African immigrants' favorable preterm birth rates challenge genetic etiology of the Black-White disparity in preterm birth.

Background: We examined over a million California birth records for 2010 through 2021 to investigate whether disparities in preterm birth (PTB) by nativity and race support the widely held but hitherto unsubstantiated belief that genetic differences explain the persistent Black-White disparity in PTB. Methods: We examined PTB rates and risk ratios among African-, Caribbean-, and U.S.-born Black women compared to U.S.-born White women. Multivariate analyses adjusted for maternal age, education, number of live births, delivery payer, trimester of prenatal care initiation, pre-pregnancy BMI, smoking, and prevalence of poverty in a woman's residence census tract; and for paternal education. Results: In adjusted analyses, African-born Black women's PTB rates were no different from those of U.S.-born White women. Discussion: The results add to prior evidence making a genetic etiology for the racial disparity in PTB unlikely. If genetic differences tied to "race" explained the Black-White disparity in PTB among U.S.-born women, the African immigrants in this study would have had higher rates of PTB, not the lower rates observed. Multiple explanations for the observed patterns and their implications are discussed. Failure to distinguish causes of PTB from causes of the racial disparity in PTB have likely contributed to erroneous attribution of the racial disparity to genetic differences. Based on the literature, unmeasured experiences of racism, including racism-related stress and adverse environmental exposures, are plausible explanations for the PTB disparity between Black and White U.S.-born women. The favorable birth outcomes of African-born Black immigrants may reflect less exposure to racism during sensitive life periods, e.g., childhood, when they were in African countries, where Black people are in the racial majority.

Severe maternal hardships are associated with food insecurity among low-income/lower-income women during pregnancy: results from the 2012-2014 California maternal infant health assessment.

BACKGROUND: Assess the associations between ten severe maternal hardships and food insecurity experienced during pregnancy. METHODS: Data on 14,274 low-income/lower-income women (below 400% of the income to federal poverty guideline ratio) from the statewide-representative 2010-2012 California Maternal and Infant Health Assessment were used to estimate food security status prevalence. Prevalence of severe maternal hardships by food security status was estimated. Multinomial logistic regression was used to assess the associations between severe maternal hardship and food security status, adjusting for sociodemographic characteristics. RESULTS: Food insecurity was common among low- and lower-income pregnant women in California; 23.4% food insecure and an additional 11.5% marginally secure. In adjusted analysis, nine of ten hardships were associated with food security status. Only the respondent or someone close to the respondent having a problem with alcohol or drugs was not associated with food security status after adjusting for socioeconomic factors. Husband/partner losing a job, depressive symptoms, not having practical support and intimate partner violence were consistently associated with marginal, low and very low food security status. Each additional severe maternal hardship a woman experienced during pregnancy was associated with a 36% greater risk of reporting marginal food security (Relative Risk Ratio 1.36, 95% CI: 1.27, 1.47), 54% for low food security (Relative Risk Ratio 1.54, 95% CI: 1.44, 1.64), and 99% for very low food security (Relative Risk Ratio 1.99, 95% CI: 1.83, 2.15). CONCLUSIONS: Food security status was strongly linked with several maternal hardships that could jeopardize maternal and/or infant health. Services-including prenatal care and nutritional assistance-for a large proportion of pregnant women should address a wide range of serious unmet social needs including food insecurity.

The Affordable Care Act and Changes in Women's Health Insurance Coverage Before, During, and After Pregnancy in California.

OBJECTIVES: Having health insurance is associated with improvements in health care access and use, health behaviors, and outcomes. We examined changes in health insurance coverage for California women before, during, and after pregnancy after implementation of the Affordable Care Act (ACA). METHODS: We used data from the 2011-2017 California Maternal and Infant Health Assessment, an annual representative survey of women sampled from birth certificates (n = 47 487). We examined health insurance coverage at baseline before ACA implementation (2011-2013) and in each survey year from 2014 to 2017 for 3 periods (before, during, and after pregnancy). We calculated prevalence ratios to evaluate changes in health insurance coverage, adjusting for changes in demographic characteristics. Few women were uninsured during pregnancy before implementation of the ACA; therefore, analyses focused on health insurance before pregnancy and postpartum. RESULTS: Before ACA implementation, 24.4% of women reported being uninsured before pregnancy, which decreased to 10.1% in 2017. About 17% of women reported being uninsured postpartum before ACA implementation, and this percentage decreased to 7.5% in 2017. ACA implementation resulted in a >50% adjusted decline in the likelihood of being uninsured before pregnancy or postpartum, primarily because of substantial increases in Medicaid coverage. CONCLUSIONS: ACA implementation resulted in a dramatic reduction in mothers in California who were uninsured before and after pregnancy. Medicaid expansion played a major role in this improvement.

