Birth outcomes among urban African-American women: A multilevel analysis of the role of racial residential segregation

doi:10.1016/j.socscimed.2006.08.011

Social Science & Medicine

Volume 63, Issue 12, December 2006, Pages 3030-3045

https://doi.org/10.1016/j.socscimed.2006.08.011 Get rights and content

Abstract

Residential segregation is a common aspect of the urban experiences of African-Americans in the United States (US), yet few studies have considered how segregation might influence perinatal health. Here, we develop a conceptual model of relationships between segregation and birth outcomes and test the implications of the model in a sample of 434,376 singleton births to African-American women living in 225 US Metropolitan Statistical Areas (MSAs). Data from the National Center for Health Statistics 2002 birth files were linked to data from the 2000 US Census and two distinct measures of segregation: an index of isolation (the probability that an African-American resident will encounter another African-American resident in any random neighborhood encounter) and an index of clustering (the extent to which African-Americans live in contiguous neighborhoods). Using multilevel regression models, controlling for individual- and MSA-level socioeconomic status and other covariates, we found higher isolation was associated with lower birthweight, higher rates of prematurity and higher rates of fetal growth restriction. In contrast, higher clustering was associated with more optimal outcomes. We propose that isolation reflects factors associated with segregation that are deleterious to health including poor neighborhood quality, persistent discrimination and the intra-group diffusion of harmful health behaviors. Associations with clustering may reflect factors associated with segregation that are health-promoting such as African-American political power empowerment, social support and cohesion. Declines in isolation could represent positive steps toward improving birth outcomes among African-American infants while aspects of racial contiguity appear to be mitigating or indeed beneficial. Segregation is a complex multidimensional construct with both deleterious and protective influences on birth outcomes, depending on the dimensions under consideration. Further research to understand racial/ethnic and economic health disparities could benefit from a focus on the contributory role of neighborhood attributes associated with the dimensions segregation and other social geographies.

Section snippets

Background

Differences in health status between Black (or African-American) and White infants have persisted for generations in the United States despite advances in perinatal care and declines in infant mortality rates (National Center for Health Statistics [NCHS], 2004; Yankauer, 1950). In 2002, African-American infants were more likely than White infants to have low birthweight (13.3% versus 7.8%), shortened gestation (17.5% versus 12.0%) or fetal growth impairment (16.0% versus 9.0%) and were more

Purpose

We tested two specific hypotheses in a population of singleton births to US-born, African-American women:

1.
Isolation is associated with poor birth outcomes, controlling for clustering, maternal race/ethnicity, SES and other important individual and ecological covariates.
2.
Clustering is associated with improved birth outcomes, controlling for isolation, maternal race/ethnicity, SES and other important individual and ecological covariates.

Design and data

A cross-sectional design and data from three publicly available sources were used to describe relationships between segregation and birth outcomes. Maternal and infant data were obtained from the 2002 US birth files issued by the National Center for Health Statistics and linked to MSA-level data collected for the 2000 US Census (Summary File 3) and measures of African-American–White segregation obtained from the US Census Bureau, Housing and Household Economic Statistics Division (Iceland et

Results

In the 225 MSAs, the mean population was 2.5 million residents (Standard Deviation=570,275; Median=194,378; Range: 102,008 to 9,519,338). The mean proportion of African-American residents was 0.16 (Standard Deviation=0.09; Median=0.14; Range=0.02–0.51). A summary of the distribution of the study variables is presented in Table 2.

Although isolation and clustering are correlated (Cutler, Glaeser, & Vigdor, 1999; Massey & Denton, 1988; Massey et al., 1996), the correlation coefficients for the

Discussion

This study adds to the growing evidence of associations between segregation and birth outcomes among African-American infants. Our analysis indicates that some of the risk of poor birth outcomes is indeed associated with segregation but that the effects might differ according to the dimension considered. We defined segregation in terms of isolation and clustering, finding that both dimensions had meaningful, opposite associations with infant birth status. We found that segregation was

Conclusions

The conceptual model established for this study is a basis for future work on segregation and health. This model and the results of our analysis suggest that aspects of segregation may be both deleterious and protective, depending on the dimension of segregation under investigation. Future declines in isolation could represent positive steps toward improving birth outcomes among African-American infants while aspects of racial contiguity appear to be mitigating or indeed beneficial. These

Acknowledgements

Dr. Bell gratefully acknowledges receiving funding for this work from the Agency for Healthcare Research and Quality (Grant #: T32-HS013853-01).

