Neighborhood Gun Violence and Birth Outcomes in Chicago

Epigenomic pathways from racism to preterm birth: secondary analysis of the Nulliparous Pregnancy Outcomes Study: monitoring Mothers-to-be (nuMoM2b) cohort study in the USA to examine how DNA methylation mediates the relationship between multilevel racism and preterm birth in black women: a study protocol

INTRODUCTION

Preterm birth is a significant contributor to pregnancy-related morbidity and mortality, particularly affecting black women. Racism is a key driver of perinatal inequities, but mechanisms remain unclear. Epigenomics research offers promise in understanding how environmental exposures, including racism, influence gene expression and adverse pregnancy outcomes. We present our study protocol describing how we will investigate the interactive effects of individual- and structural-level racism on preterm birth within and across black and white women, characterise the blood-based methylome of black pregnant women and identify whether DNA methylation mediates the association between multilevel racism and preterm birth in black women.

METHODS AND ANALYSIS

We will conduct a secondary analysis of data from 6843 participants in the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b), a longitudinal, prospective cohort study (2010-2014). Individual-level racism was collected using the Experiences of Discrimination scale. Structural racism measures include racial residential segregation, income and racial polarisation, political participation, judicial treatment, homeownership and employment. These measures will be calculated using geocoded participant addresses and publicly available census data for black and white populations. Epigenome-wide methylation analyses will be conducted on stored DNA for all enrolled black women using the EPIC 2.0 BeadChip. Preterm birth was determined by abstraction from participant electronic health records. We will determine the joint effects of individual and structural racism on preterm birth, characterise DNA methylation profiles associated with preterm birth among black women and explore the mediating role of DNA methylation in the association between multilevel racism and preterm birth.

ETHICS AND DISSEMINATION

Study procedures were approved by the Columbia University Institutional Review Board (#AAAU0215). This study aims to fill critical knowledge gaps regarding the role of racism and epigenomics in preterm birth among black women.

Exposure to Racism and Adverse Pregnancy Outcomes for Black Women: A Systematic Review and Meta-Analysis

Research suggests that stress due to racism may underlie the disproportionately high rates of adverse pregnancy outcomes experienced by Black women in the US. Study objectives: (1) Identify forms of systemic racism affecting pregnancy outcomes and (2) increase understanding about the role of racism in adverse pregnancy outcomes for Black women. A systematic review was conducted to explore the relationship between systemic racism and pregnancy outcomes for Black women. Searches were performed using EBSCO Academic Search Complete, CINAHL Complete, and Consumer Health Complete first between January to April 2021 and subsequently between November 2023 to January 2024. Included studies were observational, written in English, had full-text availability, examined at least one form of systemic racism and pregnancy outcome, and reported results for Black women. A meta-analysis was performed using a random effects model, summary effect estimates were pooled by pregnancy outcome. The I2 statistic was used to measure heterogeneity between studies. A total of 32 studies were included in the review. Significant pooled effects of exposure to systemic racism were observed for preterm birth 0.30 (95% CI 0.12-0.48), small for gestational age 0.31 (95% CI 0.05-0.58), and low birth weight 0.24 (95% CI 0.11-0.37). Among studies that compared results by race, exposure to systemic racism had a significant and rather large effect on preterm birth for Black women (ds = 0.62; 95% CI 0.06-0.41). Exposure to systemic racism has a significant effect on preterm birth, small for gestational age, and low birth weight for Black women. Having knowledge of how racism contributes to stress and poor pregnancy outcomes can help health professionals improve delivery of quality care to Black women. Future research should continue identifying forms of racism positively related to adverse pregnancy outcomes.

Prevalence of Hypertensive Disorders of Pregnancy and Gestational Diabetes Mellitus by Race and Ethnicity in Illinois, 2018 to 2020

PURPOSE

Use administrative discharge data from 2018 to 2020 to determine if there are differences in the prevalence of hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) by race and ethnicity in Illinois.

STUDY DESIGN AND METHODS

This retrospective cross-sectional study used administrative discharge records from all patients who had live births in Illinois over a 3-year period; 2018, 2019, 2020. Multivariate analyses were performed to control for covariates and determine if associations vary by race and ethnicity for HDP and GDM.

