiological evidence supports an association between maternal exposure to air pollution and low birth weight. A popular method to estimate this association while identifying windows of susceptibility is a distributed lag model (DLM), which regresses an outcome onto exposure history observed at multiple time points. However, the standard DLM framework does not allow for modification of the association between repeated measures of exposure and the outcome. We propose a distributed lag interaction model that allows modification of the exposure‐time‐response associations across individuals by including an interaction between a continuous modifying variable and the exposure history. Our model framework is an extension of a standard DLM that uses a cross‐basis, or bi‐dimensional function space, to simultaneously describe both the modification of the exposure‐response relationship and the temporal structure of the exposure data. Through simulations, we showed that our model with penalization out‐performs a standard DLM when the true exposure‐time‐response associations vary by a continuous variable. Using a Colorado, USA birth cohort, we estimated the association between birth weight and ambient fine particulate matter air pollution modified by an area‐level metric of health and social adversities from Colorado EnviroScreen.
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County-level jail incarceration, community economic distress, rurality, and preterm birth among women in the US South
Article
Full-text available
  • Oct 2022
Introduction The USA has higher rates of preterm birth and incarceration than any other developed nation, with rates of both being highest in Southern states and among Black Americans, potentially due to rurality and socioeconomic factors. To test our hypothesis that prior-year county-level rates of jail admission, economic distress, and rurality were positively associated with premature birth rates in the county of delivery in 2019 and that the strength of these associations is greater for Black women than for White or Hispanic women, we merged five datasets to perform multivariable analysis of data from 766 counties across 12 Southern/rural states. Methods We used multivariable linear regression to model the percentage of babies born premature, stratified by Black (Model 1), Hispanic (Model 2), and White (Model 3) mothers. Each model included all three independent variables of interest measured using data from the Vera Institute, Distressed Communities Index, and Index of Relative Rurality. Results In fully fitted stratified models, economic distress was positively associated with premature births among Black ( F = 33.81, p < 0.0001) and White ( F = 26.50, p < 0.0001) mothers. Rurality was associated with premature births among White mothers ( F = 20.02, p < 0.0001). Jail admission rate was not associated with premature births among any racial group, and none of the study variables were associated with premature births among Hispanic mothers. Conclusions Understanding the connections between preterm birth and enduring structural inequities is a necessary scientific endeavor to advance to later translational stages in health-disparities research
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Nativity and Perinatal Outcome Disparities in the United States: Beyond the Immigrant Paradox
Article
  • Aug 2022
  • SEMIN PERINATOL
In the United States (US), epidemiologists have long documented paradoxically lower rates of adverse perinatal health outcomes among immigrant birthing people than what might be expected in light of socioeconomic and language barriers to healthcare, especially as compared to their US-born racial and ethnic counterparts. However, researchers have also documented significant variability in this immigrant birth paradox when examining within and across racial and ethnic subgroups. This review paper summarizes fifty years of research regarding differences in low, preterm birth, and infant mortality in the US, according to the nativity status of the birthing person. While there is ample evidence of the importance of nativity in delineating a pregnant person's risk of adverse infant outcomes, this review also highlights the relative paucity of research exploring the intersection of acculturation, ethnic enclaves, and structural segregation. We also provide recommendations for advancing the study of perinatal outcomes among immigrants.
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Joint effects of ethnic enclave residence and ambient volatile organic compounds exposure on risk of gestational diabetes mellitus among Asian/Pacific Islander women in the United States
Article
Full-text available
  • May 2021
  • ENVIRON HEALTH-GLOB
Background Asian/Pacific Islander (API) communities in the United States often reside in metropolitan areas with distinct social and environmental attributes. Residence in an ethnic enclave, a socially distinct area, is associated with lower gestational diabetes mellitus (GDM) risk, yet exposure to high levels of air pollution, including volatile organic compounds (VOCS), is associated with increased GDM risk. We examined the joint effects of ethnic enclaves and VOCs to better understand GDM risk among API women, the group with the highest prevalence of GDM. Methods We examined 9069 API births in the Consortium on Safe Labor (19 hospitals, 2002–2008). API ethnic enclaves were defined as areas ≥66th percentile for percent API residents, dissimilarity (geographic dispersal of API and White residents), and isolation (degree that API individuals interact with another API individual). High levels of 14 volatile organic compounds (VOC) were defined as ≥75th percentile. Four joint categories were created for each VOC: Low VOC/Enclave (reference group), Low VOC/No Enclave, High VOC/Enclave, High VOC/No Enclave. GDM was reported in medical records. Hierarchical logistic regression estimated odds ratios (OR) and 95% confidence intervals (95%CI) between joint exposures and GDM, adjusted for maternal factors and area-level poverty. Risk was estimated for 3-months preconception and first trimester exposures. Results Enclave residence was associated with lower GDM risk regardless of VOC exposure. Preconception benzene exposure was associated with increased risk when women resided outside enclaves [High VOC/No Enclave (OR:3.45, 95%CI:1.77,6.72)], and the effect was somewhat mitigated within enclaves, [High VOC/Enclave (OR:2.07, 95%:1.09,3.94)]. Risks were similar for 12 of 14 VOCs during preconception and 10 of 14 during the first trimester. Conclusions API residence in non-enclave areas is associated with higher GDM risk, regardless of VOC level. Ethnic enclave residence may mitigate effects of VOC exposure, perhaps due to lower stress levels. The potential benefit of ethnic enclaves warrants further study.
