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Online Assignment #2
This assignment is designed to increase students’ comfort levels synthesizing peer-reviewed scientific literature related to urban public health.
Choose ONE article and write a three-page summary / reflection paper (double-spaced with one-inch margins). There are a number of articles related to residential segregation and various health outcomes (e.g. cardiovascular disease, breast cancer, etc – so you should be able to find something that interests you!). The paper should 1) summarize the article you have chosen in “plain language” (as though you were explaining the main findings to a colleague) and 2) include your personal reactions to the article. These could include but are not limited to answering the following suggested questions:
- What made you choose this article/topic?
- Do you see any glaring limitations in the methods or interpretation of results?
- What would you change about the study?
- How is the article connected to course material?
Be sure to use academic/professional writing and proofread your work.
The article summary section of your paper should take up no more than 1.5 page (6.25 pts). Your personal reactions/reflection should take up the rest of the (three-page) paper (6.25 pts).
OBSTETRICS Associations of neighborhood-level racial residential segregation with adverse pregnancy outcomes Arturo D. Salow, BS; Lindsay R. Pool, PhD; William A. Grobman, MD; Kiarri N. Kershaw, PhD BACKGROUND: 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. OBJECTIVE: 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 nonHispanic 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 ¼ 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. RESULTS: 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 ¼ .046, respectively). The associations of high segregation with overall preterm birth (odds ratio, 1.31; 95% confidence interval, 1.02e1.69) and spontaneous preterm birth (oddsratio, 1.37; 95% confidence interval, 1.02e1.85) remained significant with adjustment for neighborhood poverty, insurance status, parity, and maternal medical conditions. CONCLUSION: 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: electronic medical records, medically indicated preterm birth, preterm birth, segregation, small for gestational age, spontaneous preterm birth Introduction Compared to non-Hispanic White women, non-Hispanic Black women are more likely to experience adverse pregnancy outcomes such as preterm birth (PTB), defined as birth <37 weeks’ gestation.1,2 This disparity in PTB is directly related to disproportionately high levels of infant mortality among Black infants.1,2 Because differences in individual-level maternal characteristics have been unable to account fully for differences in birth outcomes, investigators have considered the environmental factors that may contribute to obstetric disparities.2-5 Aspects of the social environment, particularly racial residential segregation, appear to be associated with a higher risk of experiencing adverse pregnancy outcomes.6-11 The studies that have demonstrated these associations largely have used administrative data and have been limited to outcomes such as low birthweight (applied to newborns weighing <2500 g) or overall rates of PTB. These studies, however, have not been able to adequately assess the underlying reasons for PTB, the main subtypes being spontaneous or medically indicated etiologies. Moreover, low birthweight, which includes neonates born preterm as well as those born due to fetal growth restriction, is a grouping that ignores the differences in underlying etiologies.12 Accordingly, the relationship between segregation and small-for-gestational-age birth, which is defined as birthweight <10th percentile for their gestational age and that better reflects abnormal intrauterine growth, has not been well evaluated.12-14 Furthermore, birth certificate data often lack information regarding maternal health conditions, limiting the ability of these studies to analyze or control for individual-level variations and confounders, and this has been identified as an area needing further investigation by previous authors.11 In this study, we utilized electronic medical records, and the more granular data they provide, to examine associations of segregation among nonHispanic Black women with overall PTB, spontaneous PTB, medically indicated PTB, and small-for-gestational-age birth. Materials and Methods Study population Patient data from Northwestern University Memorial Hospital in Chicago, IL, were obtained from the Northwestern Cite this article as: Salow AD, Pool LR, Grobman WA, et al. Associations of neighborhood-level racial residential segregation with adverse pregnancy outcomes. Am J Obstet Gynecol 2018;218:351.e1-7. 