Individual and regional differences in the effects of school racial segregation on Black students' health.

Background: School racial segregation in the US has risen steadily since the 1990s, propelled by Supreme Court decisions rolling back the legacy of Brown v. Board. Quasi-experimental research has shown this resegregation harms Black students' health. However, whether individual or family characteristics (e.g., higher family incomes) are protective against segregation's health harms-or whether segregation is more damaging in regions of the US with fewer public sector investments-remains unclear. We leverage the quasi-random timing of school districts being released from Brown-era integration plans to examine heterogeneity in the association between resegregation and Black students' health. Methods & findings: We took an instrumental variables approach, using the timing of integration order releases as an instrument for school segregation and analyzing a pre-specified list of theoretically-motivated modifiers in the Panel Study of Income Dynamics. In sensitivity analyses, we fit OLS models that directly adjusted for relevant covariates. Results suggest resegregation may have been particularly harmful in the South, where districts resegregated more quickly after order releases. We find little evidence that the effects of school segregation differed across family income, gender, or age. Conclusion: The end of court-ordered integration threatens the health of Black communities-especially in the US South. Modestly higher incomes do not appear protective against school segregation's harms. Research using larger samples and alternative measures of school segregation-e.g., between districts, instead of within districts-may further our understanding of segregation's health effects, especially in Northern states.

Who are the "police" in "police violence"? Fatal violence by U.S. law enforcement agencies across levels of government.

BACKGROUND: Police violence is increasingly recognized as an urgent public health problem. Basic questions about police violence, however, remain unanswered, including which types of law enforcement agency are responsible for fatal police violence deaths. METHODS: We estimated the proportion of police violence deaths in the U.S. (2013-2022) that were attributable to local, county, state, federal, or tribal police agencies, using mapping police violence data. We examined proportions overall, by decedent race/ethnicity, and by state. RESULTS: Nationally, 60% of decedents were killed by municipal, 29% by county, 8% by state, and 3% by federal, police, with < 1% killed by tribal or other officers. These proportions varied by race/ethnicity, with 56% of Native American decedents killed by municipal police compared to 70-75% among other racially minoritized people. While municipal police were responsible for most deaths in most states, in the Southeast, county police predominated. In some Northeastern states (and Alaska), state police were responsible for > 40% of deaths. CONCLUSIONS: We identify wide geographic & racial/ethnic variation in the agencies responsible for fatal police violence. Findings suggest that the budgetary and infrastructural shifts required to prevent fatal police violence need to occur at multiple levels of government.

Moving Because of Unaffordable Housing and Disrupted Social Safety Net Access Among Children.

OBJECTIVES: To measure associations between residential moves because of unaffordable housing costs and disruptions in access to the Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; and Medicaid in a health care-based sample of families with young children. METHODS: We used cross-sectional survey data on social safety net-eligible caregivers and children recruited into the Children's HealthWatch study from emergency departments and primary care clinics in Baltimore and Philadelphia (2011-2019). Children's HealthWatch measured residential moves (cost-driven and noncost-driven) in the past year and disruptions in safety net access. We used logistic regression to estimate associations between each type of move and disrupted access to social safety nets. RESULTS: Across 9344 children, cost-driven residential moves were associated with higher odds of disrupted access to at least 1 safety net program (Supplemental Nutrition Assistance Program; the Special Supplemental Nutrition Program for Women, Infants, and Children; or Medicaid; adjusted odds ratio 1.44; 95% confidence interval 1.16-1.80), as well as higher odds of disruption to each program separately. Noncost-driven moves were also associated with disruptions to at least 1 safety net program, but less strongly so (adjusted odds ratio 1.14; confidence interval 1.01-1.29; P value for comparison with cost-driven = .045). CONCLUSIONS: Residential moves, particularly cost-driven moves, are associated with social safety net benefit disruptions. The association between these events suggests a need for action to ensure consistent safety net access among children facing cost-driven moves and vice versa (ie, access to housing supports for children with disrupted safety net access).

Eviction as a community health exposure.

Evidence suggests that being evicted harms health. Largely ignored in the existing literature is the possibility that evictions exert community-level health effects, affecting evicted individuals' social networks and shaping broader community conditions. In this narrative review, we summarize evidence and lay out a theoretical model for eviction as a community health exposure, mediated through four paths: 1) shifting ecologies of infectious disease and health behaviors, 2) disruption of neighborhood social cohesion, 3) strain on social networks, and 4) increasing salience of eviction risk. We describe methods for parsing eviction's individual and contextual effects and discuss implications for causal inference. We conclude by addressing eviction's potentially multilevel consequences for policy advocacy and cost-benefit analyses.

