Maeve E Wallace

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• Blackson, E. A., Williams, B., Judson, J., Bell, C., & Wallace, M. (2025). The Association Between Structural Disadvantage and Adverse Birth Outcomes: Analyzing Preterm Birth and Low Birth Weight Using the Structural Racism Effect Index. Journal of Racial and Ethnic Health Disparities. doi:10.1007/s40615-025-02454-1
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  Patterns of risk for adverse birth outcomes, including low birth weight and preterm birth, are influenced by structural disadvantage. The Structural Racism Effect Index (SREI) measures these disadvantages across nine different domains, including education, income, housing, and employment. This study examines the association between structural disadvantage, as measured by the SREI, and adverse birth outcomes in the USA. Using the National Center for Health Statistics’ 2020 natality file, modified Poisson regression models with robust variance adjusted for maternal age, education, prenatal care initiation, previous preterm birth, and payment source estimated the relative risks of low birth weight and preterm birth associated with exposure to level of SREI at the maternal county of residence. Among 2,376,030 birth records, higher SREI scores were significantly associated with increased risks of adverse outcomes. Medium and high SREI levels were linked to 7.4% (95% CI 6.3–8.5%) and 18.8% (95% CI 16.9–20.8%) higher risks for preterm birth, respectively, and 6.1% (95% CI 4.9–7.2%) and 17.0% (95% CI 15.8–18.2%) higher risks for low birth weight, respectively, compared to low SREI scores. Stratified analyses revealed that the impact of SREI on adverse birth outcomes varied significantly by maternal race, highlighting differential effects across racial groups. Cuzick’s test for linear trend confirmed the dose–response relationship between the extent of structural disadvantage and the likelihood of adverse birth outcomes.
• Cartwright, A. F., Angeles, G., Su, J., Wallace, M., Curtis, S., & Speizer, I. S. (2025). Impacts of Medicaid Expansion on Contraceptive Use Among Women in Neighborhoods of Racialized Socioeconomic Deprivation in the United States. Women's Health Issues. doi:10.1016/j.whi.2025.07.002
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  Introduction: Medicaid expansion has the potential to increase access to contraception and improve women's health, although existing research examining state-level variation provides mixed evidence. The neighborhood context plays a crucial role in understanding the effects of Medicaid expansion on contraceptive use, as structural inequalities within neighborhoods may shape access to health care and reproductive services. Materials and Methods: We used a unique restricted dataset of 13,224 female respondents ages 15–44 years interviewed in the 2011–2019 waves of the National Survey of Family Growth (NSFG). We merged these data with indicators of state Medicaid expansion status and respondents’ neighborhood context, operationalized as Index of Concentration at the Extremes (ICE) scores. We used quasi-experimental difference-in-differences models to assess if Medicaid expansion impacted provider-dependent contraceptive use and method type differentially by neighborhood-level context. We used multivariable linear probability and multinomial logistic regression models adjusting for individual and community covariates and state/region fixed effects. Results: Living in a Medicaid expansion state was associated with significant increases in provider-dependent contraceptive method use among respondents in the most deprived neighborhoods (17.9 percentage points, 95% CI [9.0, 26.9], by 2017–2019). Specifically, long-acting reversible contraception (LARC) use increased 7.6 percentage points (95% CI [0.6–14.7]) and use of no method or barrier/coital methods declined 17.5 percentage points (95% CI [−26.3, −8.7]) among those in the most deprived neighborhoods by 2017–2019. Conclusions: Changes in state-level policies can have major impacts on health systems, but the example of Medicaid expansion underscores the differential impacts on people with less access to health resources, such as those living in structurally disadvantaged neighborhoods. Ultimately, further expansion of Medicaid could facilitate access to the full range of contraceptive methods and advance population health equity in additional U.S. states.
• Cartwright, A. F., Angeles, G., Su, J., Wallace, M., Curtis, S., & Speizer, I. S. (2025). Impacts of Medicaid Expansion on Contraceptive Use Among Women in Neighborhoods of Racialized Socioeconomic Deprivation in the United States. Women's health issues : official publication of the Jacobs Institute of Women's Health, 35(5), 314-323.
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  Medicaid expansion has the potential to increase access to contraception and improve women's health, although existing research examining state-level variation provides mixed evidence. The neighborhood context plays a crucial role in understanding the effects of Medicaid expansion on contraceptive use, as structural inequalities within neighborhoods may shape access to health care and reproductive services.