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Prenatal Ambient Particulate Matter Exposure and Longitudinal Weight Growth Trajectories in Early Childhood
Article
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Air pollution exposure during pregnancy has been associated with impaired fetal growth and postnatal weight gain, but few studies have examined the effect on weight growth trajectories. We examine the association between validated 1 km2 resolution particulate matter (PM2.5) concentrations, averaged over pregnancy, and sex-specific growth trajectories from birth to age six of participants in the Boston-based Children’s HealthWatch cohort (4797 participants, 84,283 measures). We compared weight trajectories, predicted using polynomial splines in mixed models, between prenatal PM2.5 above or below the median (9.5 µg/m3), and examined birth weight as an effect modifier. Females exposed to average prenatal PM2.5 ≥ 9.5 µg/m3 had higher weights compared to females exposed to < 9.5 µg/m3 throughout the study period (0.16 kg at 24 months, 0.61 kg at 60 months). In males, higher prenatal PM2.5 exposure was associated with significantly lower weights after 24 months of age, with differences increasing with time (−0.17 at 24 months, −0.72 kg at 60 months). Associations were more pronounced among low birth weight (<2500 g) females, but did not differ by birth weight status in males. Our findings demonstrate the complex association between air pollution exposures and childhood weight trajectories and emphasize the importance of sex-stratified analyses.
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Ethnic Enclaves and Pregnancy and Behavior Outcomes Among Asian/Pacific Islanders in the USA
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Full-text available
  • Nov 2019
Objectives Ethnic enclaves are ethnically, spatially, and socially distinct communities that may promote health through access to culturally appropriate resources and reduced exposure to discrimination. This study examined ethnic enclave residence and pregnancy outcomes among Asian/Pacific Islander (API) women in the USA. Design We examined 9206 API births in the Consortium on Safe Labor (2002–2008). Ethnic enclaves were defined as hospital regions with high percentage of API residents (> 4%), high dissimilarity index (> 0.41; distribution of API and white residents within a geographic area), and high isolation index (> 0.03; interaction between API and white residents in an area). Gestational diabetes mellitus (GDM), preterm birth (PTB), small for gestational age (SGA), and smoking and alcohol use during pregnancy were reported in medical records supplemented with ICD-9 codes. Hierarchical logistic regression models estimated associations between ethnic enclaves and pregnancy outcomes, adjusted for maternal factors, area-level poverty, and air pollution. Results Women in enclaves had lower odds of GDM (OR 0.61; 95%CI 0.45, 0.82), PTB (OR 0.74; 95%CI 0.56, 0.99), and SGA (OR 0.68; 95%CI 0.52, 0.89) compared with women in non-enclaves. Prenatal smoking and alcohol use appeared less likely in enclaves, but estimates were imprecise. Within enclaves, about 10.5% of homes speak an API language, compared with 6.0% in non-enclaves. The mean percent of foreign-born API populations was 67.4% in enclaves and 68.8% in non-enclaves. Conclusions API women residing in ethnic enclaves had better pregnancy outcomes than API women residing in non-enclave areas. Access to culturally appropriate social supports and resources may be important for health promotion among API populations.