RESULTS

A total of 287,250 discharge records were included. Multivariate analyses showed that after adjusting for covariates, non-Hispanic Black women had 1.60 increased odds of HDP compared to non-Hispanic White women (OR, 1.60; 95% CI, 1.55-1.65). Hispanic women (OR, 1.45; 95% CI, 1.40-1.50), Asian/Pacific Islander women (OR, 2.07; 95% CI, 1.97-2.17), and American Indian/Alaska Native women (OR, 1.43; 95% CI, 1.17-1.74) had an increased odds of GDM compared to non-Hispanic White women.

CLINICAL IMPLICATIONS

Women of color were at increased odds for HDP and GDM in Illinois. To eliminate poor maternal outcomes in women of color at risk for HDP and GDM, more culturally congruent health equity practices, policies, and comprehensive care interventions must be adopted.

Association Between Social Vulnerability Index and Hospital Readmission Following Gunshot Injuries

INTRODUCTION

No association regarding classification of social vulnerability and outcomes of patients with gunshot injury have been described. Our goal was to assess whether the socioeconomic vulnerability index (SVI), is associated with an increased risk of hospital readmission following gunshot wounds.

METHODS

We conducted an exploratory retrospective cohort study on Massachusetts patients with trauma following gunshot wounds from January 1, 2012 to December 31, 2020 using the institutional trauma registry. We estimated the association between high social vulnerability (defined by the Centers for Disease Control and Prevention as ≥90th percentile) and incidence of all-cause readmission at 30, 60, and 90 d (overall and stratified over sex, race, and age groups). Estimates from unadjusted log-binomial regression were reported using relative risks (RRs) and 95% confidence intervals. Time-to-event (readmission) was assessed using Kaplan-Meier plots.

RESULTS

A total of 386 patients were included for analysis: 211 (55%) with SVI <0.90 and 175 (45%) with SVI ≥0.90. The mean (standard deviation) age was 29 (13) y, with majority being male (89%). There was no strong risk of readmission associated with SVI ≥0.90; the interval with the greatest risk was at 60 d (RR = 1.34; 95% confidence interval [0.73, 2.45]). Among stratified analyses, the strongest associations were observed when restricting to young adults (aged 18-35) with RRs of 2.49, 2.62, and 2.45 for 30, 60, and 90 d readmission, respectively.

CONCLUSIONS

Overall, high SVI was not associated with all-cause readmission; however, subanalyses suggest an association among young adults. Future research should explore SVI as a tool for identifying patients with trauma at risk for readmission.

Associations between neighborhood stress and maternal sex steroid hormones in pregnancy

BACKGROUND

Neighborhood stressors (e.g., crime and deprivation) have been associated with adverse pregnancy outcomes including preterm birth and low birth weight. A potential mechanism is disruption of maternal endocrine pathways. While stress hormones (e.g., cortisol) have received much attention, other relevant hormones, including sex steroids, have been overlooked.

METHODS

Pregnant women in the Understanding Pregnancy Signals and Infant Development (UPSIDE) study contributed biospecimens, questionnaires, and medical record data (n = 262). In each trimester, maternal serum total testosterone [TT], estrone, estradiol, and estriol were measured using LC/MS-MS and serum free testosterone was measured by equilibrium dialysis. In the third trimester, participants reported on neighborhood stress over the last year through the validated City Stress Inventory. We examined two subscales: 11-item neighborhood disorder (e.g., vacant buildings, crime) and 7-item exposure to violence (personal experiences of violence). Composite scores were calculated and examined categorically (quartile (Q) for neighborhood disorder and any/none for exposure to violence). We fitted linear mixed models examining associations between neighborhood stressors and sex steroid hormones across pregnancy as well as trimester-specific linear regression models, all adjusting for confounders. Secondarily, we stratified by fetal sex. Results are presented as percentage change (∆%) and 95% confidence interval (CI) in hormones.

