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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