Testing mediating pathways between school segregation and health: Evidence on peer prejudice and health behaviors.

School racial segregation is increasingly recognized as a threat to US public health: rising segregation in recent decades has been linked to a range of poor health outcomes for Black Americans. Key theorized mediators of these harms remain underexamined, including experiences of interpersonal and institutional racism driving increased stress, and peers' health behaviors influencing students' own. Using cross-sectional survey data on a national sample of adolescents, we investigated associations between school segregation and these two potential mediating pathways, operationalized as adolescents' perceptions of prejudice from fellow students and the health behaviors of their peers (drinking and smoking). We further investigated whether associations were modified by individual race/ethnicity and school racial composition. Pooling across all schools and students, higher levels of school segregation were associated with decreased perceptions of peer prejudice (OR 0.54, 95% CI = 0.34-0.86), but not with peers' health behaviors. However, this masked important differences by respondents' race/ethnicity and school racial/ethnic composition. In predominantly White schools, school segregation was not associated with Black students' perceptions of peers' prejudice, but higher levels of segregation were associated with increased rates of peers' drinking and smoking. In predominantly non-White schools, in contrast-where most Black students are educated-higher levels of school segregation were not associated with perceived peer prejudice nor unhealthier peer behaviors for Black students (in fact, peers' health behaviors improved). And across both school types, higher levels of district segregation were associated with lower odds of reporting peer prejudice among non-Black students of color. Our findings suggest that the paths between school segregation and poor health depend on the type of school children attend in segregated districts. In schools predominantly serving students of color, structural factors upheld by school segregation-i.e., material, educational, disciplinary, or economic disadvantage-likely dominate over peer behaviors as the primary drivers of segregation's health harms.

Policing sexuality: Sexual minority youth, police contact, and health inequity.

Police contact is increasingly recognized as an adverse childhood experience and determinant of poor mental health. While targeting of LGBTQ sex and community spaces by law enforcement has a long precedent in US history-and while LGBTQ people continue to protest unfair police treatment-little population-level research has examined police contact disparities by sexual orientation or gender identity. We test whether sexual minority (SM) youth have higher risk of police contact through young adulthood. We analyze a nationally representative cohort of >15,000 US young adults who were in middle/high school in the mid-1990s, with police contact histories collected at age 18-25. Using four different, equally reasonable approaches to coding youth-reported sexual orientation, we identified ∼500-1900 SMs. Compared to heterosexual youth, SM youth had 1.86 times the odds of ever being stopped by police (95% CI = 1.56-2.22, p < 0.001), were stopped 1.60 times as often (CI = 1.38-1.86, p < 0.001), and were stopped at younger ages (survival time ratio = 0.91, CI = 0.88-0.93, p < 0.001). Inequities were particularly driven by SM women, among whom disparities were severe (ever stopped OR = 2.18, stop count ratio = 2.44, survival time ratio = 0.87). For men, inequities only emerged once a broad definition of SM was adopted, suggesting that young SM men who do not identify as LGB (or who are reticent to report themselves as such) may be at particular risk. Results were robust to adjustment for race/ethnicity and parental nativity, though small cells meant models stratified by race/ethnicity were underpowered. Given substantially heightened police contact among SM youth (particularly, young SM women), care providers and educators working with them should explicitly combat homophobic and criminal legal system stigma and screen for police contact and its psychological sequelae. More data on LGBTQ communities' criminal legal system contact throughout life is essential for preventing the causes and consequences of related sexual orientation-based health inequities.

The association of residential racial segregation with health among U.S. children: A nationwide longitudinal study.