• Freije, S. L., Wallace, M., & Chaparro, M. P. (2025). Overall and race-specific associations between state-level minimum wage policy and food insecurity in the United States. Journal of Epidemiology and Community Health, 79(Issue 3). doi:10.1136/jech-2024-222350
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  Background In the USA, states can set higher minimum wages than the federal government. We investigated the association between state minimum wages and racial/ethnic inequities in food insecurity. Methods Household-level food insecurity and sociodemographic data were obtained from the cross-sectional Current Population Survey 2015-2019 (n=189 665 households) and merged by state and year with minimum wage and cost-of-living data obtained from the US Department of Labor and US Bureau of Economic Analysis, respectively. We fitted Poisson regression models with robust standard errors with 12-month or 30-day household food insecurity as the outcome, and minimum wage or inflation-adjusted minimum wage (ie, real wage) as the predictor, adjusting for cost of living, sociodemographic covariates and state fixed-effects. We tested interactions between minimum wage and race/ethnicity and ran race/ethnicity-stratified models. Results In adjusted models, the real wage was not associated with 12-month or 30-day food insecurity. Minimum wage was associated with 5% lower prevalence rate of 12-month food insecurity (PR 0.95, 95% CI=0.93 to 0.98) and 7% lower prevalence rate of 30-day food insecurity (PR 0.93, 95% CI 0.91 to 0.96) for all households. The interaction p values for race/ethnicity with real wage and minimum wage were p
• Vilda, D., Agénor, M., Wallace, M. E., Lian, I. B., Charlton, B. M., Reynolds, C. A., & Harville, E. W. (2025). Adverse Obstetric and Perinatal Outcomes Among Birthing People in Same-Sex and Different-Sex Relationships in Louisiana. LGBT Health, 12(Issue 1). doi:10.1089/lgbt.2023.0377
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  Purpose: We investigated sexual orientation disparities in several obstetric and perinatal outcomes in Louisiana and examined whether these disparities differed among Black, Latine, and White populations. Methods: We analyzed cross-sectional vital records data on singleton live births in Louisiana (2016-2022). Same-sex relationships (SSR) vs. different-sex relationships (DSR) were classified based on the sex of the parents listed on the birth certificate. Using modified Poisson regression, we estimated adjusted risk ratios and 95% confidence intervals among birthing persons in SSR vs. DSR for preterm birth (PTB), low birthweight (LBW), spontaneous labor, Cesarean delivery, gestational hypertension, and gestational diabetes. We examined within and across group disparities in models stratified by sexual orientation and race/ethnicity. Results: In the total birthing population, those in SSR experienced higher risk of gestational hypertension and gestational diabetes and were less likely to have spontaneous labor compared with persons in DSR. The risk of PTB and LBW was two-fold higher among Black birthing people in SSR compared with White birthing people in SSR and DSR. Latine birthing people in SSR experienced higher risk of gestational hypertension and gestational diabetes compared with their peers in DSR and White people in DSR. Some of these disparities were partially explained by including socioeconomic and health risk factors. Conclusion: Sexual orientation-related disparities exist across and within racial/ethnic groups among birthing people in Louisiana. Adopting an intersectional approach that considers the mutually constituted nature of heterosexism and racism is critical to addressing sexual orientation-related inequities in reproductive and perinatal health.
