Racial and Economic Neighborhood Segregation, Site of Delivery, and Morbidity and Mortality in Neonates Born Very Preterm

Abstract

Objective: To assess the influence of racial and economic residential segregation of home or hospital neighborhood on very preterm birth morbidity and mortality in neonates born very preterm.

Study design: We constructed a retrospective cohort of n = 6461 infants born <32 weeks using 2010-2014 New York City vital statistics-hospital data. We calculated racial and economic Index of Concentration at the Extremes for home and hospital neighborhoods. Neonatal mortality and morbidity was defined as death and/or severe neonatal morbidity. We estimated relative risks for Index of Concentration at the Extremes measures and neonatal mortality and morbidity using log binomial regression and the risk-adjusted contribution of delivery hospital using Fairlie decomposition.

Results: Infants whose mothers live in neighborhoods with the greatest relative concentration of Black residents had a 1.6 times greater risk of neonatal mortality and morbidity than those with the greatest relative concentration of White residents (95% CI 1.2-2.1). Delivery hospital explained more than one-half of neighborhood differences. Infants with both home and hospital in high-concentration Black neighborhoods had a 38% adjusted risk of neonatal mortality and morbidity compared with 25% of those with both home and hospital high-concentration White neighborhoods (P = .045).

Conclusions: Structural racism influences very preterm birth neonatal mortality and morbidity through both the home and hospital neighborhood. Quality improvement interventions should incorporate a framework that includes neighborhood context.

Keywords: NICU; hospital quality; preterm birth; structural racism.

Figure 1.

Joint effects of home neighborhood and hospital neighborhood on very preterm morbidity and mortality. ICE Race is the relative concentration of non-Hispanic black vs. non-Hispanic white population in mother’s zip code of residence (“home”) or zip code of birth hospital (“hospital”); Q1 is the highest relative concentration non-Hispanic black, Q5 is the lowest. ICE Income is the relative concentration of low-income households vs. high-income households in mother’s zip code of residence (“home”) or zip code of birth hospital (“hospital”); Q1 is the highest relative concentration low-income households, Q5 is the lowest. ICE Race-income is the relative concentration of low-income black households vs. high-income white households in mother’s zip code of residence (“home”) or zip code of birth hospital (“hospital”); Q1 is the highest relative concentration of low income black households, Q5 is the lowest.