Race, place, and scale: Residential segregation and racialdisparities in very preterm birth Public

Abstract

Very preterm (VPT) birth (<32 weeks gestation) is a leading cause of infant mortality, accounting for one third of all infant deaths, and a significant portion of neurocognitive pediatric morbidity. In the US, black women experience triple the risk of VPT birth compared to non-Hispanic white women, accounting for 80% of the racial disparity in infant mortality. There is geographic variation in the magnitude of the racial disparity in VPT birth as a result of wide variation in the risk for black women across Metropolitan Statistical Areas (MSAs), with relatively little inter-MSA variation for white women. A small body of literature has suggested that residential segregation may be a determinant of racial disparities in health. Four questions motivate the exploration of the association between segregation and prematurity. 1. How should residential segregation be conceptualized and measured in epidemiologic research? 2. If segregation is associated with preterm birth, is the association similar for very and moderately preterm births? 3. Through what mechanisms might segregation influence VPT birth? 4. Does adjustment for segregation explain any of the geographic variation in VPT disparities? Recently introduced spatial measures of residential segregation were validated against traditional Census-tract derived indices as predictors of commonly hypothesized health mediating variables including individual socioeconomic attainment and neighborhood socioeconomic environment. In each case spatial measures of isolation or dissimilarity outperformed census tract derived measures in explaining inter-MSA variation. In analyses conducted at two scales (nationally comparing segregation in 231 MSAs, and locally comparing neighborhoods in the Atlanta MSA) spatial isolation segregation increased risk for very preterm births in black women, net of individual factors. Controlling for segregation reduced the inter-MSA variation in the racial disparity of VPT birth. Although residential segregation was associated with risk for preterm birth in black women under various model specifications, joint control for measured risk factors only explained a portion of the racial disparity. Better understanding the mediating pathways between segregation and health may open opportunities for effective intervention to reduce disparities, but currently much of the excess risk experienced by black women remains unexplained.

Table of Contents

Table of Contents . vii List of Tables . x List of Figures . xiii List of Equations . xv Introduction .. 1 Dissertation Aims . 4 Chapter 1 Understanding preterm birth .. 6 Physiology of normal and abnormal parturition .. 7 Normal physiology of human parturition .. 7 Physiology of premature parturition .. 12 Summary: physiology of normal and abnormal parturition .. 34 Epidemiology of preterm birth .. 35 Measurement and classification of preterm birth in population research .. 35 Temporal trends in preterm birth .. 44 Spatial distribution of very preterm birth .. 51 Consequences of prematurity: mortality, morbidity, and economic cost . 54 Individual level risk factors for preterm birth in black and white women .. 60 Preterm birth: So, what do we know? . 82 Chapter 2 A social epidemiology of pregnancy outcomes . 85 Social epidemiology theory .. 87 Psychosocial theory .. 88 Neo-materialist theory .. 92 Application of social theory .. 94 Social epidemiology methods . 95 The effects of place: context and composition .. 96 Ecologic fallacy to multilevel inference . 98 Segregation .. 101 Segregation: Causes and consequences . 101 Measuring segregation .. 111 Social determinants of preterm birth .. 123 Neighborhood effects and preterm birth .. 125 Segregation and preterm birth .. 128 Public health relevance: Is segregation a modifiable risk factor? . 131 Summary .. 135 Outcome . 136 Exposure . 136 Study design .. 137 Chapter 3 Methods . 151 A general approach to the problem ... 151 Data Sources . 157 Individual level data . 157 Area-Based Data . 158 Protection of human subjects in research activities . 160 General methods for measuring spatial segregation .. 160 Chapter 4 Measures matter: validating new indices of residential racial segregation for population health research .. 169 Abstract . 169 Introduction .. 169 Dimensions of segregation .. 171 Causal pathways . 173 Operationalizing neighborhoods . 174 Methods . 176 Measures of segregation .. 177 Health mediating variables . 178 Analysis . 180 Results . 181 Discussion .. 185 Dimensions of segregation .. 185 Segregation and pathways to health .. 187 Neighborhood scale . 188 Limitations . 189 Conclusions . 190 Chapter 5 Metropolitan residential segregation and racial disparities in very preterm birth 198 Abstract . 198 Introduction .. 199 Early and late preterm births . 199 Place-based risk factors . 200 Residential segregation and preterm birth .. 201 Study Questions . 203 Methods . 204 Data sources . 204 Analysis . 208 Results . 211 Discussion .. 214 Limitations . 216 Conclusions . 217 Chapter 6 Does metropolitan residential segregation interact with age-specific risk for preterm birth in black and white women? A test of the weathering hypothesis . 226 Abstract . 226 Introduction .. 227 Methods . 229 Individual level variables . 229 Metropolitan level variables . 230 Analysis . 232 Results . 233 Discussion .. 236 Limitations . 237 Conclusions . 238 Chapter 7 Race and place in Atlanta: neighborhood segregation and racial disparities in very preterm birth .. 245 Abstract . 245 Introduction .. 246 Methods . 248 Conceptual model 248 Individual-level variables . 249 Measures of neighborhood segregation .. 250 Other neighborhood variables . 252 Analysis . 252 Results . 253 Discussion .. 256 Limitations . 258 Conclusions . 259 Chapter 8 Dissertation in context: Strengths, weaknesses and public health contributions 267 Contributions . 268 Limitations . 271 Conclusions . 272 Appendix 1 .. 273 Appendix 2 .. 286 Appendix 3 .. 287 Appendix 4. Supplemental tables for chapter 4 .. 288 Appendix 4. Supplemental tables for chapter 4 .. 288 Appendix 5. Supplemental tables to chapter 5 .. 304 Appendix 6. Supplemental figures for chapter 7 .. 305 Literature cited 309

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School	Laney Graduate School
Department	Epidemiology
Degree	PhD
Submission	Dissertation
Language	English
Research Field	Health Sciences, Epidemiology
Mot-clé	Residential segregation Preterm birth Social epidemiology Race Health disparities
Committee Chair / Thesis Advisor	Hogue, Carol J, Emory University
Committee Members	Oakley Jr., Godfrey, Emory University Drews-Botsch, Carolyn D, Emory University Waller, Lance, Emory University Cooper, Hannah, Emory University

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