• Wallace, M. E., & Jahn, J. L. (2025). Pregnancy-Associated Mortality Due to Homicide, Suicide, and Drug Overdose. JAMA Network Open, 8(Issue 2). doi:10.1001/jamanetworkopen.2024.59342
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  Importance: Despite growing national concern about high and increasing rates of pregnancy-associated mortality due to homicide, suicide, and drug overdose, state-level incidence has previously not been available. Objective: To identify cases of pregnancy-associated homicide, suicide, drug overdose, and deaths involving firearms in the US from calendar year 2018 to 2022 and estimate 5-year proportionate mortality and mortality ratios per 100000 live births by state and cause of death. Design, Setting, and Participants: This cross-sectional study is a population-based analysis of the 2018-2022 restricted-use mortality files provided by the National Center for Health Statistics. These data include all deaths occurring in the US, with geographic identifiers for state of residence. All records in which the decedent was female aged 10 to 44 years and pregnant at the time of death or up to 1 year earlier were included in the analysis. Data were analyzed from July 1 to December 1, 2024. Main Outcomes and Measures: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes for underlying cause of death were used to identify cases of homicide, suicide, drug overdose, and deaths involving firearms occurring in each state from 2018 to 2022. Proportionate mortality was estimated as the count of cases divided by the total count of deaths of pregnant and postpartum women in each state. Cause-specific mortality ratios were estimated as the count of cases divided by the total count of live births in each state from 2018 to 2022. Results: Nationally, there were 10715 deaths of people who were pregnant or within 1 year post partum from 2018 to 2022, including 837 homicides, 579 suicides, 2083 drug overdoses, and 851 that involved firearms. Proportionate mortality and mortality ratios for homicide, suicide, and drug overdose varied across the US. Of states with more than 9 cases, pregnancy-associated homicide mortality was highest in Mississippi (12.86 per 100000 live births), pregnancy-associated suicide mortality was highest in Montana (21.55 deaths per 100000 live births), and pregnancy-associated drug overdose was highest in Delaware (36.03 deaths per 100000 live births). Firearms accounted for as many as 15.56% of pregnancy-associated deaths in Colorado, and pregnancy-associated firearm mortality was highest in Mississippi (13.42 deaths per 100000 live births). Conclusions and Relevance: The information in this study may provide relevant guidance for state and local intervention strategies to advance the health, safety, and well-being of women during pregnancy and beyond.
• Wallace, M. E., & Jahn, J. L. (2025). Pregnancy-Associated Mortality Due to Homicide, Suicide, and Drug Overdose. JAMA network open, 8(2), e2459342.
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  Despite growing national concern about high and increasing rates of pregnancy-associated mortality due to homicide, suicide, and drug overdose, state-level incidence has previously not been available.
• Cartwright, A. F., Wallace, M., Su, J., Curtis, S., Angeles, G., & Speizer, I. S. (2024). Neighborhood-level racialized socioeconomic deprivation and contraceptive use in the United States, 2011-2019. Perspectives on sexual and reproductive health, 56(2), 182-196.
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  The social and structural environments where people live are understudied in contraceptive research. We assessed if neighborhood measures of racialized socioeconomic deprivation are associated with contraceptive use in the United States.
• Dyer, L., Judson, J., Jahn, J. L., & Wallace, M. (2024). Investigating the Black Birth Experience: A Race-Stratified Analysis of Preterm Birth Risk and Exposure to Metropolitan Statistical Area-Level Police-Related Deaths, US 2018-2019. Journal of urban health : bulletin of the New York Academy of Medicine, 101(3), 464-472.
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  Police-related violence may be a source of chronic stress underlying entrenched racial inequities in reproductive health in the USA. Using publicly available data on police-related fatalities, we estimated total and victim race-specific rates of police-related fatalities (deaths per 100,000 population) in 2018-2019 for Metropolitan Statistical Areas (MSA) and counties within MSAs in the USA. Rates were linked to data on live births by maternal MSA and county of residence. We fit adjusted log-Poisson models with generalized estimating equations and cluster-robust standard errors to estimate the relative risk of preterm birth associated with the middle and highest tertiles of police-related fatalities compared to the lowest tertile. We included a test for heterogeneity by maternal race/ethnicity and additionally fit race/ethnicity-stratified models for associations with victim race/ethnicity-specific police-related fatality rates. Fully adjusted models indicated significant adverse associations between police-related fatality rates and relative risk of preterm birth for the total population, non-Hispanic Black, and non-Hispanic White groups separately. Results confirm the role of fatal police violence as a social determinant of population health outcomes and inequities, including preterm birth.
• Freije, S. L., Wallace, M., & Chaparro, M. P. (2024). Overall and race-specific associations between state-level minimum wage policy and food insecurity in the United States. Journal of epidemiology and community health.
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  In the USA, states can set higher minimum wages than the federal government. We investigated the association between state minimum wages and racial/ethnic inequities in food insecurity.