References (92)

G.R. Alexander et al.
A United States national reference for fetal growth
Obstetrics and Gynecology
(1996)
J.F. Culhane et al.
Exposure to chronic stress and ethnic differences in rates of bacterial vaginosis among pregnant women
American Journal of Obstetrics and Gynecology
(2002)
P. Diehr et al.
Do communities differ in health behaviors?
Journal of Clinical Epidemiology
(1993)
C. Duncan et al.
Do places matter? A multi-level analysis of regional variations in health-related behaviour in Britain
Social Science & Medicine
(1993)
P.B. English et al.
Changes in the spatial pattern of low birth weight in a southern California county: The role of individual and neighborhood level factors
Social Science & Medicine
(2003)
S. Gennaro
Overview of current state of research on pregnancy outcomes in minority populations
American Journal of Obstetrics and Gynecology
(2005)
T. Johnson et al.
Low birth weight: A women's health issue
Womens Health Issues
(1999)
S. Macintyre et al.
Place effects on health: How can we conceptualise, operationalise and measure them?
Social Science & Medicine
(2002)
K.M. Paarlberg et al.
Psychosocial factors and pregnancy outcome: A review with emphasis on methodological issues
Journal of Psychosomatic Research
(1995)
T.E. Patrick et al.
Research strategies for optimizing pregnancy outcomes in minority populations
American Journal of Obstetrics and Gynecology
(2005)

K.E. Pickett et al.

Neighborhood socioeconomic status, maternal race and preterm delivery: A case–control study

Annals of Epidemiology

(2002)

K.E. Pickett et al.

The effects of racial density and income incongruity on pregnancy outcomes

Social Science & Medicine

(2005)

J.W. Rich-Edwards et al.

Psychosocial stress and neuroendocrine mechanisms in preterm delivery

American Journal of Obstetrics and Gynecology

(2005)

C.E. Ross

Walking, exercising, and smoking: Does neighborhood matter?

Social Science & Medicine

(2000)

A.R. Samadi et al.

Maternal hypertension and associated pregnancy complications among African-American and other women in the United States

Obstetrics and Gynecology

(1996)

D.A. Savitz et al.

Epidemiologic characteristics of preterm delivery: Etiologic heterogeneity

American Journal of Obstetrics and Gynecology

(1991)

S.V. Subramanian et al.

Racial residential segregation and geographic heterogeneity in black/white disparity in poor self-rated health in the US: A multilevel statistical analysis

Social Science & Medicine

(2005)

D. Acevedo-Garcia et al.

Residential segregation and health

D. Acevedo-Garcia et al.

Future directions in residential segregation and health research: A multilevel approach

American Journal of Public Health

(2003)

G.R. Alexander et al.

Quantifying the adequacy of prenatal care: A comparison of indices

Public Health Reports

(1996)

G. Almgren et al.

The urban ecology of hospital failure: Hospital closures in the City of Chicago, 1970–1991

Journal of Sociology and Social Welfare

(1999)

C.V. Ananth et al.

Small-for-gestational-age births in the United States: An age-period-cohort analysis

Epidemiology

(2004)

C.V. Ananth et al.

Placental abruption and perinatal mortality in the United States

American Journal of Epidemiology

(2001)

W. Bell

A probability model for the measurement of ecological segregation

Social Forces

(1954)

G.S. Berkowitz

Employment-related physical activity and pregnancy outcome

Journal of the American Medical Womens Association

(1995)

S.L. Buka et al.

Neighborhood support and the birth weight of urban infants

American Journal of Epidemiology

(2003)

C.A. Collins et al.

Segregation and mortality: The deadly effects of racism?

Sociological Forum

(1999)

J.W. Collins et al.

Very low birthweight in African American infants: The role of maternal exposure to interpersonal racial discrimination

American Journal of Public Health

(2004)

J.W. Collins et al.

African-American mothers’ perception of their residential environment, stressful life events, and very low birthweight

Epidemiology

(1998)

C.J. Coulton et al.

Mapping residents’ perceptions of neighborhood boundaries: A methodological note

American Journal of Community Psychology

(2001)

S. Curtis et al.

Is there a place for geography in the analysis of health inequality?

Sociology of Health and Illness

(1998)

D.M. Cutler et al.

The rise and decline of the American ghetto

Journal of Political Economy

(1999)

A. Deaton

The analysis of household surveys

(1997)

A.V. Diez Roux

Investigating neighborhood and area effects on health

American Journal of Public Health

(2001)

D.L. DiGiuseppe et al.

