A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms.

Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.

Health Equity Impact Assessment Related to Air Pollution Reduction.

Despite considerable improvements in terms of prevention, management, and regulation, air pollution remains a leading environmental health issue worldwide [...].

Study protocol to explore the social effects of environmental exposure and lifestyle behaviours on pregnancy outcome: an overview of cohort of pregnant women study.

INTRODUCTION: A growing number of international studies have highlighted the adverse consequences of lived experience in the first thousand days of pregnancy and early life on the probability of stillbirth, child mortality, inadequate growth and healthy development during both childhood and adulthood. The lived experience of the fetus inside the womb and at the birth is strongly related to both maternal health during pregnancy and maternal exposure to a set of environmental factors known as 'exposome' characteristics, which include environmental exposure, health behaviours, living conditions, neighbourhood characteristics and socioeconomic profile. The aim of our project is to explore the relationships between exposome characteristics and the health status of pregnant women and their newborns. We are particularly interested in studying the relationships between the social inequality of adverse pregnancy outcomes and (1) short-term exposure to atmospheric pollution (MobiFem project) and (2) pregnancy lifestyle (EnviFem project). METHODS AND ANALYSIS: Ours is a prospective, observational and multisite cohort study of pregnant women, involving one teaching hospital across two sites in the Strasbourg metropolitan area.The research team at University Hospital of Strasbourg (HUS) Health collects data on outcomes and individual characteristics from pregnancy registries, clinical records data and questionnaires administered via email to study participants. Recruitment began in February 2021 and will be complete by December 2021. Participants are recruited from first trimester antenatal ultrasound examinations (conducted on weekdays across both sites); each woman meeting our inclusion criteria enters the cohort at the end of her first trimester. Study participants receive a total of three online questionnaires covering sociodemographic characteristics, travel behaviour patterns and lifestyle. Participants complete these questionnaires at recruitment, during the second and third trimester. The level of personal exposure to air pollution is characterised using a dynamic spatiotemporal trajectory model that describes the main daily movements of pregnant women and the time spent in each place frequented. Univariate, multilevel and Bayesian model will be used to investigate the relationships between exposome characteristics and the health status of pregnant women and their newborns. ETHICS AND DISSEMINATION: Our research was approved by the Commission de Protection des Personnes (CPP) Ile de France VI (Paris) on 9 December 2020 (File reference No. 20.09.15.41703 ID RCB: 2020-A02580-39 and No. 20 080-42137 IDRCB 2020-A02581-38). The Agence Nationale de Sécurité du Médicament was informed of it on 15 December 2020. Findings from the study will be disseminated through publications and international conferences and through presentation at meetings with local stakeholders, researchers and policy-makers. TRIAL REGISTRATION NUMBERS: NCT04705272, NCT04725734.

Exposome and Social Vulnerability: An Overview of the Literature Review.

Background-The exposome concept refers to the totality of exposures from internal and external sources, including chemical and biological agents from conception throughout the lifetime. Exposome is also made up of psychosocial components such as socio-economic status (SES), which will focus on in this review. Despite exposures to the same environmental nuisances, individuals and groups are impacted differently. According to the literature, health inequalities exist among different socioeconomic groups, and SES may influence the association between environmental nuisances and health outcomes. However, the variation of this interaction across ages has rarely been studied. There is a need to adopt a life course approach to understand the history of diseases better. Objective-The main objective of this review is to document how SES could modify the association between environmental nuisances and health outcomes, across different ages, as a first crucial step introducing the emerged concept of social exposome. Methods-The PubMed database was searched from January 2010 to August 2021 for systematic reviews published in English addressing the interaction between SES, environmental nuisances, and health outcomes. Socio-economic indicators considered include education, level of income, neighborhood environment. Environmental nuisances considered many environment nuisances, mainly air pollution and noise. Results-Among 242 literature reviews identified, 11 of them address the question of the effect modification. Overall, our work reveals that environmental nuisances were mostly associated with poorer health outcomes and that SES modified this association, increasing the health risk among the poorest. Very interestingly, our work reports the existence of this interaction across different ages, including pregnancy, childhood, and adulthood, and for various environmental nuisances. Conclusion-In conclusion, our work confirms that we are not all equal to face environmental nuisances. The poorest are more vulnerable to the health effect of environmental nuisances. Policy decisions and interventions should target this high-risk population as a priority. Further investigations are needed to formalize the concept of social exposome more precisely and then communicate about it.