RESULTS

Most participants (73%) reported one or more exposures to neighborhood disorder; 22% reported any exposure to violence. In adjusted models, neighborhood disorder was associated with higher TT across pregnancy (Q2: %∆= 37.3, 95%CI: 13.2, 66.5; Q3: %∆= 22.2, 95%CI: 1.2, 47.5; and Q4: %∆= 25.7, 95%CI: 1.6, 55.3), with the strongest associations observed in the third trimester (Q2: %∆= 38.0, 95%CI: 10.6, 72.1; Q3: %∆= 29.2, 95%CI: 4.4, 59.9; and Q4: %∆=33.4, 95%CI: 4.9, 69.6). In stratified models, neighborhood disorder was associated with higher TT among women carrying male fetuses (%∆ range: 48.2-84.8). Exposure to violence was not associated with any hormones.

CONCLUSION

Neighborhood disorder is associated with higher maternal testosterone levels, which may have implications for maternal and child health. Additional research is needed to understand the mechanisms by which neighborhood stress impacts endocrine physiology.

Fetal Origins of Health Disparities: Transgenerational Consequences of Racism

Despite advances in perinatal medicine, racial disparity in birth outcomes remains a public health problem in the USA. The underlying mechanisms for this long-standing racial disparity are incompletely understood. This review presents transgenerational risk factors for racial disparities in preterm birth, exploring the impact of interpersonal and structural racism, theoretical models of stress, and biological markers of racial disparities.

Current practice and recommendations for advancing how human variability and susceptibility are considered in chemical risk assessment

A key element of risk assessment is accounting for the full range of variability in response to environmental exposures. Default dose-response methods typically assume a 10-fold difference in response to chemical exposures between average (healthy) and susceptible humans, despite evidence of wider variability. Experts and authoritative bodies support using advanced techniques to better account for human variability due to factors such as in utero or early life exposure and exposure to multiple environmental, social, and economic stressors.This review describes: 1) sources of human variability and susceptibility in dose-response assessment, 2) existing US frameworks for addressing response variability in risk assessment; 3) key scientific inadequacies necessitating updated methods; 4) improved approaches and opportunities for better use of science; and 5) specific and quantitative recommendations to address evidence and policy needs.Current default adjustment factors do not sufficiently capture human variability in dose-response and thus are inadequate to protect the entire population. Susceptible groups are not appropriately protected under current regulatory guidelines. Emerging tools and data sources that better account for human variability and susceptibility include probabilistic methods, genetically diverse in vivo and in vitro models, and the use of human data to capture underlying risk and/or assess combined effects from chemical and non-chemical stressors.We recommend using updated methods and data to improve consideration of human variability and susceptibility in risk assessment, including the use of increased default human variability factors and separate adjustment factors for capturing age/life stage of development and exposure to multiple chemical and non-chemical stressors. Updated methods would result in greater transparency and protection for susceptible groups, including children, infants, people who are pregnant or nursing, people with disabilities, and those burdened by additional environmental exposures and/or social factors such as poverty and racism.

Determinants of preterm birth: proposal for a hierarchical theoretical model

Abstract Preterm birth (PB) is a syndrome resulting from a complex relationship between multiple factors which do not have fully understood relationships and causality. This article discusses a hierarchical theoretical model of PB determinants, considering maternal characteristics such as sociodemographic, psychosocial, nutritional, behavioral and biological aspects, traditionally associated with increased risk of PB. The variables were distributed in six dimensions within three hierarchical levels (distal, intermediate and proximal). In this model, the socioeconomic determinants of the mother, family, household and neighborhood play indirect effects on PB through variables at the intermediate level, which in turn affect biological risk factors at the proximal level that have a direct effect on PB. The study presents a hierarchical theoretical model of the factors involved in the PB determination chain and their interrelationships. Understanding these interrelationships is an important step in trying to break the causal chain that makes some women vulnerable to preterm birth.