Residential racial segregation in the U.S. has been hypothesized as a fundamental cause driving health disparities across racial groups. Potential mechanisms include economic and social marginalization, subsequent constrained opportunities, and high stress. Yet evidence on residential segregation's association with health among Black and White children-particularly longitudinally-is sparse. This study aims to address this gap. We used data from the Panel Study of Income Dynamics (PSID), a national longitudinal study of U.S. households, analyzing information on 1,251 Black and 1,427 White children who participated in the Child Development Supplement (CDS) at least twice (survey waves 1997, 2002, 2007, 2014). We fit individual fixed-effects models to estimate the within-person association of neighborhood-level residential segregation, measured with local Getis-Ord G* statistics, with three outcomes (general health, weight status, and behavioral problems). We examined heterogeneous effects by age and sex. We also examined associations between health and childhood segregation trajectories, i.e., the pattern of children's residential segregation exposures from birth through when their health outcomes were measured, providing additional insight on dynamic experiences of segregation. In fixed effects models, among Black children, higher segregation was associated with worse self-rated health, especially for Black children who were older (aged 11-17 years). In trajectory models, among White children, moving out of highly segregated neighborhoods was associated with a lower probability of poor self-rated health, while moving into those neighborhoods or back and forth between neighborhood types were both associated with increased behavioral problems. Our findings highlight the importance of early-life residential segregation in shaping persistent racial health disparities, as well as the costs of segregation for all children living in highly segregated neighborhoods.

Disaggregating Asian American and Pacific Islander Risk of Fatal Police Violence.

High rates and racial inequities in U.S. fatal police violence are an urgent area of public health concern and policy attention. Asian Americans and Pacific Islanders (AAPIs) have been described as experiencing low rates of fatal police violence, yet AAPI subgroups vary widely on nearly every demographic and economic metric. Here, we calculate fatal police violence rates by AAPI regional and national/ethnic background, finding wide variation. We compile a list of AAPI people killed in interactions with police in 2013-2019, then use web searches and surname algorithms to identify decedents' backgrounds. Rates are then calculated by combining this numerator data with population denominators from the American Community Survey and fitting Poisson models. Excluding 18% of deaths with missing regional backgrounds, East and South Asian Americans died at a rate of 0.05 and 0.04 deaths per 100,000 (95% CI: 0.04-0.06 and 0.02-0.08), respectively, less than a third of Southeast Asian Americans' rate (0.16, CI: 0.13-0.19). Pacific Islanders suffered higher rates (0.88, CI: 0.65-1.19), on par with Native and Black Americans. More granularly, Southeast Asian American groups displaced by US war in Southeast Asia suffered higher rates than others from the same region. Traditional racial classifications thus obscure high risks of fatal police violence for AAPI subgroups. Disaggregation is needed to improve responses to fatal police violence and its racial/ethnic inequities.

The long shadow of residential racial segregation: Associations between childhood residential segregation trajectories and young adult health among Black US Americans.

Residential racial segregation is a key manifestation of anti-Black structural racism, thought to be a fundamental cause of poor health; evidence has shown that it yields neighborhood disinvestment, institutional discrimination, and targeting of unhealthy products like tobacco and alcohol. Yet research on the long-term impacts of childhood exposure to residential racial segregation is limited. Here, we analyzed data on 1823 Black participants in the Panel Study of Income Dynamics, estimating associations between childhood segregation trajectories and young adult health. Black young adults who consistently lived in high-segregation neighborhoods throughout childhood experienced unhealthier smoking and drinking behaviors and higher odds of obesity compared to other trajectory groups, including children who moved into or out of high-segregation neighborhoods. Results were robust to controls for neighborhood and family poverty. Findings underscore that for Black children who grow up in segregated neighborhoods, the roots of structurally-determined health inequities are established early in life.

Building health equity through housing policies: critical reflections and future directions for research.

Housing may be at once the most powerful and underused tool at our disposal to improve population health. Using examples from the USA, we argue that current levels of housing insecurity are the result of clear and inequitable policy choices, leading to the entrenchment of health inequities-particularly, across race and class. Solutions to housing insecurity must, therefore, be structural. The COVID-19 pandemic has opened a window of opportunity for these structural housing policy reforms. Through justice- and action-oriented research, health researchers can inform the development and implementation of housing policies that advance health equity. We offer a series of recommendations to better position our field to achieve this goal.

School racial segregation and long-term cardiovascular health among Black adults in the US: A quasi-experimental study.