Medical Provider Promotion of Oral Health and Women's Receipt of Dental Care During Pregnancy.

Objectives Dental care during pregnancy is important. We examined whether promotion of oral health by medical providers during pregnancy and pregnant women's receipt of dental care improved between 2009 and 2012 in California. Methods We used population-based postpartum survey data collected during 2009 (n = 3105) and 2012 (n = 6810) to compare the prevalence of women's reports that, during pregnancy, (a) their medical providers discussed oral health and/or suggested they see a dentist, and (b) they received dental care. Results Between 2009 and 2012, the proportion of women reporting that their medical providers talked about oral health or referred them to a dentist increased significantly overall (from 36 to 42%, and 21-26%, respectively, p < 0.001). The proportion of women with a dental visit during pregnancy also increased, from 38% in 2009 to 42% in 2012 (p < 0.005). The improvements were largely among women of lower income and education levels, those covered by Medi-Cal, and Latinas. Women whose medical providers promoted oral health care were approximately two times more likely to report having had a dental visit during pregnancy, even after adjusting for several potential confounders. Conclusions for Practice Characteristics of women reporting that their medical providers promoted, and that they received, dental care during pregnancy in 2012 suggests that the increases in promotion and use of oral health care were largely concentrated among Medi-Cal recipients. Further improvement is needed for all populations of pregnant women. Both public and private providers need to incorporate promotion of and referral for dental care into routine prenatal care protocols.

Economic Hardship in Childhood: A Neglected Issue in ACE Studies?

Objectives Adverse childhood experiences (ACEs) have been linked with ill-health in adulthood, but ACE literature has focused on family disruption or dysfunction (e.g., child abuse, parental separation), with less attention to economic adversity. We examined whether a mother's economic hardship in childhood (EHC) was associated with women's hardships and health-risk behaviors during/just before pregnancy. Methods We analyzed population-based survey data on 27,102 postpartum California women. EHC included respondents' reports that during childhood they/their families experienced hunger because of inability to afford food or moved because of problems paying rent/mortgage and the frequency of difficulty paying for basic needs. We examined six maternal hardships/behaviors during/just before pregnancy, including four hardships (poverty, food insecurity, homelessness/no regular place to sleep, intimate partner violence) and two behaviors (smoking, binge drinking). Prevalence ratios (PRs) were calculated from sequential logistic regression models estimating associations between EHC (categorized by level of hardship) and each maternal hardship/behavior, first without adjustment, then adjusting for other childhood and current maternal factors, and finally adding family disruption/dysfunction. Results Before adjustment for family disruption/dysfunction, the highest and intermediate EHC levels were associated with each maternal hardship/behavior; after full adjustment, those associations persisted except with smoking. Higher EHC levels generally appeared associated with larger PRs, although confidence intervals overlapped. Conclusions for Policy/Practice These findings link childhood economic hardship with women's hardships, binge drinking, and possibly smoking around the time of pregnancy. Without establishing causality, they support previous research indicating that childhood economic adversity should be considered an ACE.

Worry about racial discrimination: A missing piece of the puzzle of Black-White disparities in preterm birth?