[Societal inequalities and the urban exposome: Social origins for different exposures]. / Inégalités sociétales et exposome urbain - Des origines sociales pour des expositions différentes.

Today, many epidemiological studies have proved the adverse health consequences of environmental exposure. For instance, air pollution exposure is recognized to be related with respiratory and cardiovascular diseases as well as adverse pregnancy outcomes. Noise nuisances are also known to increase cardiovascular diseases and to disturb the sleeping quality. Inversely, the access and availability of various resources, as parks, green spaces, and playgrounds positively affect health, psychological and physical well-being, and favorable health behaviors. In this present literature review, we will focus on the urban dimension of exposome, defined by Robinson et al. as the accumulation of all urban settings favorable or unfavorable to health, from the time of life in utero [1].

TITLE: Inégalités sociétales et exposome urbain - Des origines sociales pour des expositions différentes. ABSTRACT: Les études épidémiologiques sont nombreuses aujourd'hui à révéler l'association entre des facteurs d'exposition environnementale et des problèmes de santé, aigus comme chroniques, survenant à différents stades de la vie. Citons, par exemple, l'exposition à la pollution de l'air associée à de nombreuses infections respiratoires, maladies cardiovasculaires et à certaines issues défavorables de la grossesse. L'exposition aux nuisances sonores est également reconnue comme pouvant augmenter le risque de maladies cardiovasculaires et perturber la qualité du sommeil. Inversement, l'accès à certaines ressources et leur disponibilité, comme les parcs, les aires de jeux, ou les espaces verts, sont associés à un meilleur état de santé, de bien-être physique et psychique et à des comportements favorables à la santé. Dans cette Synthèse, nous nous intéresserons plus particulièrement à l'exposome dit « urbain ¼, défini par Robinson et al. comme l'ensemble des éléments de l'environnement urbain favorables et défavorables à la santé, et ce, dès la vie in utero [1].

Measuring Burden of Disease Attributable to Air Pollution Due to Preterm Birth Complications and Infant Death in Paris Using Disability-Adjusted Life Years (DALYs).

Several studies have found maternal exposure to particulate matter pollution was associated with adverse birth outcomes, including infant mortality and preterm birth. In this context, our study aims to quantify the air pollution burden of disease due to preterm birth complications and infant death in Paris, with particular attention to people living in the most deprived census blocks. Data on infant death and preterm birth was available from the birth and death certificates. The postal address of mother's newborn was converted in census block number. A socioeconomic deprivation index was built at the census block level. Average annual ambient concentrations of PM10 were modelled at census block level using the ESMERALDA atmospheric modelling system. The number of infant deaths attributed to PM10 exposure is expressed in years of life lost. We used a three-step compartmental model to appraise neurodevelopmental impairment among survivors of preterm birth. We estimated that 12.8 infant deaths per 100,000 live births may be attributable to PM10 exposure, and about one third of these infants lived in deprived census blocks. In addition, we found that approximately 4.8% of preterm births could be attributable to PM10 exposure, and approximately 1.9% of these infants died (corresponding to about 5.75 deaths per 100,000 live birth). Quantification of environmental hazard-related health impacts for children at local level is essential to prioritizing interventions. Our study suggests that additional effort is needed to reduce the risk of complications and deaths related to air pollution exposure, especially among preterm births. Because of widespread exposure to air pollution, significant health benefits could be achieved through regulatory interventions aimed at reducing exposure of the population as a whole, and particularly of the most vulnerable, such as children and pregnant women.

Development of Serious Games (Equit'Game) to Address Health and Environmental Inequalities: Protocol for an App-Delivered Program to Perform a Territorial Diagnosis.