BACKGROUND: Cardiovascular disease (CVD) disproportionately affects Black adults in the United States. This is increasingly acknowledged to be due to inequitable distribution of health-promoting resources. One potential contributor is inequities in educational opportunities, although it is unclear what aspects of education are most salient. School racial segregation may affect cardiovascular health by increasing stress, constraining socioeconomic opportunities, and altering health behaviors. We investigated the association between school segregation and Black adults' CVD risk. METHODS AND FINDINGS: We leveraged a natural experiment created by quasi-random (i.e., arbitrary) timing of local court decisions since 1991 that released school districts from court-ordered desegregation. We used the Panel Study of Income Dynamics (PSID) (1991 to 2017), linked with district-level school segregation measures and desegregation court order status. The sample included 1,053 Black participants who ever resided in school districts that were under a court desegregation order in 1991. The exposure was mean school segregation during observed schooling years. Outcomes included several adult CVD risk factors and outcomes. We fitted standard ordinary least squares (OLS) multivariable linear regression models, then conducted instrumental variables (IV) analysis, using the proportion of schooling years spent in districts that had been released from court-ordered desegregation as an instrument. We adjusted for individual- and district-level preexposure confounders, birth year, and state fixed effects. In standard linear models, school segregation was associated with a lower probability of good self-rated health (-0.05 percentage points per SD of the segregation index; 95% CI: -0.08, -0.03; p < 0.001) and a higher probability of binge drinking (0.04 percentage points; 95% CI: 0.002, 0.07; p = 0.04) and heart disease (0.01 percentage points; 95% CI: 0.002, 0.15; p = 0.007). IV analyses also found that school segregation was associated with a lower probability of good self-rated health (-0.09 percentage points; 95% CI: -0.17, -0.02, p = 0.02) and a higher probability of binge drinking (0.17 percentage points; 95% CI: 0.04, 0.30, p = 0.008). For IV estimates, only binge drinking was robust to adjustments for multiple hypothesis testing. Limitations included self-reported outcomes and potential residual confounding and exposure misclassification. CONCLUSIONS: School segregation exposure in childhood may have longstanding impacts on Black adults' cardiovascular health. Future research should replicate these analyses in larger samples and explore potential mechanisms. Given the recent rise in school segregation, this study has implications for policies and programs to address racial inequities in CVD.

School Racial Segregation and the Health of Black Children.

OBJECTIVES: Few researchers have evaluated whether school racial segregation, a key manifestation of structural racism, affects child health, despite its potential impacts on school quality, social networks, and stress from discrimination. We investigated whether school racial segregation affects Black children's health and health behaviors. METHODS: We estimated the association of school segregation with child health, leveraging a natural experiment in which school districts in recent years experienced increased school segregation. School segregation was operationalized as the Black-White dissimilarity index. We used ordinary least squares models as well as quasi-experimental instrumental variables analysis, which can reduce bias from unobserved confounders. Data from the Child Development Supplement of the Panel Study of Income Dynamics (1997-2014, n = 1248 Black children) were linked with district-level school segregation measures. Multivariable regressions were adjusted for individual-, neighborhood-, and district-level covariates. We also performed subgroup analyses by child sex and age. RESULTS: In instrumental variables models, a one standard deviation increase in school segregation was associated with increased behavioral problems (2.53 points on a 27-point scale; 95% CI, 0.26 to 4.80), probability of having ever drunk alcohol (0.23; 95% CI, 0.049 to 0.42), and drinking at least monthly (0.20; 95% CI, 0.053 to 0.35). School segregation was more strongly associated with drinking behaviors among girls. CONCLUSIONS: School segregation was associated with worse outcomes on several measures of well-being among Black children, which may contribute to health inequities across the life span. These results highlight the need to promote school racial integration and support Black youth attending segregated schools.

Eviction, Healthcare Utilization, and Disenrollment Among New York City Medicaid Patients.

INTRODUCTION: Although growing evidence links residential evictions to health, little work has examined connections between eviction and healthcare utilization or access. In this study, eviction records are linked to Medicaid claims to estimate short-term associations between eviction and healthcare utilization, as well as Medicaid disenrollment. METHODS: New York City eviction records from 2017 were linked to New York State Medicaid claims, with 1,300 evicted patients matched to 261,855 non-evicted patients with similar past healthcare utilization, demographics, and neighborhoods. Outcomes included patients' number of acute and ambulatory care visits, healthcare spending, Medicaid disenrollment, and pharmaceutical prescription fills during 6 months of follow-up. Coarsened exact matching was used to strengthen causal inference in observational data. Weighted generalized linear models were then fit, including censoring weights. Analyses were conducted in 2019-2021. RESULTS: Eviction was associated with 63% higher odds of losing Medicaid coverage (95% CI=1.38, 1.92, p<0.001), fewer pharmaceutical prescription fills (incidence rate ratio=0.68, 95% CI=0.52, 0.88, p=0.004), and lower odds of generating any healthcare spending (OR=0.72, 95% CI=0.61, 0.85, p<0.001). However, among patients who generated any spending, average spending was 20% higher for those evicted (95% CI=1.03, 1.40, p=0.017), such that evicted patients generated more spending on balance. Marginally significant estimates suggested associations with increased acute, and decreased ambulatory, care visits. CONCLUSIONS: Results suggest that eviction drives increased healthcare spending while disrupting healthcare access. Given previous research that Medicaid expansion lowered eviction rates, eviction and Medicaid disenrollment may operate cyclically, accumulating disadvantage. Preventing evictions may improve access to care and lower Medicaid costs.