OBJECTIVES: The causes of the large and persistent Black-White disparity in preterm birth (PTB) are unknown. It is biologically plausible that chronic stress across a woman's life course could be a contributor. Prior research suggests that chronic worry about experiencing racial discrimination could affect PTB through neuroendocrine, vascular, or immune mechanisms involved in both responses to stress and the initiation of labor. This study aimed to examine the role of chronic worry about racial discrimination in Black-White disparities in PTB. METHODS: The data source was cross-sectional California statewide-representative surveys of 2,201 Black and 8,122 White, non-Latino, U.S.-born postpartum women with singleton live births during 2011-2014. Chronic worry about racial discrimination (chronic worry) was defined as responses of "very often" or "somewhat often" (vs. "not very often" or "never") to the question: "Overall during your life until now, how often have you worried that you might be treated or viewed unfairly because of your race or ethnic group?" Prevalence ratios (PRs) with 95% Confidence Intervals (CI) were calculated from sequential logistic regression models, before and after adjustment for multiple social/demographic, behavioral, and medical factors, to estimate the magnitude of: (a) PTB risks associated with chronic worry among Black women and among White women; and (b) Black-White disparities in PTB, before and after adjustment for chronic worry. RESULTS: Among Black and White women respectively, 36.9 (95% CI 32.9-40.9) % and 5.5 (95% CI 4.5-6.5) % reported chronic worry about racial discrimination; rates were highest among Black women of higher income and education levels. Chronic worry was significantly associated with PTB among Black women before (PR 1.73, 95% CI 1.12-2.67) and after (PR 2.00, 95% CI 1.33-3.01) adjustment for covariates. The unadjusted Black-White disparity in PTB (PR 1.59, 95%CI 1.21-2.09) appeared attenuated and became non-significant after adjustment for chronic worry (PR 1.30, 95% CI 0.93-1.81); it appeared further attenuated after adding the covariates (PR 1.17, 95% CI 0.85-1.63). CONCLUSIONS: Chronic worry about racial discrimination may play an important role in Black-White disparities in PTB and may help explain the puzzling and repeatedly observed greater PTB disparities among more socioeconomically-advantaged women. Although the single measure of experiences of racial discrimination used in this study precluded examination of the role of other experiences of racial discrimination, such as overt incidents, it is likely that our findings reflect an association between one or more experiences of racial discrimination and PTB. Further research should examine a range of experiences of racial discrimination, including not only chronic worry but other psychological and emotional states and both subtle and overt incidents as well. These dramatic results from a large statewide-representative study add to a growing-but not widely known-literature linking racism-related stress with physical health in general, and shed light on the links between racism-related stress and PTB specifically. Without being causally definitive, this study's findings should stimulate further research and heighten awareness of the potential role of unmeasured social variables, such as diverse experiences of racial discrimination, in racial disparities in health.

Are the poverty histories of neighbourhoods associated with psychosocial well-being among a representative sample of California mothers? An observational study.

BACKGROUND: We examine the association between the poverty histories of neighbourhoods and three indicators of psychosocial well-being-depressive symptoms, sense of control and number of stressors-in an observational study of mothers of young children in California. We also consider if length of residence in a neighbourhood moderates the association between neighbourhood poverty history and psychosocial well-being. METHODS: Data come from the Geographic Research on Well-being (GROW) Study, a subsample of mothers who completed the population-based California Maternal and Infant Health Assessment in 2003-2007 and were reinterviewed in 2012-2013. Poverty histories of neighbourhoods were constructed using the Neighbourhood Change Database (1970-2000) and American Community Survey (2005-2009). The analytic sample included 2726 women from GROW residing in 1906 census tracts. RESULTS: Adjusting for individual socioeconomic and demographic characteristics, women living in neighbourhoods where poverty decreased over the 40-year period had lower odds of depressive symptoms and a greater sense of control than women living in long-term, low-poverty neighbourhoods. Women living in long-term high-poverty neighbourhoods or in neighbourhoods where poverty increased over the 40-year period reported lower sense of control than women living in long-term, low-poverty neighbourhoods and these effects were modified by length of time living in the neighbourhood. No significant effects of neighbourhood poverty histories were found for number of stressors. CONCLUSIONS: Policies aimed at reducing neighbourhood poverty may improve mothers' psychosocial well-being.

Latina Birth Outcomes in California: Not so Paradoxical.

