Immigrant Latino neighborhoods and mortality among infants born to Mexican-origin Latina women

The Influence of County Contexts on Preterm Births Among Latina Mothers in the US

Preterm birth (PTB), defined as delivery before 37 weeks of gestation, is a significant public health issue, with implications for newborns, families, and society. The residential contexts in which mothers live may, in part, shape their risk of delivering preterm. Although ethnic enclaves-residential settings with a large concentration of people from the same ethnic group-exist within counties, little is known about how different county contexts shape PTB. This national study investigates the association between living in distinct county types and preterm births among Latina mothers (N = 1,084,867). Data are from 2 years (2017-2018) of US birth records merged with demographic and policy datasets. A county-level classification scheme that integrates social (i.e., Latino ethnic density, immigrant concentration), economic (i.e., socioeconomic indicators), and geography-related (i.e., suburban and urban) county characteristics was used to represent different areas. We fit multiple logistic regression models, adjusting for individual, community, and structural-level covariates, and found significant differences in PTB across county types (p < 0.001). In fully adjusted models, Latina mothers in almost all county types reported 5-25% higher odds of PTB than their counterparts in suburban counties with medium Latino concentration, high immigrant density, and low economic disadvantage. These areas were distinct from the high-disadvantage suburban counties with a large share of Latinos and immigrants, where Latina mothers experienced the highest likelihood of PTB (OR = 1.25, 95% CI 1.20, 1.30). County-level social, economic, and geography-related determinants interact, shaping Latina mothers' PTB risk. To ensure healthy environments for all, initiatives that bolster local communities are needed.

The association between local area immigrant fraction and prevalence of cardiovascular diseases in the United States: an observational study

Background

Local area immigrant fraction is strongly and positively correlated with local life expectancy in the United States. The aim of the study was to determine the relationship between local area immigrant fraction and local prevalence of coronary heart disease (CHD) and stroke.

Methods

Cross-sectional study design, with ZIP code as the unit of observation. Demographic data was obtained from the American Community Survey, and linked to indicators of health access (e.g., insurance, annual check-ups, cholesterol screening), obesity, behavior (smoking, exercise), and cardiovascular outcomes data from the 2020 Population Level Analysis and Community Estimates. Multivariable regression and path analyses were used to assess both direct and indirect relationships among variables.

Findings

CHD prevalence was lower in the second (3.9% relative difference, 95% CI: 3.1-4.5%), third (6.5%, 95% CI: 5.8-7.1%), and fourth (14.8%, 95% CI: 14.1-15.8%) quartiles of immigrant fraction compared to the lowest (p-trend <0.001). These effects remained robust in multivariable analysis following adjustment for indicators of access, obesity, and behavioral variables (p-trend <0.0001). For stroke, only the highest quartile demonstrated a significant difference in prevalence (2.1%, 95% CI: 1.2-3.0% with full adjustment). In CHD path analysis, ∼45% of the association of immigrant fraction was direct, and ∼55% was mediated through lower prevalence of deleterious behaviors (e.g., smoking). In stroke path analysis, the effect was entirely mediated through indirect effects.

Interpretation

In the United States, ZIP codes with higher immigrant fractions have lower prevalence of cardiovascular diseases. These associations are partially mediated through differences in health behaviors at the community level.

Funding

NIH (K08CA252635, P30AG0059304, K24HL150476), Stanford University, Rutgers University.

Mexican-American Women's Lifelong Residence in the United States Is Associated with an Increased Risk of Gastroschisis: A Population-Based Study

OBJECTIVE

To determine whether nativity is associated with abdominal wall defects among births to Mexican-American women.

STUDY DESIGN

Using a cross-sectional, population-based design, stratified and multivariable logistic regression analyses were performed on the 2014-2017 National Center for Health Statistics live-birth cohort dataset of infants of US-born (n = 1 398 719) and foreign-born (n = 1 221 411) Mexican-American women.

RESULTS

The incidence of gastroschisis was greater among births to US-born compared with Mexico-born Mexican-American women: 36.7/100 000 vs 15.5/100 000, RR = 2.4 (2.0, 2.9). US-born (compared with Mexico-born) Mexican-American mothers had a greater percentage of teens and cigarette smokers, P < .0001. In both subgroups, gastroschisis rates were greatest among teens and decreased with advancing maternal age. Adjusting for maternal age, parity, education, cigarette smoking, pre-pregnancy body mass index, prenatal care usage, and infant sex), OR of gastroschisis for US-born (compared with Mexico-born) Mexican-American women was 1.7 (95% CI 1.4-2.0). The population attributable risk of maternal birth in the US for gastroschisis equaled 43%. The incidence of omphalocele did not vary by maternal nativity.