0002-9378/$36.00 ª 2018 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.2018.01.022 MARCH 2018 American Journal of Obstetrics & Gynecology 351.e1 Original Research ajog.org Medicine Enterprise Data Warehouse system. We extracted birth records for all non-Hispanic Black women who delivered singleton gestations from Jan. 1, 2009, through Dec. 31, 2013. We limited our sample to women who had a home address within the Chicago-JolietNaperville, IL-IN-WI metropolitan statistical area (MSA). Non-Hispanic White women were excluded from this study due to insufficient overlap in the racial composition of census tracts among Black and White women, a challenge that has been described previously in other studies of segregation.15,16 Patient addresses at time of birth were geocoded in software (ArcMap, Version 10.5; Environmental Systems Research Institute, Redlands, CA). This study was approved by the Institutional Review Board at Northwestern University. Racial residential segregation The local Getis-Ord Gi* statistic was used to measure neighborhood-level non-Hispanic Black racial segregation using 2010 US Census tracts as a proxy for neighborhood.17 For each defined area (ie, census tract), the Gi* statistic returns a z-score, representing the degree to which the racial composition of the particular tract and its neighboring tracts deviate from the mean racial composition of a larger geographical unit (ie, the Chicago MSA). Racial composition within a census tract was defined as the percentage of nonHispanic Black residents. The tractlevel Gi* statistic was linked to the geocoded patient addresses. Higher and positive Gi* statistic indicates a neighborhood with a higher level of segregation (overrepresentation) of non-Hispanic Black individuals than would be expected given the racial composition of the larger MSA. At the a ¼ 0.05 level, the Gi* statistic of 1.96 corresponds to statistically significant overrepresentation. Scores near 0 indicate that the racial composition of the neighborhood approximates that of the larger area; lower and negative scores suggest a lower than expected representation of Black individuals. Women were grouped for analytical purposes based on the degree of segregation of the census tract in which they lived, as quantified by the Gi* statistic, according to the following categories: low (z < 0), medium (z ¼ 0-1.96), and high (z > 1.96) categories. These cut points have been used previously to examine associations of residential segregation with health.18 Birth outcomes Outcomes of interest included PTB and small-for-gestational-age birth. PTB was defined as birth at gestational age <37 weeks.19 PTB
was divided into spontaneous and medically indicated etiologies. Spontaneous PTB was considered to have occurred if women delivered after preterm premature rupture of membranes or after preterm labor. Medically indicated PTB was considered to have occurred if women underwent labor induction or cesarean delivery without labor for a medical complication (eg, hypertensive disorder of pregnancy). Small-forgestational-age birth was defined as birthweight <10th percentile for a given gestational age.13 Birth records showing gestational age <24 weeks were excluded (n ¼ 23) as well. Covariates Both maternal health and socioeconomic characteristics were used as covariates. These included: maternal age at delivery, parity (nulliparous or multiparous), and maternal medical conditions reported in the electronic medical records including chronic hypertension, preexisting diabetes mellitus, asthma, mental health conditions, and substance abuse. Substance abuse included tobacco, alcohol, and illicit drug use during pregnancy. Infant sex was also included as a covariate, as was insurance status (public, private, none), and neighborhood poverty (the proportion of the population within the woman’s census tract that reported household income below the federal poverty threshold based on data from the 2009 through 2013 US Census American Community Survey). Statistical Analysis Descriptive statistics were calculated for maternal, neonatal, and geographic characteristics. The c2 test was used to compare separately unadjusted differences in overall PTB, spontaneous PTB, medically indicated PTB, and small for gestational