Determinants of preterm birth: proposal for a hierarchical theoretical model

Preterm birth (PB) is a syndrome resulting from a complex relationship between multiple factors which do not have fully understood relationships and causality. This article discusses a hierarchical theoretical model of PB determinants, considering maternal characteristics such as sociodemographic, psychosocial, nutritional, behavioral and biological aspects, traditionally associated with increased risk of PB. The variables were distributed in six dimensions within three hierarchical levels (distal, intermediate and proximal). In this model, the socioeconomic determinants of the mother, family, household and neighborhood play indirect effects on PB through variables at the intermediate level, which in turn affect biological risk factors at the proximal level that have a direct effect on PB. The study presents a hierarchical theoretical model of the factors involved in the PB determination chain and their interrelationships. Understanding these interrelationships is an important step in trying to break the causal chain that makes some women vulnerable to preterm birth.

Black Babies Matter

Despite dramatic advancements in neonatal intensive care since the 1960s, African-American infants still have more than a two-fold higher first-year mortality rate than non-Latinx White infants. Our essay examines the impact of upstream factors closely linked to the historical and contemporary context of structural racism in the United States on the African-American women's birth outcome disadvantage. In the process, we propose a paradigm to address the racial health inequity in adverse birth outcome by considering the interplay of racism and social class.

Declining violence and improving birth outcomes in the US: Evidence from birth certificate data

The decline in crime that occurred in the last decade of the 20th century was one of the most important societal changes in recent US history. In this paper, we leverage the sharp decline in violence that began in the 1990s to estimate the relationship between county-level murder rates and individual-level birth outcomes for Black, Hispanic, and White mothers. Using the FBI's Uniform Crime Reporting data from 1992 to 2002 and individual-level data from more than 30,000,000 US birth certificates, we employ two-way fixed effects models with a rich set of controls to compare births to similar women in the same county who experienced different crime rates during their pregnancies. Elevated murder rates are associated with substantially higher risks of low birth weight for White mothers, low birth weight and small for gestational age among Black mothers, and small for gestational age among Hispanic mothers. Sensitivity analyses show that the existence of confounders that would invalidate these inferences is highly unlikely, suggesting that we have identified causal relationships, even if some uncertainty about the precision of our estimates remains. These findings have potential implications for prenatal and postpartum care, and they add to a growing body of evidence showing that the "Great American Crime Decline" was strongly linked to improved outcomes among groups that experienced the steepest declines in violence.

Firearm-related research articles in health sciences by funding status and type: A scoping review

Federal funding for firearm-related research in the health sciences has incurred Congressional restrictions and executive actions. Little is known about the funding landscape for published scholarship in this field. This study's aim was to characterize the number and sources of funding, including federal and non-federal sources, for firearm-related research articles published in health sciences journals. We performed a scoping review of original, empirical, peer-reviewed articles related to firearms published in health science journals and indexed in PubMed between January 2000 and December 2019, using the PRISMA extension for Scoping Review checklist. Four reviewers independently screened each article twice for inclusion. Included articles were reviewed again to identify funding sources. Articles were characterized as having explicitly declared funding, explicitly declared no funding, or no explicit funding declaration. Among articles with funding, we examined proportions by funding source. 812 articles met the inclusion criteria. 119 (14.7%) of the articles declared not having received any funding, and 240 (29.6%) had no funding declaration. 453 (55.8%) of the articles declared at least one source of funding. Of those, 221 (48.8%) reported at least one federal grant, and 232 (51.2%) reported at least one philanthropic grant. The number of published articles increased by 328.6% between 2000 and 2019. While the volume increased during the study period, the proportion of articles with funding was lower in 2019 (55.6%) than it was in 2000 (87.5%; proportion difference: 31.9%; 95% CI: 16.7%-47.2%). This study highlights the continued funding limitations in this field despite a growing volume of research.

Stress response asymmetries in African American emerging adults exposed to chronic social adversity

Chronic stress is linked to social adversity and underlies many health disparities among ethnic minorities. Cortisol and salivary alpha-amylase (sAA) reflect sensitivity to adversity and are related to health outcomes. Our aim was to understand how social adversity influences biological responses to experimental and daily stressors in a sample of low-income African American emerging adults. In the three-week study, participants completed questionnaires, the Trier Social Stress Task (TSST), and provided four salivary samples. In week 2, participants collected saliva at home immediately after waking and just before bed for three days. Results demonstrated an asymmetrical pattern between cortisol and sAA reactivity that was related to experiences with racism and interpersonal trauma. Further, daily stress was related to lower morning and higher nighttime cortisol, indicating atypical diurnal rhythm. These findings are consistent with other forms of social adversity that lead to long-term changes in the HPA axis response pattern.LAY SUMMARYAfrican American emerging adults showed divergent cortisol and sAA responses.Social adversity predicted an asymmetrical response pattern for sAA and cortisol.Atypical diurnal rhythms were found for participants reporting high daily stress.