CONCLUSIONS

Mexican-American women's birth in the US vs Mexico is an independent risk factor for gastroschisis but not omphalocele. Moreover, a substantial proportion of gastroschisis lesions among Mexican-American infants is attributable to factors closely related to their mother's nativity.

Health Care for Children in Immigrant Families: Key Considerations and Addressing Barriers

One in four US children is a child in an immigrant family. Children in immigrant families (CIF) have distinct health and health care needs that vary by documentation status, countries of origin, and health care and community experience caring for immigrant populations. Health insurance access and language services are fundamental to providing health care to CIF. Promoting health equity for CIF requires a comprehensive approach to both the health and social determinants of health needs of CIF. Child health providers can promote health equity for this population through tailored primary care services and partnerships with immigrant-serving community organizations.

Disparities in Mortality Trends for Infants of Teenagers: 1996 to 2019

BACKGROUND AND OBJECTIVES

Although mortality rates are highest for infants of teens aged 15 to 19, no studies have examined the long-term trends by race and ethnicity, urbanicity, or maternal age. The objectives of this study were to examine trends and differences in mortality for infants of teens by race and ethnicity and urbanicity from 1996 to 2019 and estimate the contribution of changes in the maternal age distribution and maternal age-specific (infant) mortality rates (ASMRs) to differences in infant deaths in 1996 and 2019.

METHODS

We used 1996 to 2019 period-linked birth and infant death data from the United States to assess biennial mortality rates per 1000 live births. Pairwise comparisons of rates were conducted using z test statistics and Joinpoint Regression was used to examine trends. Kitagawa decomposition analysis was used to estimate the proportion of change in infant deaths because of changes in the maternal age distribution and ASMRs.

RESULTS

From 1996 to 2019, the mortality rate for infants of teens declined 16.7%, from 10.30 deaths per 1000 live births to 8.58. The decline was significant across racial and ethnic and urbanization subgroups; however, within rural counties, mortality rates did not change significantly for infants of Black or Hispanic teens. Changes in ASMRs accounted for 93.3% of the difference between 1996 and 2019 infant mortality rates, whereas changes in the maternal age distribution accounted for 6.7%.

CONCLUSIONS

Additional research into the contextual factors in rural counties that are driving the lack of progress for infants of Black and Hispanic teens may help inform efforts to advance health equity.

Nativity and perinatal outcome disparities in the United States: Beyond the immigrant paradox

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.

The Hispanic/Latinx Perinatal Paradox in the United States: A Scoping Review and Recommendations to Guide Future Research

For decades, epidemiologists have documented a health advantage among Hispanic/Latinx individuals who live in the United States, despite their significant socioeconomic barriers. This observation is often described as the "Hispanic paradox." In this scoping review, we aimed to summarize literature published on Hispanic/Latinx perinatal outcomes over the past two decades and place these findings within the context of the overarching "Healthy Immigrant" paradox. Studies were eligible for inclusion if they utilized large population datasets to describe rates of preterm birth, low birth weight and infant mortality among Hispanic/Latinx women living in the United States. To focus on the most recent trends, studies were excluded if they were published prior to the year 2000. Globally, Hispanic/Latinx women appear to continue to have improved perinatal outcomes compared to non-Hispanic Black infants, while rates of adverse outcomes appear similar for Hispanic/Latinx and non-Hispanic White women. However, our review emphasizes the heterogeneity of outcomes experienced by Hispanic/Latinx women. The epidemiologic advantage among Hispanic/Latinx women and their infants may be largely concentrated among specific national origin subgroups or among recently arrived foreign-born Hispanic/Latinx women. Given the disparities that exist among Hispanic/Latinx women, we provide a summary of themes to explore in future research and methodologic recommendations that may assist in identifying important subgroup differences and their determinants.

Primary Care Provider Density and Elective Total Joint Replacement Outcomes

BACKGROUND

Primary care physicians (PCPs) are often gatekeepers to specialist care. This study assessed the relationship between PCP density and total knee (TKA) and total hip arthroplasty (THA) outcomes.

METHODS

We obtained patient-level data from an institutional registry on patients undergoing elective primary TKA and THA for osteoarthritis, including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores at baseline and 2 years. Using geocoding, we identified the number of PCPs in the patient's census tract (communities). We used Augmented Inverse Probability Weighting and Cross-validated Targeted Minimum Loss-Based Estimation to compare provider density and outcomes adjusting for potential confounders.

RESULTS

Our sample included 3606 TKA and 4295 THA cases. The median number of PCPs in each community was similar for both procedures: TKA 2 (interquartile range 1, 6) and for THA 2 (interquartile range 1, 7). Baseline and 2-year follow-up WOMAC pain, function, and stiffness scores were not statistically significantly different comparing communities with more than median number of PCPs to those with less than median number of PCPs. In sensitivity analyses, adding 1 PCP to a community with zero PCPs would not have statistically significantly improved baseline or 2-year follow-up WOMAC pain, function, and stiffness scores.