Childhood eviction and cognitive development: Developmental timing-specific associations in an urban birth cohort.

Eviction upends children's lives and exacerbates deprivation; it remains largely unexamined as a determinant of cognitive development. We assess whether children evicted in infancy, early childhood, and middle childhood exhibit lower scores on four cognitive assessments (measuring executive function, mathematical reasoning, written language skills, and vocabulary skills) at age 9. Using linear regression and selection weights, we analyze longitudinal data from the Fragile Families and Child Wellbeing Study, a national, urban birth cohort (N = 1724 for eviction during infancy, 2126 for early childhood, 1979 for middle childhood). These stages of childhood follow the timing of FFCWS' data collection waves, with "infancy" data collected in the first year of life, "early childhood" in the third and fifth years of life, and "middle childhood" in the ninth year. In adjusted models, children evicted in middle childhood exhibited scores 0.20-0.43 SDs below similar children who were not (depending on the assessment; p-values = 0.004-0.055), the equivalent of as much as a full year of schooling. Point estimates of the association between eviction in infancy and 3/4 cognitive skills at age 9 were also large, but imprecisely estimated (between -0.25 and -0.28 SDs; p-values = 0.053-0.101), while point estimates for eviction in early childhood were near zero and statistically insignificant. Our large estimates for middle childhood and infancy, compared to earlier residential mobility studies, indicate downwardly mobile moves may exhibit more severe associations with future cognition. Estimates suggest preventing eviction may be a powerful, cost-effective way to safeguard children's cognitive development.

Variation in State-Level Eviction Moratorium Protections and Mental Health Among US Adults During the COVID-19 Pandemic.

Importance: Although evictions have been associated with adverse mental health outcomes, it remains unclear which stages of the eviction process are associated with mental distress among renters. Variation in COVID-19 pandemic eviction protections across US states enables identification of intervention targets within the eviction process to improve renters' mental health. Objective: To measure the association between the strength of eviction protections (ie, stages blocked by eviction moratoriums) and mental distress among renters during the COVID-19 pandemic. Design, Setting, and Participants: This cohort study used individual-level, nationally representative data from the Understanding Coronavirus in America Survey to measure associations between state eviction moratorium protections and mental distress. The sample of 2317 respondents included renters with annual household incomes less than $75 000 who reported a state of residence and completed surveys between March 10 and September 3, 2020, prior to the federal eviction moratorium order by the Centers for Disease Control and Prevention. Exposures: Time-varying strength of state moratorium protections as a categorical variable: none, weak (blocking court hearings, judgments, or enforcement without blocking notice or filing), or strong (blocking all stages of the eviction process beginning with notice and filing). Main Outcomes and Measures: Moderate to severe mental distress was measured using the 4-item Patient Health Questionnaire. Linear regression models were adjusted for time-varying state COVID-19 incidence and mortality, public health restrictions, and unemployment rates. Models included individual and time fixed effects as well as clustered standard errors. Results: The sample consisted of 2317 individuals (20 853 total observations) composed largely (1788 [78%] weighted) of middle-aged adults (25-64 years of age) and women (1538 [60%]); 640 respondents (23%) self-reported as Hispanic or Latinx, 314 respondents (20%) as non-Hispanic Black, and 1071 respondents (48%) as non-Hispanic White race and ethnicity. Relative to no state-level eviction moratorium protections, strong protections were associated with a 12.6% relative reduction (risk ratio, 0.87; 95% CI, 0.76-0.99) in the probability of mental distress, whereas weak protections were not associated with a statistically significant reduction (risk ratio, 0.96; 95% CI, 0.86-1.06). Conclusions and Relevance: This analysis of the Understanding Coronavirus in America Survey data found that strong eviction moratoriums were associated with protection against mental distress, suggesting that distress begins early in the eviction process with notice and filing. This finding is consistent with the idea that to reduce mental distress among renters, policy makers should focus on primary prevention of evictions.

Expiring Eviction Moratoriums and COVID-19 Incidence and Mortality.