Community gun violence and functional disability: An ecological analysis among men in four U.S. cities

This study uses data on neighborhoods in four U.S. cities over five years to examine the relationship between fatal and non-fatal gun violence and rates of functional disability among men. Descriptive analyses indicate significant disparities in shooting rates across neighborhoods and heightened associated disability in high shooting communities. Multivariate results show that rates of non-fatal shootings correspond to greater functional disability among young men, but not older men. Fatal gun violence is not associated with increased community disability. The findings suggest that improvements in local gun violence prevention may serve to address broader community disparities in health and well-being.

Associations between neighborhood violence during pregnancy and birth outcomes: evidence from São Paulo's Western Region Birth Cohort

BACKGROUND

Low birth weight and prematurity remain leading causes of infant mortality and morbidity globally. Although extensive literature has highlighted the importance of socioenvironmental characteristics for birth outcomes, the role of indirect violence on health remains fairly understudied.

METHODS

Using geocoded birth records from the ongoing Western Region Birth Cohort (Região Oeste Coorte - ROC-Cohort) of infants born between 2012 and 2014 and geocoded crime reports, we assessed the associations between exposure to violent crimes during pregnancy within a 1-km radius of the mother's residence and low birth weight, preterm delivery, and being born small-for-gestational-age. Violent crime exposure was categorized into quintiles. Multivariate logistic regressions were used to examine the associations between violence exposure and birth outcomes. Models were adjusted for sex, maternal age and education, socioeconomic status, and risk factors such as hypertension, diabetes, smoking, and drinking during pregnancy.

RESULTS

Among the 5268 children included, the average crime exposure during the first two trimesters of pregnancy ranged from 0.44 violent crimes in the least exposed quintile to 12.74 crimes in the most exposed. Compared to children with the lowest violence exposure, children in the highest exposure quintile had higher odds of being born small-for-gestational-age (1.41[1.06-1.89]), preterm (1.35[1.01-1.80]), and low birth weight (1.42[1.03-1.98]). While socioeconomic status and maternal education were positively associated with lower violence exposure, no associations were found between these characteristics and birth outcomes.

CONCLUSIONS

Higher exposure to violent crimes in the close vicinity of pregnant women's residence is associated with substantial increases in the odds of adverse birth outcomes. Policies to improve neighborhood safety can potentially contribute not only to the short-term wellbeing of populations but may also have large social, economic, and health benefits in the long term.

Understanding Racial Disparities of Preterm Birth Through the Placenta

The racial disparity associated with preterm birth is a public health concern in the United States. The placenta is the principal metabolic, respiratory, and endocrine organ of the fetus and a key route by which environmental exposures are transmitted from mother to offspring. Available at every delivery, it may serve as a marker of differences in prenatal exposures that manifest differently by race. Recently, we described differences in placental pathology between African-American and White preterm births: the prevalence of chronic inflammation was higher among African-American women's placentas compared with those of White women. Similarly, racial differences have been shown in placental malperfusion and placental weight. Social determinants such as poverty and stress from discrimination have been implicated in racial disparities in preterm birth. To date, however, the underlying biological mechanisms, whether through inflammatory, oxidative stress, or other pathways involving epigenetic programming, remain largely unknown. The placenta, complemented by maternal and umbilical cord blood biomarkers, may provide important information on the perinatal environment that explains the origins of racial disparities in preterm birth rates and subsequent health outcomes. This article reviews existing literature and current research gaps. Opportunities are discussed for future placental research that may reveal novel mechanisms leading to the development of new approaches in the prevention and management of preterm birth and its outcomes.