CONCLUSIONS

In this sample of patients who underwent elective TKA or THA for osteoarthritis, we found no statistically significant association between PCP density and pain, function, or stiffness outcomes at baseline or 2 years. Further studies should examine what other provider factors affect access and outcomes in THA and TKA.

Association of Acculturation With Adverse Pregnancy Outcomes

OBJECTIVE

To evaluate the relationship between acculturation and adverse pregnancy outcomes, and whether these relationships differ across racial or ethnic groups.

METHODS

This is a planned secondary analysis of the nuMoM2b study (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be), a prospective observational cohort study of 10,038 pregnant women at eight academic health care centers in the United States. Nulliparous pregnant women with singleton gestations were recruited between 6 0/7 and 13 6/7 weeks of gestation from October 2010-September 2013. Acculturation was defined by birthplace (United States vs non-United States), language used during study visits (English or Spanish), and self-rated English proficiency. The adverse pregnancy outcomes of interest were preterm birth (less than 37 weeks of gestation, both iatrogenic and spontaneous), preeclampsia or eclampsia, gestational hypertension, gestational diabetes, stillbirth, small for gestational age, and large for gestational age. Multivariable regression modeling was performed, as was an interaction analysis focusing on the relationship between acculturation and adverse pregnancy outcomes by maternal race or ethnicity.

RESULTS

Of the 10,006 women eligible for this analysis, 8,100 (80.9%) were classified as more acculturated (eg, born in the United States with high English proficiency), and 1,906 (19.1%) were classified as having less acculturation (eg, born or not born in the United States with low proficiency in English or use of Spanish as the preferred language during study visits). In multivariable logistic regression modeling, more acculturation was significantly associated with higher frequency of preterm birth (odds ratio [OR] 1.46, adjusted odds ratio [aOR] 1.50, 95% CI 1.16-1.95); spontaneous preterm birth (OR 1.54, aOR 1.62, 95% CI 1.14-2.24); preeclampsia or eclampsia (OR 1.39, aOR 1.31, 95% CI 1.03-1.67); preeclampsia without severe features (OR 1.44, aOR 1.43, 95% CI 1.03-2.01); and gestational hypertension (OR 1.68, aOR 1.48, 95% CI 1.22-1.79). These associations did not differ by self-described race or ethnicity.

CONCLUSION

In a large cohort of nulliparous women, more acculturation, regardless of self-described race or ethnicity, was associated with increased odds of several adverse pregnancy outcomes.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01322529.

Living in immigrant communities does not impact total knee arthroplasty outcomes: experience from a high-volume center in the United States

Background

Community characteristics such as poverty affect total knee arthroplasty (TKA) outcomes. However, it is unknown whether other community factors such as immigrant proportion (IP) also affect outcomes. Our objective was to determine the association of neighborhood IP on preoperative (pre-op) and 2-year postoperative (post-op) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function after elective TKA.

Methods

Patients in a high volume institutional TKA registry between May 2007 and February 2011 were retrospectively analyzed. Demographics, pre-op and 2-year post-op WOMAC pain and function scores, and geocodable addresses were obtained. Patient-level variables were linked to US Census Bureau census tract data. The effect of patient and neighborhood-level factors on WOMAC scores were analyzed using linear mixed effects models.

Results

3898 TKA patients were analyzed. Pre-op and 2-year post-op WOMAC pain and function scores were between 2.75–4.88 WOMAC points worse in neighborhoods with a high IP (≥ 40%) compared to low IP (< 10%). In multivariable analyses, these differences were not statistically significant. Women had worse pre-op and 2-year post-op WOMAC scores (all p ≤ 0.04), but this difference was not influenced by neighborhood IP (all p_interaction NS).

Conclusions

Patients living in high (≥40%) IP neighborhoods do not have worse pre-op or 2-year post-op pain and function outcomes after TKA compared to those living in low (< 10%) IP neighborhoods. Although sex differences favoring males are notable, these differences are not associated with IP. High neighborhood IP do not appear to affect outcomes after TKA.

Nativity/language, neighborhoods, and teen pregnancy norms among U.S. Hispanics

This study examined the relations of nativity, language, and neighborhood context to pregnancy norms among U.S. Hispanic teens. We used data from a sample of 972 Hispanic females and 960 Hispanic males from Waves I and II (1994-1996) of the National Longitudinal Study of Adolescent to Adult Health (Add Health) collected in eighty high schools and fifty-two middle schools across the country. Results indicated that nativity, language, and neighborhood context were related to Hispanic teen pregnancy norms, although these relationships varied by gender. Specifically, foreign-born, non-English speaking females and those who lived in immigrant neighborhoods held stronger norms against unmarried teen pregnancies compared to English speakers and/or lived elsewhere. Yet, no relationship was demonstrated for males. The results of this study suggest an immigrant advantage related to female teen pregnancy norms, and that context matters in the formation of pregnancy norms for Hispanic females.