• Goldin Evans, M., Wallace, M., Bazzano, A. N., Biggio, J. R., Cruz, K., Gamble, A., Green, C., Jah, Z., Longo, S., Perez, S., Reed, R. N., Shaffer, J. G., Shi, L., & Harville, E. (2024). The Southern Center for Maternal Health Equity (SCMHE): a multisector multifaceted community-based approach to reduce disparities in maternal morbidity and mortality in the Gulf South. Frontiers in Public Health, 12. doi:10.3389/fpubh.2024.1465779
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  Introduction: The maternal mortality crisis in the United States disproportionately affects women who are Black, especially those living in the Gulf South. These disparities result from a confluence of healthcare, policy, and social factors that systematically place Black women at greater risk of maternal morbidities and mortality. This study protocol describes the Southern Center for Maternal Health Equity (SCMHE), a research center funded by the National Institutes of Health in 2023 to reduce preventable causes of maternal morbidity and mortality while improving health equity. This is a seven year program with pilot and implementation phases. SCMHE is co-led by three organizations: Reproductive Health Impact (a fiscally sponsored project of the Praxis Project), an advocacy community-based organization; Tulane University, an academic research institute; and Ochsner Health, a large regional nonprofit health system. Methods: SCMHE applies a multilevel life course approach based on the Social Ecological Model to prevent maternal morbidity and mortality with interventions at individual, interpersonal, institutional, community, and societal levels. This community-focused research center uses an intersectional lens and the Reproductive Justice framework in its aims to improve maternal health and strengthen community-based maternal health research capacity in Louisiana and Mississippi. Discussion: To advance the field of maternal health using participatory, community-centered, and radically equity-focused approaches previously underutilized and under-evaluated, the Center will lead three R01 projects to assess the implementation of existing evidence-based strategies and build the evidence base for translational research strategies. Ethics and dissemination: By leveraging our team's existing network with local, regional, and national partners while continuing to build new, unique interdisciplinary partnerships, we will build upon our distinctive interdisciplinary strengths and community connections to bring our outreach and technical assistance efforts to diverse audiences.
• Goldin Evans, M., Wallace, M., Bazzano, A. N., Biggio, J. R., Cruz, K., Gamble, A., Green, C., Jah, Z., Longo, S., Perez, S., Reed, R. N., Shaffer, J. G., Shi, L., & Harville, E. (2024). The Southern Center for Maternal Health Equity (SCMHE): a multisector multifaceted community-based approach to reduce disparities in maternal morbidity and mortality in the Gulf South. Frontiers in public health, 12, 1465779.
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  The maternal mortality crisis in the United States disproportionately affects women who are Black, especially those living in the Gulf South. These disparities result from a confluence of healthcare, policy, and social factors that systematically place Black women at greater risk of maternal morbidities and mortality. This study protocol describes the Southern Center for Maternal Health Equity (SCMHE), a research center funded by the National Institutes of Health in 2023 to reduce preventable causes of maternal morbidity and mortality while improving health equity. This is a seven year program with pilot and implementation phases. SCMHE is co-led by three organizations: Reproductive Health Impact (a fiscally sponsored project of the Praxis Project), an advocacy community-based organization; Tulane University, an academic research institute; and Ochsner Health, a large regional nonprofit health system.
• Haley, C. O., King, L. E., Dyer, L., Evans, M. G., Theall, K. P., & Wallace, M. (2024). Maternity Care Deserts in Louisiana and Breastfeeding Initiation. Women's Health Issues, 34(Issue 3). doi:10.1016/j.whi.2023.11.010
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  Background: Breastfeeding provides physical, psychological, and immunological benefits to both the mother and infant, but breastfeeding rates are suboptimal. The purpose of this study was to examine whether residing in a maternity care desert (a county with no hospital offering obstetric care and no OB/GYN or certified nurse midwife providers) was associated with lower breastfeeding rates among birthing people in Louisiana from 2019 to 2020. Methods: Data provided by the March of Dimes were used to classify Louisiana parishes by level of access to maternity care. Using data on all live births provided by the Louisiana Office of Vital Records (n = 112,151), we fit adjusted modified Poisson regression models with generalized estimating equations and exploratory geospatial analysis to examine the association between place of residence and breastfeeding initiation and racial disparities in initiation. We conducted a secondary within-group analysis by fitting the fully adjusted model stratified by race/ethnicity for non-Hispanic white and non-Hispanic Black birthing people. Results: We found that residing in a parish with limited (odds ratio [OR] = 0.87; 95% confidence interval [CI] [0.77, 0.99]) to no access (OR = 0.88; 95% CI [0.80, 0.97]) was significantly associated with lower breastfeeding initiation rates. The within-group analysis determined that both non-Hispanic Black and non-Hispanic white birthing people residing in a parish with limited or no maternity care access had lower breastfeeding initiation rates. Conclusion: Reducing rural and racial inequities in breastfeeding may require structural changes and investments in infrastructure to deliver pregnancy care.