Objectives To investigate Latina-White differences in birth outcomes in California from 2003 to 2010, looking for evidence of the often-cited "Latina paradox" and assessing the possible role of socioeconomic factors in observed differences. MethodsUsing statewide-representative data from the California Maternal and Infant Health Assessment, an annual population-based postpartum survey, we compared rates of preterm birth (PTB) and low birth weight (LBW) in five groups: U.S.-born non-Latina Whites ("Whites"), U.S.-born Mexican-Americans, U.S.-born non-Mexican Latinas, Mexican immigrants, and non-Mexican Latina immigrants. Logistic regression models examined the relative likelihood of PTB and LBW for women in each Latina subgroup compared with Whites, before and after adjustment for socioeconomic and other covariates. Results In unadjusted analyses, women in each Latina subgroup appeared more likely than White women to have PTB and LBW, although the increased likelihood of LBW among Mexican immigrants was statistically non-significant. After adjustment for less favorable socioeconomic characteristics among Latinas compared with Whites, observed differences in the estimated likelihoods of PTB or LBW for Latina subgroups relative to Whites were attenuated and (with the exception of PTB among U.S.-born Mexican Americans) no longer statistically significant. Conclusions We found no evidence of a "Latina paradox" in birth outcomes, which some have cited as evidence that social disadvantage is not always health-damaging. As observed in several previous studies, our findings were non-paradoxical: consistent with their socioeconomic disadvantage, Latinas had worse birth outcomes than non-Latina White women. Policy-makers should not rely on a "Latina paradox" to ensure good birth outcomes among socioeconomically disadvantaged Latina women.

Post-partum Residential Mobility Among a Statewide Representative Sample of California Women, 2003-2007.

OBJECTIVES: Researchers often examine neighborhood socioeconomic environment and health during the perinatal period using geocoded addresses recorded on birth certificates at the time of delivery. Our objective was to assess the potential for post-partum neighborhood misclassification by examining whether women move neighborhoods during the immediate post-partum period, whether they move to neighborhoods of different socioeconomic status (SES), and whether mobility differs by maternal characteristics. METHODS: We used data from the 2003-2007 California Maternal and Infant Health Assessment (MIHA), an annual, statewide-representative survey of post-partum women, to examine women's neighborhood mobility patterns between giving birth and completing a survey 2-7 months post-partum. We examined whether women changed neighborhoods, whether moves were to neighborhoods of higher, lower, or similar socioeconomic status (SES), and whether these patterns differed by maternal race/ethnicity, maternal SES, or other demographic characteristics. RESULTS: Overall, 93% of women either did not move neighborhoods or moved to a neighborhood of similar SES post-partum. Only 4% of women moved to a neighborhood of lower SES and 3% to an area of higher SES. Mothers who were non-Hispanic black or US-born Hispanic, young, unmarried, primiparous, or lower SES were slightly more likely to move overall and more likely to move to neighborhoods with different SES, compared to other women. CONCLUSIONS: These findings suggest that geocoded addresses from birth certificates can be used to estimate women's neighborhood SES during the early post-partum period with little misclassification, an especially relevant finding for researchers using post-partum surveys.

Beyond the cross-sectional: neighborhood poverty histories and preterm birth.

OBJECTIVES: We examined associations between longitudinal neighborhood poverty trajectories and preterm birth (PTB). METHODS: Using data from the Neighborhood Change Database (1970-2000) and the American Community Survey (2005-2009), we categorized longitudinal trajectories of poverty for California neighborhoods (i.e., census tracts). Birth data included 23 291 singleton California births from the Maternal and Infant Health Assessment (2003-2009). We estimated associations (adjusted for individual-level covariates) between PTB and longitudinal poverty trajectories and compared these to associations using traditional, cross-sectional measures of poverty. RESULTS: Compared to neighborhoods with long-term low poverty, those with long-term high poverty and those that experienced increasing poverty early in the study period had 41% and 37% increased odds of PTB (95% confidence interval [CI] = 1.18, 1.69 and 1.09, 1.72, respectively). High (compared with low) cross-sectional neighborhood poverty was not associated with PTB (odds ratio = 1.08; 95% CI = 0.91, 1.28). CONCLUSIONS: Neighborhood poverty histories may contribute to an understanding of perinatal health and should be considered in future research.

Racial/Ethnic Disparities in Depressive Symptoms Among Pregnant Women Vary by Income and Neighborhood Poverty.

