Racial and geographic variation in effects of maternal education and neighborhood-level measures of socioeconomic status on gestational age at birth: Findings from the ECHO cohorts

Abstract

Preterm birth occurs at excessively high and disparate rates in the United States. In 2016, the National Institutes of Health (NIH) launched the Environmental influences on Child Health Outcomes (ECHO) program to investigate the influence of early life exposures on child health. Extant data from the ECHO cohorts provides the opportunity to examine racial and geographic variation in effects of individual- and neighborhood-level markers of socioeconomic status (SES) on gestational age at birth. The objective of this study was to examine the association between individual-level (maternal education) and neighborhood-level markers of SES and gestational age at birth, stratifying by maternal race/ethnicity, and whether any such associations are modified by US geographic region. Twenty-six ECHO cohorts representing 25,526 mother-infant pairs contributed to this disseminated meta-analysis that investigated the effect of maternal prenatal level of education (high school diploma, GED, or less; some college, associate’s degree, vocational or technical training [reference category]; bachelor’s degree, graduate school, or professional degree) and neighborhood-level markers of SES (census tract [CT] urbanicity, percentage of black population in CT, percentage of population below the federal poverty level in CT) on gestational age at birth (categorized as preterm, early term, full term [the reference category], late, and post term) according to maternal race/ethnicity and US region. Multinomial logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CIs). Cohort-specific results were meta-analyzed using a random effects model. For women overall, a bachelor’s degree or above, compared with some college, was associated with a significantly decreased odds of preterm birth (aOR 0.72; 95% CI: 0.61–0.86), whereas a high school education or less was associated with an increased odds of early term birth (aOR 1.10, 95% CI: 1.00–1.21). When stratifying by maternal race/ethnicity, there were no significant associations between maternal education and gestational age at birth among women of racial/ethnic groups other than non-Hispanic white. Among non-Hispanic white women, a bachelor’s degree or above was likewise associated with a significantly decreased odds of preterm birth (aOR 0.74 (95% CI: 0.58, 0.94) as well as a decreased odds of early term birth (aOR 0.84 (95% CI: 0.74, 0.95). The association between maternal education and gestational age at birth varied according to US region, with higher levels of maternal education associated with a significantly decreased odds of preterm birth in the Midwest and South but not in the Northeast and West. Non-Hispanic white women residing in rural compared to urban CTs had an increased odds of preterm birth; the ability to detect associations between neighborhood-level measures of SES and gestational age for other race/ethnic groups was limited due to small sample sizes within select strata. Interventions that promote higher educational attainment among women of reproductive age could contribute to a reduction in preterm birth, particularly in the US South and Midwest. Further individual-level analyses engaging a diverse set of cohorts are needed to disentangle the complex interrelationships among maternal education, neighborhood-level factors, exposures across the life course, and gestational age at birth outcomes by maternal race/ethnicity and US geography.

Child Opportunity Index 2.0 and acute care utilization among children with medical complexity

“…29 This study complements prior work highlighting the relationship between medical and social complexity, with more patient-level social risks among children with more medical needs 7 and frequent reports of social hardship among families of CMC. 4 Conceptually, medical and social complexity may propagate one another, with the impact of social risks contributing to higher rates of conditions that may result in medical complexity, including preterm birth 32 and injury. 33 Similarly, families of CMC may face additional financial and social hardships 34 This study has several limitations.…”

Urban-rural differences in the pregnancy-related adverse outcome

“…The observed disparities in gestational age at birth by living residency are thought to be related to individual-level socioeconomic status differences. Lower socioeconomic status individuals bear a greater burden of a variety of adverse health outcomes, and there is a consistent social gradient in the risk of preterm birth across various measures of individual-level socioeconomic status including the maternal level of education and income, marital and employment status, and type of health insurance (12). Even after controlling for demographic factors, the link between preterm birth and living residency remained signi cant.…”

Preconception Mental Health, Socioeconomic Status, and Pregnancy Outcomes in Primiparous Women

“…In our study cohort, women with mental disorders had low SES. Previous studies have shown controversial findings between low SES measured by income and educational attainment and the risk of preterm birth, low birth weight, and need for neonatal intensive care unit treatments ( 11 , 12 , 21 , 22 ).…”

“…There are conflicting results over the impact of maternal SES in pregnancy and outcomes. In many studies, there is heterogeneity of cohorts and the associations between variations remain unclear ( 11 , 21 , 22 ). In the study, the prevalence of GDM in this study was 16% as expected.…”