BACKGROUND: Territorial diagnosis is a prerequisite for local actions concerning public health and for the reduction of social, environmental, and health-related inequalities. To orient local programs or initiatives targeting health inequalities, policymakers need a simulation of territorial diagnosis tools. Yet, very few platforms have been developed for the purpose of guiding public authorities as they seek to reduce these social inequalities. OBJECTIVE: This study aimed to describe the design and methods of the development process of a territorial diagnosis tool based on a serious game named Equit'Game that puts learners at the heart of the territorial diagnosis process, asking them to review the current state of health, environmental state, and socioeconomic state of their territory. METHODS: The realistic situations employed in our serious game should encourage players, in a fun and playful manner, to (1) appropriate the data of their own territory, (2) apply their methodological knowledge in a practical way, (3) reflect on the most pertinent statistical or spatial tools for their situation, and (4) ultimately, to acquire new knowledge and skills in the use of territorial diagnosis tools with a spatial dynamic. Equit'Game was deployed over the course of a week's training and structured into 4 levels: level 1, Dataminer (identifying relevant information to respond to the question); level 2, Analyst (selecting the appropriate method of analysis); level 3, Atlas (mapping the data); and level 4, Cluster (extraction of statistical and spatial information). Equit'Game has also been designed as a sort of virtual campus, creating a fun learning environment in which each door represents a level. Users can access Equit'Game via a platform compatible with tablets, PCs, and mobile phones. RESULTS: In the first step, we tested our application interface designed especially for adults among a panel of local health professionals. The following are some of the most relevant points: font size and colors used, voice accompaniment in texts and messages guiding the user, clear and easy interfaces, and the change between successive game levels. In the second step, we used our application, Equit'Game, with postgraduate students from the School of Public Health (École des hautes études en santé publique). At the end of the game session, we conducted a satisfaction survey, including several items covering both the application interface and the execution of the game. CONCLUSIONS: Equit'Game was developed to help learners with the techniques of territorial diagnosis, with the aim of creating an innovative tool for public health capable of conveying educational messages and providing a structure for training. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/11786.

Premature Adult Death and Equity Impact of a Reduction of NO2, PM10, and PM2.5 Levels in Paris-A Health Impact Assessment Study Conducted at the Census Block Level.

Background: To support environmental policies aiming to tackle air pollution, quantitative health impact assessments (HIAs) stand out as one of the best decision-making tools. However, no risk assessment studies have quantified or mapped the health and equity impact of air pollution reduction at a small spatial scale. Objectives: We developed a small-area analysis of the impact of air pollution on "premature" death among an adult population over 30 years of age to quantify and map the health and equity impact related to a reduction of air pollution. Methods: All-cause mortality data of an adult population (>30 years) from January 2004 to December 2009 were geocoded at the residential census block level in Paris. Each census block was assigned socioeconomic deprivation levels and annual average ambient concentrations of NO2, PM10, and PM2.5. HIAs were used to estimate, at a small-area level, the number of "premature" deaths associated with a hypothetical reduction of NO2, PM10, and PM2.5 exposure. In total, considering global dose response function for the three pollutants and socioeconomic deprivation specific dose response function, nine HIAs were performed for NO2 and six and four HIAs for PM10 and PM2.5, respectively. Finally, a clustering approach was used to quantify how the number of "premature" deaths could vary according to deprivation level. Results: The number of deaths attributable to NO2, PM10, and PM2.5 exposure were equal to 4301, 3209, and 2662 deaths, respectively. The most deprived census blocks always appeared as one of the groups most impacted by air pollution. Our findings showed that "premature" deaths attributable to NO2 were not randomly distributed over the study area, with a cluster of excess "premature" deaths located in the northeastern area of Paris. Discussion: This study showed the importance of stratifying an environmental burden of disease study on the socioeconomic level, in order to take into consideration the modifier effect of socioeconomic status on the air pollution-mortality relationship. In addition, we demonstrated the value of spatial analysis to guide decision-making. This shows the need for tools to support priority-setting and to guide policymakers in their choice of environmental initiatives that would maximize health gains and reduce social inequalities in health.

Using a Clustering Approach to Investigate Socio-Environmental Inequality in Preterm Birth-A Study Conducted at Fine Spatial Scale in Paris (France).