We examined racial/ethnic disparities in depressive symptoms during pregnancy among a population-based sample of childbearing women in California (N = 24,587). We hypothesized that these racial/ethnic disparities would be eliminated when comparing women with similar incomes and neighborhood poverty environments. Neighborhood poverty trajectory descriptions were linked with survey data measuring age, parity, race/ethnicity, marital status, education, income, and depressive symptoms. We constructed logistic regression models among the overall sample to examine both crude and adjusted racial/ethnic disparities in feeling depressed. Next, stratified adjusted logistic regression models were constructed to examine racial/ethnic disparities in feeling depressed among women of similar income levels living in similar neighborhood poverty environments. We found that racial/ethnic disparities in feeling depressed remained only among women who were not poor themselves and who lived in long-term moderate or low poverty neighborhoods.

The role of socioeconomic factors in Black-White disparities in preterm birth.

OBJECTIVES: We investigated the role of socioeconomic factors in Black-White disparities in preterm birth (PTB). METHODS: We used the population-based California Maternal and Infant Health Assessment survey and birth certificate data on 10 400 US-born Black and White California residents who gave birth during 2003 to 2010 to examine rates and relative likelihoods of PTB among Black versus White women, with adjustment for multiple socioeconomic factors and covariables. RESULTS: Greater socioeconomic advantage was generally associated with lower PTB rates among White but not Black women. There were no significant Black-White disparities within the most socioeconomically disadvantaged subgroups; Black-White disparities were seen only within more advantaged subgroups. CONCLUSIONS: Socioeconomic factors play an important but complex role in PTB disparities. The absence of Black-White disparities in PTB within certain socioeconomic subgroups, alongside substantial disparities within others, suggests that social factors moderate the disparity. Further research should explore social factors suggested by the literature-including life course socioeconomic experiences and racism-related stress, and the biological pathways through which they operate-as potential contributors to PTB among Black and White women with different levels of social advantage.

Limited socioeconomic opportunities and Latina teen childbearing: a qualitative study of family and structural factors affecting future expectations.

The decrease in adolescent birth rates in the United States has been slower among Latinas than among other ethnic/racial groups. Limited research has explored how socioeconomic opportunities influence childbearing among Latina adolescents. We conducted in-depth interviews with 65 pregnant foreign- and US-born Latina women (31 adolescents; 34 adults) in two California counties. We assessed perceived socioeconomic opportunities and examined how family, immigration and acculturation affected the relationships between socioeconomic opportunities and adolescent childbearing. Compared with women who delayed childbearing into adulthood, pregnant adolescents described having few resources for educational and career development and experiencing numerous socioeconomic and social barriers to achieving their goals. Socioeconomic instability and policies limiting access to education influenced childbearing for immigrant adolescents. In contrast, family disintegration tied to poverty figured prominently in US-born adolescents' childbearing. Limited socioeconomic opportunities may play a large role in persistently high pregnancy rates among Latina adolescents.

Most pregnant women in California do not receive dental care: findings from a population-based study.

OBJECTIVES: We examined the prevalence of dental care during pregnancy and reasons for lack of care. METHODS: Using a population-based survey of 21,732 postpartum women in California during 2002-2007, we calculated prevalence of dental problems, receipt of care, and reasons for non-receipt of care. We used logistic regression to estimate odds of non-receipt of care by maternal characteristics. RESULTS: Overall, 65% of women had no dental visit during pregnancy; 52% reported a dental problem prenatally, with 62% of those women not receiving care. After adjustment, factors associated with non-receipt of care included non-European American race/ethnicity, lack of a college degree, lack of private prenatal insurance, no first-trimester prenatal insurance coverage, lower income, language other than English spoken at home, and no usual source of pre-pregnancy medical care. The primary reason stated for non-receipt of dental care was lack of perceived need, followed by financial barriers. CONCLUSIONS: Most pregnant women in this study received insufficient dental care. Odds were elevated not only among the poorest, least educated mothers, but also among those with moderate incomes or some college education. The need for dental care during pregnancy must be promoted widely among both the public and providers, and financial barriers to dental care should be addressed.

Poverty, near-poverty, and hardship around the time of pregnancy.