The coronavirus disease 2019 (COVID-19) pandemic and associated economic crisis have placed millions of US households at risk of eviction. Evictions may accelerate COVID-19 transmission by decreasing individuals' ability to socially distance. We leveraged variation in the expiration of eviction moratoriums in US states to test for associations between evictions and COVID-19 incidence and mortality. The study included 44 US states that instituted eviction moratoriums, followed from March 13 to September 3, 2020. We modeled associations using a difference-in-difference approach with an event-study specification. Negative binomial regression models of cases and deaths included fixed effects for state and week and controlled for time-varying indicators of testing, stay-at-home orders, school closures, and mask mandates. COVID-19 incidence and mortality increased steadily in states after eviction moratoriums expired, and expiration was associated with a doubling of COVID-19 incidence (incidence rate ratio = 2.1; 95% confidence interval (CI): 1.1, 3.9) and a 5-fold increase in COVID-19 mortality (mortality rate ratio = 5.4; CI: 3.1, 9.3) 16 weeks after moratoriums lapsed. These results imply an estimated 433,700 excess cases (CI: 365,200, 502,200) and 10,700 excess deaths (CI: 8,900, 12,500) nationally by September 3, 2020. The expiration of eviction moratoriums was associated with increased COVID-19 incidence and mortality, supporting the public-health rationale for eviction prevention to limit COVID-19 cases and deaths.

Health Selection Into Eviction: Adverse Birth Outcomes and Children's Risk of Eviction Through Age 5 Years.

Adverse birth outcomes put children at increased risk of poor future health. They also put families under sudden socioeconomic and psychological strain, which has poorly understood consequences. We tested whether infants experiencing an adverse birth outcome-low birthweight or prematurity, as well as lengthy hospital stays-were more likely to be evicted in early childhood, through age 5 years. We analyzed 5,655 observations contributed by 2,115 participants in the Fragile Families and Child Wellbeing Study-a national, randomly sampled cohort of infants born in large US cities between 1998 and 2000-living in rental housing at baseline. We fitted proportional hazards models using piecewise logistic regression, controlling for an array of confounders and applying inverse probability of selection weights. Having been born low birthweight or preterm was associated with a 1.74-fold increase in children's hazard of eviction (95% confidence interval: 1.02, 2.95), and lengthy neonatal hospital stays were independently associated with a relative hazard of 2.50 (95% confidence interval: 1.15, 5.44) compared with uncomplicated births. Given recent findings that unstable housing during pregnancy is associated with adverse birth outcomes, our results suggest eviction and health may be cyclical and co-constitutive. Children experiencing adverse birth outcomes are vulnerable to eviction and require additional supports.

Severe Housing Insecurity during Pregnancy: Association with Adverse Birth and Infant Outcomes.

Introduction: Housing insecurity is increasingly commonplace among disadvantaged women and children. We measured the individual- and population-level impact of severe housing insecurity during pregnancy on adverse birth and infant outcomes. Methods: We analyzed data from 3428 mother-infant dyads enrolled in the Fragile Families and Child Wellbeing Study, a prospective cohort study representing births in 20 large U.S. cities from 1998 to 2000. Severe housing insecurity was defined as threatened eviction or homelessness during pregnancy. Outcomes included low birth weight and/or preterm birth, admission to a neonatal intensive care unit (NICU) or stepdown facility, extended hospitalization after delivery, and infant health and temperament. We estimated exposure-outcome associations with risk ratios adjusted for pre-pregnancy maternal sociodemographic and heath factors and calculated a population attributable fraction (PAF) of outcomes attributable to severe housing insecurity. Results: We found statistically significant associations between severe housing insecurity during pregnancy and low birth weight and/or preterm birth (risk ratio (RR] 1.73, 95% confidence interval (CI) 1.28, 2.32), NICU or stepdown stay (RR 1.64, CI 1.17, 2.31), and extended hospitalization (RR 1.66, CI 1.28, 2.16). Associations between housing insecurity and infant fair or poor health (RR 2.62, CI 0.91, 7.48) and poor temperament (RR 1.52, CI 0.98, 2.34) were not statistically significant. PAF estimates ranged from 0.9-2.7%, suggesting that up to three percent of adverse birth and infant outcomes could be avoided by eliminating severe housing insecurity among low-income, pregnant women in US cities. Conclusions: Results suggest that housing insecurity during pregnancy shapes neonatal and infant health in disadvantaged urban families.