Background & Objectives: Today, to support public policies aiming to tackle environmental and health inequality, identification and monitoring of the spatial pattern of adverse birth outcomes are crucial. Spatial identification of the more vulnerable population to air pollution may orient health interventions. In this context, the objective of this study is to investigate the geographical distribution of the risk of preterm birth (PTB, gestational age ≤36 weeks) at the census block level in in city of Paris, France. We also aimed to assess the implication of neighborhood characteristics including air pollution and socio-economic deprivation. Material & Methods: Newborn health data are available from the first birth certificate registered by the Maternal and Child Care department of Paris. All PTB from January 2008 to December 2011 were geocoded at the mother residential census block. Each census block was assigned a socioeconomic deprivation level and annual average ambient concentrations of NO2. A spatial clustering approach was used to investigate the spatial distribution of PTB. Results: Our results highlight that PTB is non-randomly spatially distributed, with a cluster of high risk in the northeastern area of Paris (RR = 1.15; p = 0.06). After adjustment for socio-economic deprivation and NO2 concentrations, this cluster becomes not statistically significant or shifts suggesting that these characteristics explain the spatial distribution of PTB; further, their combination shows an interaction in comparison with SES or NO2 levels alone. Conclusions: Our results may inform the decision makers about the areas where public health efforts should be strengthened to tackle the risk of PTB and to choose the most appropriate and specific community-oriented health interventions.

Developing a data-driven spatial approach to assessment of neighbourhood influences on the spatial distribution of myocardial infarction.

BACKGROUND: There is a growing understanding of the role played by 'neighbourhood' in influencing health status. Various neighbourhood characteristics-such as socioeconomic environment, availability of amenities, and social cohesion, may be combined-and this could contribute to rising health inequalities. This study aims to combine a data-driven approach with clustering analysis techniques, to investigate neighbourhood characteristics that may explain the geographical distribution of the onset of myocardial infarction (MI) risk. METHODS: All MI events in patients aged 35-74 years occurring in the Strasbourg metropolitan area (SMA), from January 1, 2000 to December 31, 2007 were obtained from the Bas-Rhin coronary heart disease register. All cases were geocoded to the census block for the residential address. Each areal unit, characterized by contextual neighbourhood profile, included socioeconomic environment, availability of amenities (including leisure centres, libraries and parks, and transport) and psychosocial environment as well as specific annual rates standardized (per 100,000 inhabitants). A spatial scan statistic implemented in SaTScan was then used to identify statistically significant spatial clusters of high and low risk of MI. RESULT: MI incidence was non-randomly spatially distributed, with a cluster of high risk of MI in the northern part of the SMA [relative risk (RR) = 1.70, p = 0.001] and a cluster of low risk of MI located in the first and second periphery of SMA (RR 0.04, p value  =  0.001). Our findings suggest that the location of low MI risk is characterized by a high socioeconomic level and a low level of access to various amenities; conversely, the location of high MI risk is characterized by a high level of socioeconomic deprivation-despite the fact that inhabitants have good access to the local recreational and leisure infrastructure. CONCLUSION: Our data-driven approach highlights how the different contextual dimensions were inter-combined in the SMA. Our spatial approach allowed us to identify the neighbourhood characteristics of inhabitants living within a cluster of high versus low MI risk. Therefore, spatial data-driven analyses of routinely-collected data georeferenced by various sources may serve to guide policymakers in defining and promoting targeted actions at fine spatial level.

Small-area spatiotemporal analysis of heatwave impacts on elderly mortality in Paris: A cluster analysis approach.