age between the high and low segregation categories, and the medium and low segregation categories. Three-level hierarchical logistic regression models with random intercepts incorporated for births nested within mothers nested within census tracts to estimate odds ratios (OR) of PTB and small for gestational age associated with racial residential segregation. These models accounted for the nonindependence of births within the same census tract and for multiple births to the same woman. To further examine the associations of racial residential segregation with both spontaneous and medically indicated PTB (relative to term birth), we used 3-level hierarchical multinomial logistic regression models with the same nesting structure. The multinomial formulation employed in these models was polytomous logistic regression, in which there is no distinct ordering of the dependent variable categories. AJOG at a Glance Research Question: Why was this study conducted? This study was performed to determine whether residential segregation among Black women is associated with an increased risk of adverse pregnancy outcomes. Key Findings We found segregation is associated with overall and spontaneous preterm birth, but not medically indicated preterm or small-for-gestational-age birth. What does this add to what is known? This study furthers our understanding of how social determinants of health may influence preterm birth. Original Research OBSTETRICS ajog.org 351.e2 American Journal of Obstetrics & Gynecology MARCH 2018 Initial regression models were adjusted for neighborhood poverty, infant sex, maternal age, weight, parity, and insurance status. Subsequent models were further adjusted for maternal health conditions including asthma, mental health conditions, substance abuse, chronic hypertension, and preexisting diabetes mellitus. All models were evaluated to detect outliers and influential data points, and whether multicollinearity was present. Further, we assumed the independence of irrelevant alternatives in the multinomial model as spontaneous PTB is clinically distinct from medically indicated PTB. Adjustment for multiple comparisons was not performed. All analyses were conducted using software (SAS 9.4; SAS Institute Inc, Cary, NC). Results During the study period from 2009 through 2013, there were 5638 singleton births to 5114 non-Hispanic Black women at Northwestern Medicine Prentice Women’s Hospital. Of these, there were 5235 births to 4770 women with valid address information within the Chicago MSA and were thus considered for analysis. We then TABLE 1 Distribution of births to Black women at Prentice Women’s Hospital by maternal, neonatal, and geographic characteristics, by neighborhood of residence segregation category,a 2009 through 2013 Characteristic High segregation N ¼ 3236 62.5% of births Medium segregation N ¼ 853 16.5% of births Low segregation N ¼ 1085 21.0% of births Mother characteristics Age at delivery, y, mean (SD) 28.0 (6.3) 27.8 (6.4) 29.5 (6.3) Insurance status, % Private 43.3 45.9 58.1 Public 56.0 52.8 41.2 None/self-pay 0.7 1.3 0.6 Multiparous, % 54.3 51.7 48.4 Gestational HTN/preeclampsia, % 9.2 8.8 8.2 Gestational diabetes, % 6.0 4.5 7.8 Asthma, % 15.9 13.8 14.9 Mental health conditions, % 5.2 6.1 6.5 Substance abuse, % 5.8 5.9 3.3 Chronic HTN, % 3.8 3.2 2.6 Preexisting diabetes, % 1.9 1.3 1.5 Baby characteristics Male sex, % 50.6 49.4 52.6 Gestational age, mean (SD) 38.3 (2.9) 38.3 (2.8) 38.6 (2.7) Birthweight, g, mean (SD) 3136 (641) 3132 (597) 3244 (588) Preterm, %b 15.5 14.1 10.7 Spontaneous 9.5 9.1 6.2 Medically indicated induction of labor or cesarean for fetal/maternal issues 6.0 5.0 4.6 Small for gestational age, %c 16.8 16.0 14.3 Geographic characteristics Gi* statistic, mean (SD) 4.57 (1.10) 0.74 (0.52) e0.90 (0.47) Poverty proportion, mean (SD) 0.31 (0.14) 0.25 (0.15) 0.15 (0.09) HTN, hypertension. a Segregation categories determined by Gi* statistic of mother’s census tract of residence using following cut points: >1.96 ¼ high segregation, 0e1.96 ¼ medium segregation, <0 ¼ low segregation; b Delivery <37 wk, medically indicated vs spontaneous determined using labor and delivery chart indication; c Defined as birthweight for gestational age <10th percentile determined using cut offs in Duryea et al.13 Salow et al. Segregation and adverse pregnancy outcomes. Am J Obstet Gynecol 2018. ajog.org OBSTETRICS Original Research MARCH 2018 American Journal of Obstetrics & Gynecology 351.e3 excluded 61 births to 51 women (1%) with missing or implausible clinical