Reliability of birth certificate data: A multi-hospital comparison to medical records information

Maternal and Child Health Journal

(2002)

R. Din-Dzietham et al.

Relationship of education to the racial gap in neonatal and postneonatal mortality

Archives of Pediatrics and Adolescent Medicine

(1997)

S.A. Dobie et al.

How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies

Maternal and Child Health Journal

(1998)

I. Ellen

Is segregation bad for your health? The case of low birth weight

Brookings-Wharton Papers on Urban Affairs

(2000)

K.M. Emmons

Health behaviors in a social context

R.L. Floyd et al.

A review of smoking in pregnancy: Effects on pregnancy outcomes and cessation efforts

Annual Review of Public Health

(1993)

W.H. Greene

Econometric analysis

(2000)

A.M. Guest et al.

The ecology of race and socioeconomic distress: Infant and working-age mortality in Chicago

Demography

(1998)

S. Hoffman et al.

Stress, social support and pregnancy outcome: A reassessment based on recent research

Paediatric and Perinatal Epidemiology

(1996)

V.K. Hogan et al.

A public health framework for addressing black and white disparities in preterm delivery

Journal of the American Medical Womens Association

(2001)

C.J. Hogue et al.

Stress and preterm delivery: A conceptual framework

Paediatric and Perinatal Epidemiology

(2001)

J. Iceland et al.

Racial and ethnic segregation in the United States: 1980–2000

(2002)

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Birth outcomes among urban African-American women: A multilevel analysis of the role of racial residential segregation

Abstract

Section snippets

Background

Purpose

Design and data

Results

Discussion

Conclusions

Acknowledgements

Obstetrics and Gynecology

American Journal of Obstetrics and Gynecology

Journal of Clinical Epidemiology

Social Science & Medicine

Social Science & Medicine

American Journal of Obstetrics and Gynecology

Womens Health Issues

Social Science & Medicine

Journal of Psychosomatic Research

American Journal of Obstetrics and Gynecology

Annals of Epidemiology

Social Science & Medicine

American Journal of Obstetrics and Gynecology

Social Science & Medicine

Obstetrics and Gynecology

American Journal of Obstetrics and Gynecology

Social Science & Medicine

Residential segregation and health

Future directions in residential segregation and health research: A multilevel approach

American Journal of Public Health

Quantifying the adequacy of prenatal care: A comparison of indices

Public Health Reports

The urban ecology of hospital failure: Hospital closures in the City of Chicago, 1970–1991

Journal of Sociology and Social Welfare

Small-for-gestational-age births in the United States: An age-period-cohort analysis

Epidemiology

Placental abruption and perinatal mortality in the United States

American Journal of Epidemiology

A probability model for the measurement of ecological segregation

Social Forces

Employment-related physical activity and pregnancy outcome

Journal of the American Medical Womens Association

Neighborhood support and the birth weight of urban infants

American Journal of Epidemiology

Segregation and mortality: The deadly effects of racism?

Sociological Forum

Very low birthweight in African American infants: The role of maternal exposure to interpersonal racial discrimination

American Journal of Public Health

African-American mothers’ perception of their residential environment, stressful life events, and very low birthweight

Epidemiology

Mapping residents’ perceptions of neighborhood boundaries: A methodological note

American Journal of Community Psychology

Is there a place for geography in the analysis of health inequality?

Sociology of Health and Illness

The rise and decline of the American ghetto

Journal of Political Economy

The analysis of household surveys

Investigating neighborhood and area effects on health

American Journal of Public Health

Reliability of birth certificate data: A multi-hospital comparison to medical records information

Maternal and Child Health Journal

Relationship of education to the racial gap in neonatal and postneonatal mortality

Archives of Pediatrics and Adolescent Medicine

How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies

Maternal and Child Health Journal

Is segregation bad for your health? The case of low birth weight

Brookings-Wharton Papers on Urban Affairs

Health behaviors in a social context

A review of smoking in pregnancy: Effects on pregnancy outcomes and cessation efforts

Annual Review of Public Health

Econometric analysis

The ecology of race and socioeconomic distress: Infant and working-age mortality in Chicago

Demography

Stress, social support and pregnancy outcome: A reassessment based on recent research

Paediatric and Perinatal Epidemiology

A public health framework for addressing black and white disparities in preterm delivery

Journal of the American Medical Womens Association

Stress and preterm delivery: A conceptual framework

Paediatric and Perinatal Epidemiology

Racial and ethnic segregation in the United States: 1980–2000