To describe income levels and the prevalence of major hardships among women during or just before pregnancy. We separately analyzed 2002-2006 population-based postpartum survey data from California's Maternal and Infant Health Assessment (n = 18,332) and 19 states participating in CDC's Pregnancy Risk Assessment Monitoring System (n = 143,452) to examine income and several hardships (divorce/separation, domestic violence, homelessness, financial difficulties, spouse/partner's or respondent's involuntary job loss or incarceration, and, in California only, food insecurity and no social support) during/just before pregnancy. In both samples, over 30% of women were poor (income 400% FPL experienced one or more hardships. These findings paint a disturbing picture of experiences around the time of pregnancy in the United States for many women giving birth and their children, particularly because 60% had previous births. The high prevalence of low income and of serious hardships during pregnancy is of concern, given previous research documenting the adverse health consequences of these experiences and recognition of pregnancy as a critical period for health throughout the life course. Low income and major hardships around the time of pregnancy should be addressed as mainstream U.S. maternal-infant health and social policy issues.

Sociocultural determinants of teenage childbearing among Latinas in California.

OBJECTIVES: U.S. Latinas have a persistently high rate of teenage childbearing, which is associated with adverse outcomes for both mother and child. This study was designed to investigate the roles of socioeconomic factors and acculturation in teenage childbearing in this population. METHODS: Logistic regression was used to analyze the association of measures of acculturation (language spoken at home, nativity, and age at immigration) and respondents' parents' education with age at first birth in a stratified sample of post-partum women in California. RESULTS: The unadjusted odds ratio for teenage birth for Latinas versus non-Latina Whites was 5.2 (95% CI 4.1-6.6). Nativity was not significantly associated with teen birth, but speaking Spanish at home was positively associated and immigrating at a later age was negatively associated with teen birth. Overall, these measures of acculturation accounted for 17% (95% CI 8-28%) of the difference in odds of teen birth between Latinas and non-Latina Whites. Higher levels of education among respondents' parents had differentially protective effects across the racial/ethnic groups. Controlling for disparities in respondents' parents' education without changing its differential effects across racial/ethnic groups reduced the odds ratio for Latinas compared to non-Latina Whites by 30% (95% CI 14-60%). CONCLUSION: These findings call into question common assumptions about the protective effect of acculturation on teen fertility and suggest that improving childhood socioeconomic factors among Latinas may decrease teen childbearing.

Segmented assimilation theory and perinatal health disparities among women of Mexican descent.

A higher prevalence of infant low birth weight (<2500 g) has been observed among more acculturated mothers of Mexican descent living in the U.S. when compared to their less acculturated counterparts. Tests of the "acculturation hypothesis" have established that disparities in certain risks for low birth weight exist between subgroups of women of Mexican-origin. However, disparities observed by neighborhood of residence have yet to be explained. Most tests of the acculturation hypothesis assume a classical path of assimilation, whereby Mexican American health is expected to deteriorate with time spent residing in the U.S. and across the generations. The theory of segmented assimilation suggests that alternative paths are possible depending upon individual characteristics and the context of the neighborhood into which immigrant families and their children reside. This study tested the theory of segmented assimilation as a framework for examining the geographic, cultural, and socioeconomic underpinnings of population differences in infant low birth weight among women of Mexican descent in California using the 2000 U.S. Census and population-based data from the Maternal and Infant Health Assessment (1999-2005) (n=6442). Little support was found for the theory's hypotheses. Rather, increased odds for infant low birth weight were observed for English speakers residing in Latino immigrant neighborhoods when compared to English speakers in other neighborhoods, an effect attenuated for Spanish speakers. Elevated odds of low birth weight were also observed among English speakers residing in Latino immigrant neighborhoods when compared to Spanish speakers in the same neighborhoods. Findings suggest the transfer of health-specific social capital in ethnic neighborhoods may depend upon sociocultural consonance between individuals and neighborhood residents. The authors call for additional research that sheds light on the sociocultural dynamics of maternal and infant health at multiple levels.

Is neighborhood deprivation independently associated with maternal and infant health? Evidence from Florida and Washington.