Prevalence and Neighborhood Geomapping of COVID-19 in an Underserved Chicago Pregnant Population

Objective  The Chicago area is known to harbor some of the deepest racial and ethnic socioeconomic inequalities in the United States. We studied the prevalence and neighborhood distribution of patients who tested positive for COVID-19 after implementation of universal screening at an academic hospital providing obstetrical services to an underserved Chicago population. Study Design  From April 16 to June 16, 2020, a total of 369 patients were screened for COVID-19 at University of Illinois at Chicago with either the Abbott Point-of-Care (POC, n  = 266) or reverse transcription polymerase chain reaction test (RT-PCR, n  = 101). Patient residential data mapped using ESRI ArcGIS Pro was integrated in ESRI's Living Atlas with the Neighborhood Socioeconomic Status Index (NSEI). Results  Precisely, 7.9% (29/369) of screened patients tested positive; 69% (17/29) with the POC test and 31% (12/29) by RT-PCR. The prevalence of an outpatient RT-PCR positive result was 8.9% (9/101). All but one of the 29 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients were either Hispanic or Black, and the majority resided in disadvantaged neighborhoods. Conclusion  The disproportionate hit of COVID-19 pandemic on the Hispanic and Black communities reflects in SARS-CoV-2 positivity rates in the obstetrical population. Our report provides data that may be useful to policy makers when prioritizing resources to communities in need.

Associations between historical redlining and birth outcomes from 2006 through 2015 in California

BACKGROUND

Despite being one of the wealthiest nations, disparities in adverse birth outcomes persist across racial and ethnic lines in the United States. We studied the association between historical redlining and preterm birth, low birth weight (LBW), small-for-gestational age (SGA), and perinatal mortality over a ten-year period (2006-2015) in Los Angeles, Oakland, and San Francisco, California.

METHODS

We used birth outcomes data from the California Office of Statewide Health Planning and Development between January 1, 2006 and December 31, 2015. Home Owners' Loan Corporation (HOLC) Security Maps developed in the 1930s assigned neighborhoods one of four grades that pertained to perceived investment risk of borrowers from that neighborhood: green (grade A) were considered "Best", blue (grade B) "Still Desirable", yellow (grade C) "Definitely Declining", and red (grade D, hence the term "redlining") "Hazardous". Geocoded residential addresses at the time of birth were superimposed on HOLC Security Maps to assign each birth a HOLC grade. We adjusted for potential confounders present at the time of Security Map creation by assigning HOLC polygons areal-weighted 1940s Census measures. We then employed propensity score matching methods to estimate the association of historical HOLC grades on current birth outcomes. Because tracts graded A had almost no propensity of receiving grade C or D and because grade B tracts had low propensity of receiving grade D, we examined birth outcomes in the three following comparisons: B vs. A, C vs. B, and D vs. C.

RESULTS

The prevalence of preterm birth, SGA and mortality tended to be higher in worse HOLC grades, while the prevalence of LBW varied across grades. Overall odds of mortality and preterm birth increased as HOLC grade worsened. Propensity score matching balanced 1940s census measures across contrasting groups. Logistic regression models revealed significantly elevated odds of preterm birth (odds ratio (OR): 1.02, 95% confidence interval (CI): 1.00-1.05), and SGA (OR: 1.03, 95% CI: 1.00-1.05) in the C vs. B comparison and significantly reduced odds of preterm birth (OR: 0.93, 95% CI: 0.91-0.95), LBW (OR: 0.94-95% CI: 0.92-0.97), and SGA (OR: 0.94, 95% CI: 0.92-0.96) in the D vs. C comparison. Results differed by metropolitan area and maternal race.

CONCLUSION

Similar to prior studies on redlining, we found that worsening HOLC grade was associated with adverse birth outcomes, although this relationship was less clear after propensity score matching and stratifying by metropolitan area. Higher odds of preterm birth and SGA in grade C versus grade B neighborhoods may be caused by higher-stress environments, racial segregation, and lack of access to resources, while lower odds of preterm birth, SGA, and LBW in grade D versus grade C neighborhoods may due to population shifts in those neighborhoods related to gentrification.