BACKGROUND: Heat-waves have a substantial public health burden. Understanding spatial heterogeneity at a fine spatial scale in relation to heat and related mortality is central to target interventions towards vulnerable communities. OBJECTIVES: To determine the spatial variability of heat-wave-related mortality risk among elderly in Paris, France at the census block level. We also aimed to assess area-level social and environmental determinants of high mortality risk within Paris. METHODS: We used daily mortality data from 2004 to 2009 among people aged >65 at the French census block level within Paris. We used two heat wave days' definitions that were compared to non-heat wave days. A Bernoulli cluster analysis method was applied to identify high risk clusters of mortality during heat waves. We performed random effects meta-regression analyses to investigate factors associated with the magnitude of the mortality risk. RESULTS: The spatial approach revealed a spatial aggregation of death cases during heat wave days. We found that small scale chronic PM10 exposure was associated with a 0.02 (95% CI: 0.001; 0.045) increase of the risk of dying during a heat wave episode. We also found a positive association with the percentage of foreigners and the percentage of labor force, while the proportion of elderly people living in the neighborhood was negatively associated. We also found that green space density had a protective effect and inversely that the density of constructed feature increased the risk of dying during a heat wave episode. CONCLUSION: We showed that a spatial variation in terms of heat-related vulnerability exists within Paris and that it can be explained by some contextual factors. This study can be useful for designing interventions targeting more vulnerable areas and reduce the burden of heat waves.

Influence of Socio-Economic Inequalities on Access to Renal Transplantation and Survival of Patients with End-Stage Renal Disease.

BACKGROUND: Public and scientific concerns about the social gradient of end-stage renal disease and access to renal replacement therapies are increasing. This study investigated the influence of social inequalities on the (i) access to renal transplant waiting list, (ii) access to renal transplantation and (iii) patients' survival. METHODS: All incident adult patients with end-stage renal disease who lived in Bretagne, a French region, and started dialysis during the 2004-2009 period were geocoded in census-blocks. To each census-block was assigned a level of neighborhood deprivation and a degree of urbanization. Cox proportional hazards models were used to identify factors associated with each study outcome. RESULTS: Patients living in neighborhoods with low level of deprivation had more chance to be placed on the waiting list and less risk of death (HR = 1.40 95%CI: [1.1-1.7]; HR = 0.82 95%CI: [0.7-0.98]), but this association did not remain after adjustment for the patients' clinical features. The likelihood of receiving renal transplantation after being waitlisted was not associated with neighborhood deprivation in univariate and multivariate analyses. CONCLUSIONS: In a mixed rural and urban French region, patients living in deprived or advantaged neighborhoods had the same chance to be placed on the waiting list and to undergo renal transplantation. They also showed the same mortality risk, when their clinical features were taken into account.

Spatial distribution of end-stage renal disease (ESRD) and social inequalities in mixed urban and rural areas: a study in the Bretagne administrative region of France.

BACKGROUND: Several studies have investigated the implication of biological and environmental factors on geographic variations of end-stage renal disease (ESRD) incidence at large area scales, but none of them assessed the implication of neighbourhood characteristics (healthcare supply, socio-economic level and urbanization degree) on spatial repartition of ESRD. We evaluated the spatial implications of adjustment for neighbourhood characteristics on the spatial distribution of ESRD incidence at the smallest geographic unit in France. METHODS: All adult patients living in Bretagne and beginning renal replacement therapy during the 2004-09 period were included. Their residential address was geocoded at the census block level. Each census block was characterized by socio-economic deprivation index, healthcare supply and rural/urban typology. Using a spatial scan statistic, we examined whether there were significant clusters of high risk of ESRD incidence. RESULTS: The ESRD incidence was non-randomly spatially distributed, with a cluster of high risk in the western Bretagne region (relative risk, RR = 1.28, P-value = 0.0003). Adjustment for sex, age and neighbourhood characteristics induced cluster shifts. After these adjustments, a significant cluster (P = 0.013) persisted. CONCLUSIONS: Our spatial analysis of ESRD incidence at a fine scale, across a mixed rural/urban area, indicated that, beyond age and sex, neighbourhood characteristics explained a great part of spatial distribution of ESRD incidence. However, to better understand spatial variation of ESRD incidence, it would be necessary to research and adjust for other determinants of ESRD.

Air quality and social deprivation in four French metropolitan areas--a localized spatio-temporal environmental inequality analysis.