OBJECTIVES: To determine whether a widely used measure of neighborhood-level socioeconomic deprivation was associated with unintended pregnancy, delayed/no prenatal care, low birth weight (LBW), and not breastfeeding, after adjusting for a more comprehensive set of individual-level socioeconomic factors than previously reported. METHODS: Data from CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) in Washington and Florida (1997-1998) were linked with census tract-level data (2000) based on birth certificate addresses. For each state, logistic regression models were estimated for associations between neighborhood deprivation measured by the Townsend Index and each dependent variable, unadjusted and then adjusting for maternal age, parity, racial/ethnic group, and education; paternal education; and family income. Similar models were estimated for each racial/ethnic group separately. RESULTS: Despite significant unadjusted associations between neighborhood deprivation and all dependent variables except LBW in Washington, few statistically significant associations were found in the adjusted models overall. In stratified models, African American women in low-deprivation Florida neighborhoods had higher odds of delayed/no prenatal care compared with their moderate-deprivation counterparts, and only among European American women were high-deprivation neighborhoods associated with increased odds of delayed/no prenatal care. CONCLUSIONS: These results, which may not be generalizable beyond Florida and Washington or to other health indicators, suggest that some previously reported associations between neighborhood characteristics and the selected health indicators may reflect residual confounding by individual-level socioeconomic status/position. Until methodological and conceptual challenges regarding mediation ("over-controlling") and measurement of neighborhood exposure are overcome, conclusions regarding independent neighborhood associations should be made with caution.

Early postnatal care among healthy newborns in 19 States: pregnancy risk assessment monitoring system, 2000.

OBJECTIVE: To examine early postnatal care among healthy newborns during 2000 in 19 states. METHODS: Using data from the Pregnancy Risk Assessment Monitoring System, a multistate population-based postpartum survey of women, we calculated prevalences of early discharge (ED; stays of < or =2 days after vaginal delivery and < or =4 days after Cesarean delivery) and early follow-up (within 1 week) after ED. We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) describing how ED and lack of early follow-up were associated with state legislation and maternal characteristics. RESULTS: While most healthy term newborns (83.5-93.4%) were discharged early, and most early-discharged newborns (51.5-88.5%) received recommended early follow-up, substantial proportions of early-discharged newborns did not. Compared with newborns in states where legislation covered both length of hospital stay (LOS) and follow-up, newborns in states without such legislation were more likely to have ED (aOR: 1.25; CI: 1.01-1.56). Lack of early follow-up was more likely among newborns in states with neither LOS nor follow-up legislation (aOR: 2.70, CI: 2.32-3.14), and only LOS legislation (aOR: 1.38, CI: 1.22-1.56) compared with those in states with legislation for both. ED was more likely among newborns born to multiparous women and those delivered by Cesarean section and less likely among those born to black and Hispanic mothers and mothers with less education. CONCLUSIONS: Lack of early follow-up among ED newborns remains a problem, particularly in states without relevant legislation. These findings indicate the need for continued monitoring and for programmatic and policy strategies to improve receipt of recommended care.

Socioeconomic status in health research: one size does not fit all.

Problems with measuring socioeconomic status (SES)-frequently included in clinical and public health studies as a control variable and less frequently as the variable(s) of main interest-could affect research findings and conclusions, with implications for practice and policy. We critically examine standard SES measurement approaches, illustrating problems with examples from new analyses and the literature. For example, marked racial/ethnic differences in income at a given educational level and in wealth at a given income level raise questions about the socioeconomic comparability of individuals who are similar on education or income alone. Evidence also shows that conclusions about nonsocioeconomic causes of racial/ethnic differences in health may depend on the measure-eg, income, wealth, education, occupation, neighborhood socioeconomic characteristics, or past socioeconomic experiences-used to "control for SES," suggesting that findings from studies that have measured limited aspects of SES should be reassessed. We recommend an outcome- and social group-specific approach to SES measurement that involves (1) considering plausible explanatory pathways and mechanisms, (2) measuring as much relevant socioeconomic information as possible, (3) specifying the particular socioeconomic factors measured (rather than SES overall), and (4) systematically considering how potentially important unmeasured socioeconomic factors may affect conclusions. Better SES measures are needed in data sources, but improvements could be made by using existing information more thoughtfully and acknowledging its limitations.