• Haley, C. O., Singleton, C. R., King, L. E., Dyer, L., Theall, K. P., & Wallace, M. (2024). Association of Food Desert Residency and Preterm Birth in the United States. International journal of environmental research and public health, 21(4).
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  Food deserts are a major public health concern. Inadequate access to healthy food has been associated with poor nutrition and the development of dietary related chronic conditions.
• Johnson, I., Vilda, D., Allen, E., Boisson, D., Daniel, C., Giwa, L., Goldin Evans, M., Ledet, H., Richardson, L., & Wallace, M. (2024). Building Collective Power to Advance Maternal and Child Health Equity: Lessons from the New Orleans Maternal and Child Health Coalition. Maternal and child health journal, 28(12), 2126-2136.
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  The New Orleans Maternal Child Health Coalition convenes to support and amplify the work of New Orleans-based individuals and organizations working to reduce disparities and protect the health of birthing families in the New Orleans area. The objectives of this qualitative study were to identify successes, challenges, and areas of growth for the Coalition and develop broadly generalizable recommendations for similar groups seeking to mobilize and advance health equity in their own communities.
• Potts, K. S., Gustat, J., Wallace, M. E., Ley, S. H., Qi, L., & Bazzano, L. A. (2024). Diet quality in young adulthood and sleep at midlife: a prospective analysis in the Bogalusa Heart Study. Nutrition journal, 23(1), 128.
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  Diet and sleep are both established risk factors for cardiometabolic diseases. Prior evidence suggests a potential link between these behaviors, though longitudinal evidence for how diet associates with sleep is scarce. This study aimed to determine the prospective association between diet quality in young adulthood and multiple sleep outcomes at midlife in the Bogalusa Heart Study (BHS).
• Potts, K. S., Wallace, M. E., Gustat, J., Ley, S. H., Qi, L., & Bazzano, L. A. (2024). Sleep apnoea symptoms and sleepiness associate with future diet quality: a prospective analysis in the Bogalusa Heart Study. The British journal of nutrition, 1-10.
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  Sleep apnoea is a known risk factor for cardiometabolic diseases (CMD), but it is unknown whether sleep apnoea or its symptoms contribute to increased CMD through an association with diet quality. This study assessed the association between sleep apnoea symptoms on future diet quality in the Bogalusa Heart Study (BHS). This prospective study included 445 participants who completed a sleep apnoea questionnaire in 2007-2010 and a FFQ in 2013-2016 (mean follow-up: 5·8 years; age 43·5 years; 34 % male; 71 % White/29 % Black persons). Diet quality was measured with the Alternate Healthy Eating Index (AHEI) 2010, the Healthy Eating Index (HEI) 2015 and the alternate Mediterranean diet score. Adjusted mean differences in dietary patterns by sleep apnoea risk, excessive snoring and daytime sleepiness were estimated with multivariable linear regression. Models included multi-level socio-economic factors, lifestyle and health characteristics including BMI, physical activity and depressive symptoms. Those with high sleep apnoea risk, compared with low, had lower diet quality 5·8 years later (percentage difference in AHEI (95 % CI -2·1 % (-3·5 %, -0·7 %)). Daytime sleepiness was associated with lower diet quality. After adjusting for dietary pattern scores from 2001 to 2002, having high sleep apnoea risk and excessive sleepiness were associated with 1·5 % ( < 0·05) and 3·1 % ( < 0·001) lower future AHEI scores, respectively. These findings suggest that individuals with sleep apnea or excessive sleepiness should be monitored for diet quality and targeted for dietary interventions to improve CMD risk.
• Sauter, S. R., Wallace, M. E., & Hernandez, J. H. (2024). Unequal Spatial Consequences of Abortion Restrictions in Texas, 2021-2023. American journal of public health, 114(10), 1024-1033.