or demographic information. The final analytical sample included 5174 births to 4719 unique women who lived in 972 census tracts within the Chicago MSA. The median number of mothers within a given census tract was 3 (range 1-87). The majority of mothers (78.9%) lived in medium or high segregation census tracts. Mothers living in highly segregated areas were more likely to be publicly insured, be multiparous, and report substance abuse issues compared to mothers living in low segregation neighborhoods (Table 1). Highly segregated areas also had a larger proportion of the population living in poverty. Mental health conditions were more frequently recorded among mothers who lived in low segregation tracts than among those high segregation tracts. In high segregation areas, the prevalence of overall PTB was significantly higher than that in low segregation areas (15.5% vs 10.7%, respectively; P <.001). Likewise, the prevalence of spontaneous PTB and medically indicated PTB were higher in high (9.5% and 6.0%) compared to low (6.2% and 4.6%) segregation neighborhoods (P < .001 and P ¼.046, respectively). There was no significant association between smallfor-gestational-age birth and racial segregation in unadjusted models. As shown in Table 2, after adjustment for potential confounding factors, high segregation was associated with 31% higher odds of PTB than low segregation (OR, 1.31; 95% confidence interval [CI], 1.02e1.69). Medium segregation as compared to low segregation was not significantly associated with PTB (OR, 1.22; 95% CI, 0.90e1.66). When PTB was further divided into spontaneous and medically indicated etiologies (Table 3), high segregation was associated with 37% higher odds of spontaneous PTB (OR, 1.37; 95% CI, 1.02e1.85). The odds of medically indicated PTB in high segregation neighborhoods as compared to low segregation was elevated, but not statistically significant (OR, 1.27; 95% CI, 0.89e1.83). Medium
segregation as compared to low segregation was not significantly associated with spontaneous PTB or medically indicated PTB. In adjusted models, neighborhood racial segregation also was not associated with higher odds of small for gestational age (P ¼.33) (Table 4). Comment The current analysis has used electronic medical records to demonstrate the association between high levels of neighborhood-level racial segregation and the higher odds of overall PTB. Further analysis of type of PTB demonstrated a stronger relationship between spontaneous PTB than medically indicated PTB. These findings support those of prior studies,6,7,9 and add to those findings by differentiating between spontaneous and medically indicated PTB. We did not find a significant association between small-for-gestational-age birth and level of segregation, which differs from a previous analysis done Debbink and Bader8 using birth certifi- cate data. One potential reason for this difference is that that the segregation measures used in the 2 papers are not equivalent. Segregation in the article of Debbink and Bader8 focused on the extent to which Blacks and Whites interacted with each other, whereas the Gi* statistic measures the extent to which non-Hispanic Blacks are isolated from all other race/ethnic groups. Thus, while the cutoff for the high segregation category in the current analysis is likely comparable to the Black segregated neighborhood category in the article of Debbink and Bader,8 the cutoffs for the medium and low segregation categories may not be comparable to Black and TABLE 2 Odds of preterm birtha among Black women at Prentice Women’s Hospital, 2009 through 2013 Characteristic Model 1 OR (95% CI) Model 2 OR (95% CI) Gi* statistic, vs lowb High 1.33 (1.04e1.71) 1.31 (1.02e1.69) Medium 1.23 (0.90e1.66) 1.22 (0.90e1.66) Neighborhood povertyc 1.06 (0.99e1.13) 1.05 (0.98e1.12) Male baby, vs female 1.07 (0.91e1.25) 1.06 (0.90e1.24) Mother’s age at delivery 1.00 (0.99e1.01) 0.99 (0.98e1.00) Insurance status, vs private None/self-pay 1.59 (0.71e3.52) 1.57 (0.71e3.50) Public 1.15 (0.96e1.37) 1.09 (0.91e1.30) Multiparous 1.15 (0.97e1.36) 1.12 (0.95e1.34) Asthma e 1.17 (0.95e1.45) Mental health conditions e 1.26 (0.91e1.73) Substance abuse e 1.27 (0.92e1.75) Chronic hypertension e 3.37 (2.41e4.71) Preexisting diabetes e 2.76 (1.72e4.42) Model 2 P value for trend for segregation categories: .04. CI, confidence interval; OR, odds ratio. a Preterm birth defined as delivery <37 wk; b Segregation categories determined by Gi* statistic of mother’s census tract of residence using following cut points: >1.96 ¼ high segregation, 0e1.96 ¼ medium segregation, <0 ¼ low segregation; c OR of preterm birth for each 10% increase in neighborhood poverty. Salow et al. Segregation and adverse pregnancy outcomes. Am J Obstet Gynecol 2018. Original Research OBSTETRICS ajog.org 351.e4 American Journal of Obstetrics & Gynecology MARCH 2018 White nonsegregated neighborhood categories of Debbink and Bader.8 The inclusion of chronic hypertension, preexisting diabetes mellitus, substance abuse, asthma, and mental health conditions yielded no changes in the associations between segregation and any of the adverse pregnancy outcomes of interest (model 2 in Tables 2-4). OR in the current analysis for the association between chronic hypertension, preexisting diabetes mellitus, and substance abuse with adverse pregnancy outcomes are consistent with previous studies.20-23 Inclusion of maternal health characteristics did not attenuate the relationship between segregation and adverse pregnancy outcomes reported here; this is in contrast to a previous analysis.24 This difference may be due to the previous analysis’ use of low birthweight as the primary outcome or differences in study populations. As few segregation studies have controlled for medical conditions when testing the association, further studies are warranted. The current study shows an association between segregation and overall PTB with a stronger association with spontaneous PTB, rather than medically indicated PTB. Women living in segregated neighborhoods are faced with increased rates of stressors such as violence and property crime, and face additional challenges due to diminished access to grocery stores and health care providers.6,25-27 Segregated Chicago areas are affected by diminished access to pharmacies and trauma centers; however, we do not believe this is likely an underlying cause of differences in this study as low-income women are eligible for Medicaid in Illinois and most women who deliver at our medical center have received prenatal care by an affiliated provider.28,29 This increased exposure to stressors in segregated neighborhoods during and prior to pregnancy (due to “weathering” of chronic stress) may predispose women to PTB.30 Acutely, higher levels of maternal corticotropinreleasing hormone, which is released at times of stress, is associated with higher placental levels of corticotropinreleasing hormone and increased rates of PTB.31-33 As posited by other authors, PTB may yet be another chronic disease that may result from this stress mechanism; however, this cannot be explored in the present study because medical TABLE 3 Odds of preterm birtha mechanism using multinomial logistic regression among babies born to Black women at Prentice Women’s Hospital, 2009 through 2013 Characteristic Model 1 OR (95% CI) Model 2 OR (95% CI) Spontaneous preterm birth Medically indicated preterm birth Spontaneous preterm birth Medically indicated preterm birth Gi* statistic, vs lowb High 1.37 (1.02e1.84) 1.31 (0.92e1.90) 1.37 (1.02e1.85) 1.27 (0.89e1.83) Medium 1.35 (0.95e1.91) 1.10 (0.71e1.70) 1.35 (0.95e1.92) 1.08 (0.69e1.68) Neighborhood povertyc 1.07 (0.99e1.15) 1.04 (0.94e1.14) 1.06 (0.98e1.14) 1.03 (0.94e1.13) Male baby sex, vs female 1.12 (0.92e1.36) 0.99 (0.78e1.26) 1.11 (0.92e1.35) 0.98 (0.77e1.25) Mother’s age at delivery 0.98 (0.96e1.00) 1.03 (1.00e1.05) 0.98 (0.96e1.00) 1.01 (0.98e1.03) Insurance status, vs private None/self-pay 1.72 (0.71e4.22) 1.20 (0.28e5.10) 1.62 (0.66e3.99) 1.28 (0.30e5.46) Public 1.09 (0.88e1.36) 1.28 (0.98e1.68) 1.04 (0.83e1.29) 1.21 (0.92e1.59) Multiparous 1.25 (1.01e1.54) 1.05 (0.81e1.36) 1.21 (0.98e1.50) 1.03 (0.79e1.34) Asthma e e 1.21 (0.94e1.57) 1.14 (0.82e1.57) Mental health conditions e e 1.06 (0.70e1.59) 1.62 (1.03e2.53) Substance abuse e e 1.69 (1.19e2.42) 0.66 (0.36e1.20) Chronic hypertension e e 1.35 (0.79e2.31) 6.94 (4.73e10.2) Preexisting diabetes e e 3.03 (1.73e5.32) 2.52 (1.32e4.78) Model 2 P value for trend for segregation categories medically indicated: .15. Model 2 P value for trend for segregation categories spontaneous: .06. CI, confidence interval; OR, odds ratio. a Preterm birth defined as delivery <37 wk, medically indicated vs spontaneous determined using labor and delivery chart indication; b Segregation categories determined by Gi* statistic of mother’s census tract of residence using following cut points: >1.96 ¼ high segregation, 0e1.96 ¼ medium segregation, <0 ¼ low segregation; c OR of preterm birth for each 10% increase in neighborhood poverty. Salow et al. Segregation and