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    • The association between neighborhood poverty neighborhood ra

    2018-11-09

    The association between neighborhood poverty, neighborhood racial composition and pregnancy-related weight may be related to obesogenic neighborhoods plagued with unhealthy food environments, built environments that discourage physical activity, high crime, and widespread psychosocial stressors (Culhane & Elo, 2005; Chang et al., 2009; Chang, 2006; Cummins & Macintyre, 2006; Papas et al., 2007). The factors that women may face in their neighborhood environments may be stressful, leading to adverse pregnancy outcomes (Culhane & Elo, 2005; Mendez et al., 2012). The intersections between neighborhood racial composition and poverty are important to note, particularly since other studies demonstrate that low income white populations are more likely to be more integrated with higher income white populations than low income black populations are to integrated with higher income black populations (Williams & Collins, 2001). In other words, socioeconomic segregation is more prevalent among black compared to whites, influencing black populations’ access to resources, goods, and opportunities essential for optimal health (Williams & Collins, 2001). In our study, our sample lacked black women living in predominantly black, low poverty neighborhoods. It would be worthwhile to determine the prevalence of inadequate weight gain among this group in other geographic regions in the US. Approaches vary in terms of addressing residential segregation or neighborhood income or economic factors as a means to improve health. One well-known national program implemented by the US Department of Housing and Urban Development (HUD), Moving to Opportunity (MTO), glibenclamide are given the opportunity to move from high poverty to low poverty neighborhoods via housing vouchers. An analysis of health outcomes among the MTO families found that moving to a residence in low poverty neighborhoods compared to controls was associated with modest reductions in extreme obesity (Ludwig et al., 2011). Another study found that residential segregation was associated with an increase in obesity among black women and went further to suggest that policies and interventions should consider how the mechanisms in which upstream factors such as neighborhood segregation and poverty may influence weight (Bower et al., 2015). Although the present study is focused on pregnancy, neighborhood poverty was associated with pre-pregnancy obesity among our study\'s population, having implications for how exposure to these neighborhood contexts, particularly segregation and poverty may influence weight prior to and during pregnancy and avenues for improving health. There are a few limitations to this study. Since this is a cross-sectional study of birth records in Pennsylvania, we could not capture residence or neighborhood characteristics over time or throughout life. However, prior studies indicate that although some women may change residences during pregnancy, resulting in potential misclassification, women are likely to remain in similar types of neighborhoods when they move (Miller, Siffel & Correa, 2010; Fell, Dodds & King, 2004; Briem, 2011; Saadeh et al., 2013). Most studies, including the present study, examining neighborhood contexts and weight or obesity are observational, limiting our full understanding of whether neighborhood-level interventions may change weight outcomes among the general population and specifically among pregnant women. One well-known study, Moving to Opportunity (MTO), which randomly assigned women with children to move to a lower poverty neighborhood through the Department of Housing and Human Development (HUD) voucher program, was associated with a modest reduction in the prevalence of extreme obesity (Ludwig et al., 2011). Structural confounding as a result of social stratification and ‘selection’ into certain neighborhoods, particularly racially segregated neighborhoods is an important consideration for this study (Acevedo-Garcia & Osypuk, 2008; Oakes, 2006; Messer, Oakes & Mason, 2010). As a result, our study specifically explored geographic separation for both black and whites and how this may influence the risk of pre-pregnancy overweight and poor weight gain. Although 19% of records were missing data on key outcome variables, the similarity between the multiple imputation results and the complete case analysis suggests that data may be missing at random. Misclassification of pre-pregnancy weight, height, and weight at delivery can be common particularly among the extremes of weight gain (Bodnar et al., 2014), however, our sample only had a total of 130 women with extreme weight gain values. Additionally, we did not have adequate sample size to examine other racial/ethnic groups other than non-Hispanic black and non-Hispanic white women. Although we used the census tract as a proxy for the neighborhood, prior studies assessing the relationships between neighborhood factors and pregnancy outcomes across different neighborhood units finds that tracts and block groups present similar conclusions (Vinikoor-Imler et al., 2011; Messer et al., 2012).