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Effects of Maternal Homelessness, Supplemental Nutrition Programs, and Prenatal PM2.5 on Birthweight
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Few studies examined the impact of maternal socioeconomic status and of its combined effects with environmental exposures on birthweight. Our goal was to examine the impact of maternal homelessness (mothers ever homeless or who lived in shelters during pregnancy) and participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) during pregnancy in conjunction with air pollution exposure on birthweight in the Boston-based Children’s HealthWatch cohort from 2007 through 2015 (n = 3366). Birthweight was obtained from electronic health records. Information on maternal homelessness and WIC participation during pregnancy were provided via a questionnaire. Prenatal fine particulate matter (PM2.5) exposures, estimated at the subject’s residential address, were calculated for each trimester. We fit linear regression models adjusting for maternal and child characteristics, seasonality, and block-group-level median household income and examined the interactions between PM2.5 and each covariate. Prenatal maternal homelessness was associated with reduced birthweight (−55.7 g, 95% CI: −97.8 g, −13.7 g), while participating in WIC was marginally associated with increased birthweight (36.1 g, 95% CI: −7.3 g, 79.4 g). Only average PM2.5 during the second trimester was marginally associated with reduced birthweight (−8.5 g, 95% CI: −19.3, 2.3) for a 1 µg/m3 increase in PM2.5. The association of PM2.5 during the second trimester with reduced birthweight was stronger among non-Hispanic Black mothers and trended toward significance among immigrants and single mothers. Our study emphasizes the independent and synergistic effects of social and environmental stressors on birthweight, particularly the potentially protective effect of participating in WIC for vulnerable populations.
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Racial and ethnic disparities in adverse birth outcomes: Differences by racial residential segregation
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Racial and ethnic disparities in adverse birth outcomes have persistently been wide and may be explained by individual and area-level factors. Our primary objective was to determine if county-level black-white segregation modified the association between maternal race/ethnicity and adverse birth outcomes using birth records from the National Center for Health Statistics (2012). Based on maternal residence at birth, county-level black-white racial residential segregation was calculated along five dimensions of segregation: evenness, exposure, concentration, centralization, and clustering. We conducted a two-stage analysis: (1) county-specific logistic regression to determine whether maternal race and ethnicity were associated with preterm birth and term low birth weight; and (2) Bayesian meta-analyses to determine if segregation moderated these associations. We found greater black-white and Hispanic-white disparities in preterm birth in racially isolated counties (exposure) relative to non-isolated counties. We found reduced Hispanic-white disparities in term low birth weight in racially concentrated and centralized counties relative to non-segregated counties. Area-level poverty explained most of the moderating effect of segregation on disparities in adverse birth outcomes, suggesting that area-level poverty is a mediator of these associations. Segregation appears to modify racial/ethnic disparities in adverse birth outcomes. Therefore, policy interventions that reduce black-white racial isolation, or buffer the poor social and economic correlates of segregation, may help to reduce disparities in preterm birth and term low birth weight.
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Timing and Duration of Pre- and Postnatal Homelessness and the Health of Young Children
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: media-1vid110.1542/5804912861001PEDS-VA_2017-4254Video Abstract OBJECTIVES: Prenatal homelessness is associated with elevated risks of adverse neonatal outcomes. How the timing and duration of homelessness during pregnancy and/or a child's early life relate to postnatal child health is unclear. Methods: We interviewed 20 571 low-income caregivers of children <4 years old in urban pediatric clinics and/or emergency departments in 5 US cities. Categories of homelessness timing were prenatal, postnatal, both, or never; postnatal duration was >6 months or <6 months. Results: After controlling for birth outcomes and other potential confounders, compared with never-homeless children, children who were homeless both pre- and postnatally were at the highest risk of the following: postneonatal hospitalizations (adjusted odds ratio [aOR] 1.41; confidence interval [CI] 1.18-1.69), fair or poor child health (aOR 1.97; CI 1.58-2.47), and developmental delays (aOR 1.48; CI 1.16-1.89). There was no significant association with risk of underweight (aOR 0.95; CI 0.76-1.18) or overweight status (aOR 1.07; CI 0.84-1.37). Children <1 year old with >6 months of homelessness versus those who were never homeless had high risks of fair or poor health (aOR 3.13; CI 2.05-4.79); children 1 to 4 years old who were homeless for >6 months were at risk for fair or poor health (aOR 1.89; CI 1.38-2.58). Conclusions: After controlling for birth outcomes, the stress of prenatal and postnatal homelessness was found to be associated with an increased risk of adverse pediatric health outcomes relative to those who were never homeless. Interventions to stabilize young families as quickly as possible in adequate and affordable housing may result in improved pediatric health outcomes.