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  To demonstrate the spatially uneven effects of abortion restriction laws in Texas. We used network analysis to determine the change in distance to the nearest surgical abortion provider for 5253 Texas neighborhoods after the passing of Texas Senate Bill 8 (SB8; 2021) and the US Supreme Court's (2022) decision. We identified associations between key measures of neighborhood socioeconomic context and change in distance to providers using multivariable linear regression models. After the decision, Texas residents experienced an average change in distance to the nearest provider of 457 miles (SD = 179). Neighborhoods of concentrated disadvantage experienced the greatest increase in distance to abortion providers after SB8's passing, and neighborhoods with high levels of income inequality experienced the greatest increase in distance after the decision. We document the rapidly changing abortion landscape in a highly restrictive state and show that women living in more disadvantaged and unequal areas are most affected by the increasing distance to providers. Our methods and findings will continue to be relevant in understanding the burden placed on women in areas where medical abortion has been restricted because of the decision. (. 2024;114(10):1024-1033. https://doi.org/10.2105/AJPH.2024.307652).
• Terrell, K. A., St Julien, G. N., & Wallace, M. E. (2024). Toxic air pollution and concentrated social deprivation are associated with low birthweight and preterm Birth in Louisiana. Environmental Research: Health, 2(Issue 2). doi:10.1088/2752-5309/ad3084
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  Previous studies indicate that pollution exposure can increase risks of adverse birth outcomes, but Black communities are underrepresented in this research, and the potential moderating role of neighborhood context has not been explored. These issues are especially relevant in Louisiana, which has a high proportion of Black residents, an entrenched history of structural racism, the most pounds of toxic industrial emissions annually, and among the nation’s highest rates of low birthweight (LBW), preterm birth (PTB), and infant mortality. We investigated whether air pollution and social polarization by race and income (measured via the index of concentration at the extremes [ICE]) were associated with LBW and PTB among Louisiana census tracts (n= 1101) using spatial lag models. Data sources included 2011–2020 birth records, U.S. Census Bureau 2017 demographic data, and 2017 respiratory hazard (RH) from the U.S. Environmental Protection Agency. Both RH and ICE were associated with LBW (z= 4.4,P< 0.0001;z= −27.0,P< 0.0001) and PTB (z= 2.3,P= 0.019;z= −16.7,P< 0.0001), with no interaction. Severely polluted tracts had 36% higher and 25% higher risks of LBW and PTB, respectively, versus unpolluted tracts. On average, 2166 low birthweight and 3583 preterm births annually were attributable to pollution exposure. Tracts with concentrated social deprivation (i.e. low ICE scores) had 53% higher and 34% higher risks of LBW and PTB, respectively, versus intermediate or mixed tracts. On average, 1171 low birthweight and 1739 preterm births annually were attributable to concentrated deprivation. Our ecological study found that a majority of adverse birth outcomes in Louisiana (i.e. 67% of LBW and PTB combined) are linked to air pollution exposure or disadvantage resulting from social polarization. These findings can inform research, policy, and advocacy to improve health equity in marginalized communities.
• Vilda, D., Agénor, M., Wallace, M. E., Lian, I. B., Charlton, B. M., Reynolds, C. A., & Harville, E. W. (2024). Adverse Obstetric and Perinatal Outcomes Among Birthing People in Same-Sex and Different-Sex Relationships in Louisiana. LGBT health.
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  We investigated sexual orientation disparities in several obstetric and perinatal outcomes in Louisiana and examined whether these disparities differed among Black, Latine, and White populations. We analyzed cross-sectional vital records data on singleton live births in Louisiana (2016-2022). Same-sex relationships (SSR) vs. different-sex relationships (DSR) were classified based on the sex of the parents listed on the birth certificate. Using modified Poisson regression, we estimated adjusted risk ratios and 95% confidence intervals among birthing persons in SSR vs. DSR for preterm birth (PTB), low birthweight (LBW), spontaneous labor, Cesarean delivery, gestational hypertension, and gestational diabetes. We examined within and across group disparities in models stratified by sexual orientation and race/ethnicity. In the total birthing population, those in SSR experienced higher risk of gestational hypertension and gestational diabetes and were less likely to have spontaneous labor compared with persons in DSR. The risk of PTB and LBW was two-fold higher among Black birthing people in SSR compared with White birthing people in SSR and DSR. Latine birthing people in SSR experienced higher risk of gestational hypertension and gestational diabetes compared with their peers in DSR and White people in DSR. Some of these disparities were partially explained by including socioeconomic and health risk factors. Sexual orientation-related disparities exist across and within racial/ethnic groups among birthing people in Louisiana. Adopting an intersectional approach that considers the mutually constituted nature of heterosexism and racism is critical to addressing sexual orientation-related inequities in reproductive and perinatal health.