Disparities in Self-Reported Prenatal Counseling: Does Immigrant Status Matter?

Immigrant women face unique barriers to prenatal care access and patient-provider communication. Yet, few prior studies have examined U.S.-born/immigrant differences in the content of care. The purpose of this study was to investigate the roles of immigrant status, English proficiency and race/ethnicity on the receipt of self-reported prenatal counseling using nationally representative data. We used data from the Early Childhood Longitudinal Study-Birth Cohort (N ≈ 8100). We investigated differences in self-reported prenatal counseling by immigrant status, English proficiency, and race/ethnicity using logistic regression. Counseling topics included diet, smoking, drinking, medication use, breastfeeding, baby development and early labor. In additional analyses, we separately examined these relationships among Hispanic, Mexican and Non-Hispanic (NH) Asian women. Neither immigrant status nor self-reported English proficiency was associated with prenatal counseling. However, we found that being interviewed in a language other than English language by ECLS-B surveyors was positively associated with counseling on smoking (OR, 2.599; 95% CI, 1.229-5.495) and fetal development (OR, 2.408; 95% CI, 1.052-5.507) among Asian women. Race/ethnicity was positively associated with counseling, particularly among NH black and Hispanic women. There is little evidence of systematic overall differences in self-reported prenatal counseling between U.S.-born and immigrant mothers. Future research should investigate disparities in pregnancy-related knowledge among racial/ethnic subgroups.

Maternal perchlorate exposure in pregnancy and altered birth outcomes

BACKGROUND

At high medicinal doses perchlorate is known to decrease the production of thyroid hormone, a critical factor for fetal development. In a large and uniquely exposed cohort of pregnant women, we recently identified associations between environmental perchlorate exposures and decreased maternal thyroid hormone during pregnancy. Here, we investigate whether perchlorate might be associated with birthweight or preterm birth in the offspring of these women.

METHODS

Maternal urinary perchlorate, serum thyroid hormone concentrations, birthweight, gestational age, and urinary nitrate, thiocyanate, and iodide were collected in 1957 mother-infant pairs from San Diego County during 2000-2003, a period when the county's water supply was contaminated with perchlorate. Associations between perchlorate exposure and birth outcomes were examined using linear and logistic regression analyses adjusted for maternal age, weight, race/ethnicity, and other factors.

RESULTS

Perchlorate was not associated with birth outcomes in the overall population. However, in analyses confined to male infants, log₁₀ maternal perchlorate concentrations were associated with increasing birthweight (β=143.1gm, p=0.01), especially among preterm births (β=829.1g, p<0.001). Perchlorate was associated with male preterm births ≥2500g (odds ratio=3.03, 95% confidence interval=1.09-8.40, p-trend=0.03). Similar associations were not seen in females.

CONCLUSIONS

This is the first study to identify associations between perchlorate and increasing birthweight. Further research is needed to explore the differences we identified related to infant sex, preterm birth, and other factors. Given that perchlorate exposure is ubiquitous, and that long-term impacts can follow altered birth outcomes, future research on perchlorate could have widespread public health importance.

Maternal and pediatric health and disease: integrating biopsychosocial models and epigenetics

The concepts of allostasis (stability through adaptation) and accumulated life stress (McEwen's allostatic load) aim to understand childhood and adult outcomes. Chronic malnutrition, changes in social condition, and adverse early-life experiences may program phenotypes and contribute to long-lasting disease risk. However, integration of life course approaches, social and economic contexts, and comparison among different biopsychosocial models has not generally been explored. This review critically examines the literature and evaluates recent insights into how environmental stress can alter lifelong hypothalamic-pituitary-adrenal axis and immune system responsiveness and induce metabolic and neurodevelopmental maladaptation. Models of biopsychosocial stress overlap but may consider different conditions. Concepts include allostasis, which incorporates hormonal responses to predictable environmental changes, and Geronimus's "weathering," which aims to explain how socially structured, repeated stress can accumulate and increase disease vulnerability. Weathering emphasizes roles of internalized/interpersonal racism in outcomes disparities. For Mexican immigrants and Mexican Americans, the "acculturation" framework has proven especially useful to explore disparities, including preterm birth and neuropsychiatric risks in childhood. Complexities of stress assessments and recent research into epigenetic mechanisms mediating effects of physical, nutritional, psychological, and social stress are reviewed.