Several studies have documented that more deprived populations tend to live in areas characterized by higher levels of environmental pollution. Yet, time trends and geographic patterns of this disproportionate distribution of environmental burden remain poorly assessed, especially in Europe. We investigated the spatial and temporal relationship between ambient air nitrogen dioxide (NO2) concentrations and socioeconomic and demographic data in four French metropolitan areas (Lille in the North, Lyon in the center, Marseille in the South, and Paris) during two different time periods. The geographical unit used was the census block. The dependent variable was the NO2 annual average concentration (µg/m(3)) per census block, and the explanatory variables were a neighborhood deprivation index and socioeconomic and demographic data derived from the national census. Generalized additive models were used to account for spatial autocorrelation. We found that the strength and direction of the association between deprivation and NO2 estimates varied between cities. In Paris, census blocks with the higher social categories are exposed to higher mean concentrations of NO2. However, in Lille and Marseille, the most deprived census blocks are the most exposed to NO2. In Lyon, the census blocks in the middle social categories were more likely to have higher concentrations than in the lower social categories. Despite a general reduction in NO2 concentrations over the study period in the four metropolitan areas, we found contrasting results in the temporal trend of environmental inequalities. There is clear evidence of city-specific spatial and temporal environmental inequalities that relate to the historical socioeconomic make-up of the cities and its evolution. Hence, general statements about environmental and social inequalities can be made.

An exploratory spatial analysis to assess the relationship between deprivation, noise and infant mortality: an ecological study.

BACKGROUND: Few studies have explored how noise might contribute to social health inequalities, and even fewer have considered infant mortality or its risk factors as the health event of interest.In this paper, we investigate the impact of neighbourhood characteristics - both socio-economic status and ambient noise levels - on the spatial distribution of infant mortality in the Lyon metropolitan area, in France. METHODS: All infant deaths (n = 715) occurring between 2000 and 2009 were geocoded at census block level. Each census block was assigned multi-component socio-economic characteristics and Lden levels, which measure exposure to noise. Using a spatial-scan statistic, we examined whether there were significant clusters of high risk of infant mortality according to neighbourhood characteristics. RESULTS: Our results highlight the fact that infant mortality is non-randomly distributed spatially, with clusters of high risk in the south-east of the Lyon metropolitan area (RR = 1.44; p = 0.09). After adjustments for socio-economic characteristics and noise levels, this cluster disappears or shifts according to in line with different scenarios, suggesting that noise and socio-economic characteristics can partially explain the spatial distribution of infant mortality. CONCLUSION: Our findings show that noise does have an impact on the spatial distribution of mortality after adjustments for socio-economic characteristics. A link between noise and infant mortality seems plausible in view of the three hypothetical, non-exclusive, pathways we propose in our conceptual framework: (i) a psychological pathway, (ii) a physiological disruption process and (iii) an unhealthy behaviours pathway. The lack of studies makes it is difficult to compare our findings with others. They require further research for confirmation and interpretation.

Green space, social inequalities and neonatal mortality in France.

BACKGROUND: Few studies have considered using environmental amenities to explain social health inequalities.Nevertheless, Green spaces that promote good health may have an effect on socioeconomic health inequalities. In developed countries, there is considerable evidence that green spaces have a beneficial effect on the health of urban populations and recent studies suggest they can have a positive effect on pregnancy outcomes. To investigate the relationship between green spaces and the spatial distribution of infant mortality taking account neighborhood deprivation levels. METHODS: The study took place in Lyon metropolitan area, France. All infant deaths that occurred between 2000 and 2009 were geocoded at census block level. Each census block was assigned greenness and socioeconomic deprivation levels. The spatial-scan statistic was used to identify high risk cluster of infant mortality according to these neighborhood characteristics. RESULTS: The spatial distribution of infant mortality was not random with a high risk cluster in the south east of the Lyon metropolitan area (p<0.003). This cluster disappeared (p=0.12) after adjustment for greenness level and socioeconomic deprivation, suggesting that these factors explain part of the spatial distribution of infant mortality. These results are discussed using a conceptual framework with 3 hypothetical pathways by which green spaces may have a beneficial effect on adverse pregnancy outcomes: (i) a psychological pathway, (ii) a physiological disruption process and (iii) an environmental pathway. CONCLUSIONS: These results add some evidence to the hypothesis that there is a relationship between access to green spaces and pregnancy outcomes but further research is required to confirm this.