• Wallace, M. E., Stoecker, C., Sauter, S., & Vilda, D. (2024). States' Abortion Laws Associated With Intimate Partner Violence-Related Homicide Of Women And Girls In The US, 2014-20. Health affairs (Project Hope), 43(5), 682-690.
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  Women who are pregnant or recently gave birth are significantly more likely to be killed by an intimate partner than nonpregnant, nonpostpartum women of reproductive age, implicating the risk of fatal violence conferred by pregnancy itself. The rapidly increasing passage of state legislation has restricted or banned access to abortion care across the US. We used the most recent and only source of population-based data to examine the association between state laws that restrict access to abortion and trends in intimate partner violence-related homicide among women and girls ages 10-44 during the period 2014-20. Using robust difference-in-differences ecologic modeling, we found that enforcement of each additional Targeted Regulation of Abortion Providers (TRAP) law was associated with a 3.4 percent increase in the rate of intimate partner violence-related homicide in this population. We estimated that 24.3 intimate partner violence-related homicides of women and girls ages 10-44 were associated with TRAP laws implemented in the states and years included in this analysis. Assessment of policies that restrict access to abortion should consider their potential harm to reproductive-age women through the risk for violent death.
• Wallace, M. E., Vilda, D., Dyer, L., Johnson, I., & Funke, L. (2024). Health care use and health consequences of geographic lack of access to abortion and maternity care. Birth (Berkeley, Calif.), 51(2), 363-372.
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  Recent years have brought substantial declines in geographic access to abortion facilities and maternity care across the US. The purpose of this study was to identify the reproductive health consequences of living in a county without access to comprehensive reproductive health care services.
• Dyer, L., Vilda, D., Harville, E., Theall, K., & Wallace, M. (2023). Income Inequality and Pregnancy-Associated Homicide in the US: A Longitudinal, State-Level Analysis. Violence Against Women, 29(Issue 9). doi:10.1177/10778012221120446
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  Pregnancy-associated homicide remains an understudied yet critical issue. Using restricted use mortality files provided by the National Center for Health Statistics and the National Violent Death Reporting System, annual state-level pregnancy-associated homicide ratios were estimated as the count of deaths divided by the number of live births. The exposure, the state Gini index, was categorized into tertiles to compare states by levels of income inequality. In the final adjusted longitudinal linear model, those who experienced the greatest amount of income inequality had a significant 1.28 per 100,000 homicide rate when compared to the lowest income inequality tertile.
• Grady, S. K., Grady, S. K., Dojcsak, L., Dojcsak, L., Harville, E. W., Harville, E. W., Wallace, M. E., Wallace, M. E., Vilda, D., Vilda, D., Donneyong, M. M., Donneyong, M. M., Hood, D. B., Hood, D. B., Valdez, R. B., Valdez, R. B., Ramesh, A., Ramesh, A., Im, W., , Im, W., et al. (2023). Seminar: Scalable Preprocessing Tools for Exposomic Data Analysis. Environmental Health Perspectives, 131(Issue 12). doi:10.1289/ehp12901
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  BACKGROUND: The exposome serves as a popular framework in which to study exposures from chemical and nonchemicsal stressors across the life course and the differing roles that these exposures can play in human health. As a result, data relevant to the exposome have been used as a resource in the quest to untangle complicated health trajectories and help connect the dots from exposures to adverse outcome pathways. OBJECTIVES: The primary aim of this methods seminar is to clarify and review preprocessing techniques critical for accurate and effective external exposomic data analysis. Scalability is emphasized through an application of highly innovative combinatorial techniques coupled with more traditional statistical strategies. The Public Health Exposome is used as an archetypical model. The novelty and innovation of this seminar’s focus stem from its methodical, comprehensive treatment of preprocessing and its demonstration of the positive effects preprocessing can have on downstream analytics. DISCUSSION: State-of-the-art technologies are described for data harmonization and to mitigate noise, which can stymie downstream interpretation, and to select key exposomic features, without which analytics may lose focus. A main task is the reduction of multicollinearity, a particularly formidable problem that frequently arises from repeated measurements of similar events taken at various times and from multiple sources. Empirical results highlight the effectiveness of a carefully planned preprocessing workflow as demonstrated in the context of more highly concentrated variable lists, improved correlational distributions, and enhanced downstream analytics for latent relationship discovery. The nascent field of exposome science can be characterized by the need to analyze and interpret a complex confluence of highly inhomogeneous spatial and temporal data, which may present formidable challenges to even the most powerful analytical tools. A systematic approach to preprocessing can therefore provide an essential first step in the application of modern computer and data science methods. https://doi.org/10.1289/EHP12901.