adverse pregnancy outcomes. Am J Obstet Gynecol 2018. ajog.org OBSTETRICS Original Research MARCH 2018 American Journal of Obstetrics & Gynecology 351.e5 records do not include data on psychosocial or physiologic measurements of stress. Examination of stress as a potential mediator should be investigated in future studies of segregation and obstetric outcomes. Other environmental factors, such as increased exposure to environmental toxins, may play a role in the relationship between segregation and PTB.34 Higher concentrations of lead have been seen in the neighborhoods where Black women are more likely to reside,35 and maternal blood lead levels are positively associated with increased cord and placental lead levels.36,37 The ability of lead to induce oxidative damage and initiate an inflammatory cascade could lead to PTB.36 Further, cohort studies have demonstrated an association with increased lead levels and increased odds of PTB.38,39 N
onetheless, additional studies are needed to elucidate further the relationship among segregation, lead, and birth outcomes. Strengths of the current study arise from the utilization of electronic medical records. This census of singleton births from a large, high-volume labor and delivery unit provided ample variability in patient residences to examine multiple levels of segregation and associations with small for gestational age, PTB, and etiologies of PTB while controlling for several potential confounders. Additionally, use of electronic medical records may be less daunted by recall and selection bias especially considering the medicolegal and financial incentives to maintain accurate medical records. Nevertheless, this study is not without limitations. Maternal height, weight at delivery, gestational weight gain, and body mass index were missing for a large proportion of women, so we did not include it in our analysis. Additionally, the accuracy of gestational age estimation may have been different among women living in different residential neighborhoods. Finally, because the study was performed for women in 1 urban area who delivered at 1 medical center, generalizability cannot be known. Future examination of behavioral factors such as diet quality, physical activity, and environmental toxins (eg, lead) in segregated areas may help uncover causal pathways between segregation and its association with PTB as well. Additionally, the effects of psychosocial stress and environmental exposures on the relationship between segregation and birth outcomes need further investigation. Conclusion Among Black women in an urban area, high levels of segregation were independently associated with the higher odds of spontaneous PTB. 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. n References 1. Matthews TJ, MacDorman MF, Thoma ME. Infant mortality statistics from the 2013 period linked birth/infant death data set. Natl Vital Stat Rep 2015;64:1-30. 2. Collins JW Jr, David RJ. Racial disparity in low birth weight and infant mortality. Clin Perinatol 2009;36:63-73. 3. El-Sayed AM, Paczkowski M, Rutherford CG, Keyes KM, Galea S. Social environments, genetics, and black-white disparities in infant mortality. Paediatr Perinat Epidemiol 2015;29: 546-51. 4. Willis E, McManus P, Magallanes N, Johnson S, Majnik A. Conquering racial disparities in perinatal outcomes. Clin Perinatol 2014;41:847-75. 5. White K, Borrell LN. Racial/ethnic residential segregation: framing the context of health risk and health disparities. Health Place 2011;17: 438-48. 6. 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Association of neighborhood context with offspring risk of preterm birth TABLE 4 Odds of small for gestational age babya among Black women at Prentice Women’s Hospital, 2009 through 2013 Characteristic Model 1 OR (95% CI) Model 2 OR (95% CI) Gi* statistic, vs lowb High 1.18 (0.95e1.46) 1.18 (0.95e1.46) Medium 1.11 (0.86e1.44) 1.10 (0.85e1.43) Neighborhood povertyc 1.01 (0.96e1.07) 1.01 (0.95e1.07) Male baby, vs female 1.08 (0.93e1.25) 1.07 (0.92e1.24) Mother’s age at delivery 1.00 (0.98e1.01) 1.00 (0.98e1.01) Insurance status, vs private None/self-pay 1.17 (0.51e2.70) 1.10 (0.48e2.53) Public 1.29 (1.08e1.53) 1.25 (1.05e1.49) Multiparous 0.62 (0.53e0.73) 0.60 (0.51e0.71) Asthma e 1.00 (0.81e1.23) Mental health conditions e 1.16 (0.85e1.59) Substance abuse e 1.58 (1.17e2.14) Chronic hypertension e 1.51 (1.03e2.22) Preexisting diabetes e 0.43 (0.20e0.95) Model 2 P value for trend for segregation categories: .13. 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