背景:环境正义指数是疾病控制和预防中心发布的一种工具,用于对每个人口普查区域的环境负担和社会脆弱性进行量化和排名。不良妊娠结局的种族和种族差异已经确立。个体(人水平)和环境(社区水平)危险因素对疾病患病率的相对贡献仍然知之甚少。
目的:本研究旨在确定环境正义指数在调整个体临床和社会人口统计学危险因素后是否与不良妊娠结局相关。
方法:这是一项回顾性横断面研究,对2019年1月至2022年2月期间在纽约大型学术卫生系统内的7家医院分娩妊娠≥23周的单胎新生儿的所有患者进行。如果没有家庭住址,患者将被排除在外,如果地址不能被地理编码到人口普查区,或者如果人口普查区没有相应的环境正义指数数据。如果患者先前存在糖尿病或高血压,也将其排除在外。对于在研究期间多次怀孕的患者,仅将首次妊娠纳入分析.从电子病历获得临床和人口统计学数据。环境正义指数得分,主要自变量,范围从0到1。较高的环境正义指数得分表明社区的累积环境负担增加,社会脆弱性增加。主要结局是不良妊娠结局,定义为存在≥1种以下任何一种情况:妊娠高血压疾病,妊娠期糖尿病,早产,胎儿生长受限,低出生体重,小于胎龄的新生儿,胎盘早剥,和死产。采用多因素logistic回归分析环境正义指数评分与不良妊娠结局的关系,调整潜在的混杂变量,包括体重指数组,种族和族裔群体,高龄产妇,无效,公共健康保险,和英语作为首选语言。
结果:共纳入65,273例妊娠进行分析。总的来说,不良妊娠结局发生率为37.6%(n=24,545);妊娠期高血压疾病(13.4%)和妊娠期糖尿病(12.2%)是最常见的不良妊娠结局.在未调整的分析中,对于死产,观察到环境正义指数评分与个体不良妊娠结局状况之间的最强关联(优势比,1.079;95%置信区间,1.025-1.135)和妊娠期高血压疾病(优势比,1.052;95%置信区间,1.042-1.061)。在多变量逻辑回归中,环境正义指数得分每增加0.1分,不良妊娠结局的几率增加1.4%(调整后的比值比,1.014;95%置信区间,1.007-1.021)。观察到与不良妊娠结局的最强关联与公认的临床和社会风险因素有关。包括3级肥胖(调整后的赔率比,1.710;95%置信区间,1.580-1.849;参考:体重指数<25kg/m2)以及某些种族和种族群体(参考:非西班牙裔白人),特别是亚洲和太平洋岛民(调整后的赔率比,1.817;95%置信区间,1.729-1.910),和非西班牙裔黑人(调整后的赔率比,1.668;95%置信区间,1.581-1.760)人。
结论:环境正义指数评分与不良妊娠结局呈正相关,与死产和妊娠高血压疾病密切相关。使用环境正义指数进行地理空间分析可能有助于通过确定增加妊娠并发症风险的邻里特征来提高我们对健康不平等的理解。
BACKGROUND: The Environmental Justice Index is a tool released by the Centers for Disease Control and Prevention that quantifies and ranks the environmental burden and social vulnerability of each census tract. Racial and ethnic disparities in adverse pregnancy outcomes are well established. The relative contributions of individual (person-level) and environmental (neighborhood-level) risk factors to disease prevalence remain poorly understood.
OBJECTIVE: This study aimed to determine whether the Environmental Justice Index is associated with adverse pregnancy outcomes after adjustment for individual clinical and sociodemographic risk factors.
METHODS: This was a retrospective cross-sectional study of all patients who delivered a singleton newborn at ≥23 weeks of gestation between January 2019 and February 2022 at 7 hospitals within a large academic health system in New York. Patients were excluded if their home address was not available, if the address could not be geocoded to a census tract, or if the census tract did not have corresponding Environmental Justice Index data. Patients were also excluded if they had preexisting diabetes or hypertension. For patients who had multiple pregnancies during the study period, only the first pregnancy was included for analysis. Clinical and demographic data were obtained from the electronic medical record. Environmental Justice Index score, the primary independent variable, ranges from 0 to 1. Higher Environmental Justice Index scores indicate communities with increased cumulative environmental burden and increased social vulnerability. The primary outcome was adverse pregnancy outcome, defined as the presence of ≥1 of any of the following conditions: hypertensive disorders of pregnancy, gestational diabetes, preterm birth, fetal growth restriction, low birthweight, small for gestational age newborn, placental abruption, and stillbirth. Multivariable logistic regression was performed to investigate the relationship between Environmental Justice Index score and adverse pregnancy outcome, adjusting for potential confounding variables, including body mass index group, race and ethnicity group, advanced maternal age, nulliparity, public health insurance, and English as the preferred language.
RESULTS: A total of 65,273 pregnancies were included for analysis. Overall, adverse pregnancy outcomes occurred in 37.6% of pregnancies (n=24,545); hypertensive disorders of pregnancy (13.4%) and gestational diabetes (12.2%) were the most common adverse pregnancy outcome conditions. On unadjusted analysis, the strongest associations between Environmental Justice Index score and individual adverse pregnancy outcome conditions were observed for stillbirth (odds ratio, 1.079; 95% confidence interval, 1.025-1.135) and hypertensive disorders of pregnancy (odds ratio, 1.052; 95% confidence interval, 1.042-1.061). On multivariable logistic regression, every 0.1 increase in Environmental Justice Index score was associated with 1.4% higher odds of adverse pregnancy outcome (adjusted odds ratio, 1.014; 95% confidence interval, 1.007-1.021). The strongest associations with adverse pregnancy outcomes were observed with well-established clinical and social risk factors, including class 3 obesity (adjusted odds ratio, 1.710; 95% confidence interval, 1.580-1.849; reference: body mass index <25 kg/m2) and certain race and ethnicity groups (reference: non-Hispanic White), particularly Asian and Pacific Islander (adjusted odds ratio, 1.817; 95% confidence interval, 1.729-1.910), and non-Hispanic Black (adjusted odds ratio, 1.668; 95% confidence interval, 1.581-1.760) people.
CONCLUSIONS: Environmental Justice Index score is positively associated with adverse pregnancy outcomes, and most strongly associated with stillbirth and hypertensive disorders of pregnancy. Geospatial analysis with Environmental Justice Index may help to improve our understanding of health inequities by identifying neighborhood characteristics that increase the risk of pregnancy complications.