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Association between Z-score for birth weight and postoperative outcomes in neonates and infants with congenital heart disease
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  • Jan 2021
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Objective We hypothesize that infants with fetal growth restrictions have increased mortality and morbidity after congenital heart disease surgery. Methods The study included patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 to 2016) undergoing cardiac surgery at a corrected gestational age ≤ 44 weeks. Patients were classified as severely (birth weight Z-score -4 to -2), moderately (Z-score -2 to -1) and mildly growth restricted (Z-score -1.0 to -0.5) and compared to a reference population (Z-score 0 to 0.5). Multivariable logistic regression clustering on center was used to evaluate the association of birth weight Z-score with operative mortality and postoperative complications and its interaction with gestational age was assessed. Results In 25,244 patients, operative mortality was 8.6% and major complications occurred in 19.4%. Compared to the reference group, the adjusted odds (AOR) of mortality was increased in infants with severe (AOR 2.4, 95% CI 2.0-3.0), moderate (AOR 1.7, 95% CI 1.4-2.0) and mild growth restriction (AOR 1.4, 95% CI 1.2-1.6). The AOR for major postoperative complications was increased for severe (AOR 1.4, 95% CI 1.2-1.7) and moderate growth restriction (AOR 1.2, 95% CI 1.1-1.4). There was significant interaction between birth weight Z-score and gestational age (p=0.007). Conclusions Even birth weight Z-scores slightly below average are independent risk factors for mortality and morbidity in infants undergoing cardiac surgery. The strongest association between poor fetal growth and operative mortality exists in early-term infants. These novel findings may account for some of the previously unexplained variation in cardiac surgical outcomes.
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Do fine particulate air pollution (PM2.5) exposure and its attributable premature mortality differ for immigrants compared to those born in the United States?
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  • Oct 2020
In the United States (US), immigrants constitute a considerable and growing proportion of the general population. Compared to the US-born, immigrants have differential health risks, and it is unclear if environmental exposures contribute. In this work, we estimated disparities between immigrants and the US-born in fine particulate matter (PM2.5) exposure and attributable premature mortality, including by region of origin and time since immigration. With PM2.5 estimates from a validated model at ~1 km² spatial resolution and residential Census tract population data, we calculated the annual area-weighted average PM2.5 exposure for immigrants overall, the US-born, and immigrants separately by geographic region of origin and time since immigration. We then calculated the premature mortality attributed to PM2.5 for each population group, assessing disparities by immigrant status in PM2.5 exposure and attributable premature mortality in the US as a whole and in each US county to evevaluate spatial heterogeneity. Overall, immigrants were exposed to slightly higher PM2.5 (0.36 μg/m³, 3.8%) than the US-born. This exposure difference translates to 2.11 more premature deaths attributable to PM2.5 per 100,000 in population for immigrants compared to the US-born in 2010. Immigrant – US-born disparities in PM2.5 and attributable premature mortality were more severe among immigrants originating from Asia, Africa, and Latin America than those from Europe, Oceania, and North America. Disparities between immigrant groups by time since immigration were comparatively small. Sensitivity analyses using 2000 data and a non-linear set of PM2.5 attributable mortality coefficients identified similar patterns. Our findings suggest that environmental exposure disparities, such as in PM2.5, may contribute to immigrant health disparities in the US.
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Mortgage discrimination and preterm birth among African American women: An exploratory study
Article
  • Sep 2019
  • HEALTH PLACE
Objective: To examine whether mortgage discrimination, or redlining, is a risk factor for preterm birth among African American women in Chicago, and how it is related to racial residential segregation. Methods: This was a retrospective cross-sectional study in Chicago, Illinois, 1989-1991. African American mothers (n = 33,586) in the Illinois Transgenerational Birth File were linked to the 1990 census and the 1990-1995 Home Mortgage Disclosure Act database. Logistic regression models assessed the relationship between redlining and preterm birth rates. Results: Preterm birth rates were higher among African American women in redlined areas (18.5%) vs. non-redlined areas (17.1%). Unadjusted and adjusted odds ratio for preterm birth among African American women in redlined neighborhoods, compared to non-redlined neighborhoods, were 1.08 (95% CI 1.03-1.14) and 1.12 (1.04-1.20), respectively. By level of racial residential segregation, preterm birth rate was elevated (18.2%) in redlined, high-proportion African American areas compared to non-redlined high-proportion African American areas (16.7%), redlined low- (16.2%) and mid-proportion (16.1%) African American areas. Conclusions: Mortgage discrimination may be an important measure of institutional racism to be used in understanding racial disparities in preterm birth.
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