• Jahn, J. L., Wallace, M., Theall, K. P., & Hardeman, R. R. (2023). Neighborhood Proactive Policing and Racial Inequities in Preterm Birth in New Orleans, 2018–2019. American Journal of Public Health, 113. doi:10.2105/ajph.2022.307079
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  Objectives. To measure neighborhood exposure to proactive policing as a manifestation of structural racism and its association with preterm birth. Methods. We linked all birth records in New Orleans, Louisiana (n 5 9102), with annual census tract rates of proactive police stops using data from the New Orleans Police Department (2018–2019). We fit multilevel Poisson models predicting preterm birth across quintiles of stop rates, controlling for several individual- and tract-level covariates. Results. Nearly 20% of Black versus 8% of White birthing people lived in neighborhoods with the highest rates of proactive police stops. Fully adjusted models among Black birthing people suggest the prevalence of preterm birth in the neighborhoods with the highest proactive policing rates was 1.41 times that of neighborhoods with the lowest rates (95% confidence interval 5 1.04, 1.93), but associations among White birthing people were not statistically significant. Conclusions. Taken together with previous research, high rates of proactive policing likely contribute to Black–White inequities in reproductive health. Public Health Implications. Proactive policing is widely implemented to deter violence, but alternative strategies without police should be considered to prevent potential adverse health consequences.
• Potts, K. S., Wallace, M. E., Gustat, J., Ley, S. H., Qi, L., & Bazzano, L. A. (2023). Diet Quality and Sleep Characteristics in Midlife: The Bogalusa Heart Study. Nutrients, 15(Issue 9). doi:10.3390/nu15092078
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  Background: Sleep and diet contribute to cardiometabolic disease, but evidence is sparse for the association between these behaviors. This study analyzed the cross-sectional relationship between diet quality and multiple sleep outcomes in the Bogalusa Heart Study (BHS). Methods: Diet and sleep characteristics, including insomnia and sleep apnea symptoms, were measured with validated questionnaires. Poisson regression using generalized estimating equations with a log link estimated prevalence rate ratios (PRR) of sleep outcomes by dietary pattern scores (quintile (Q) and per SD). Models were adjusted for body mass index (BMI), multi-level socioeconomic factors, physical activity, depressive symptoms, and other potential confounders. Results: In 824 participants, higher diet quality, measured by the Alternate Healthy Eating Index-2010, was associated with lower sleep apnea risk score after adjustment (PRR [95% confidence interval (CI)] Q5 vs. Q1: 0.59 [0.44, 0.79], per SD increase: 0.88 [0.81, 0.95], p-trend < 0.0001). There were no statistically significant associations with the Healthy Eating Index 2015 or the Alternate Mediterranean dietary patterns, or for insomnia symptoms or a healthy sleep score. Conclusions: Higher diet quality, after adjustment for BMI, was associated with a lower sleep apnea risk score in a cohort with substantial minority representation from a semi-rural, lower-income community.
• Vilda, D., Walker, B. C., Hardeman, R. R., & Wallace, M. E. (2023). Associations Between State and Local Government Spending and Pregnancy-Related Mortality in the U.S.. American Journal of Preventive Medicine, 64(Issue 4). doi:10.1016/j.amepre.2022.10.022
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  Introduction: There is limited evidence on how government spending is associated with maternal death. This study investigates the associations between state and local government spending on social and healthcare services and pregnancy-related mortality among the total, non-Hispanic Black, Hispanic, and non-Hispanic White populations. Methods: State-specific total population and race/ethnicity-specific 5-year (2015–2019) pregnancy-related mortality ratios were estimated from annual natality and mortality files provided by the National Center for Health Statistics. Data on state and local government spending and population-level characteristics were obtained from U.S. Census Bureau surveys. Generalized linear Poisson regression models with robust SEs were fitted to estimate adjusted rate ratios and 95% CIs associated with proportions of total spending allocated to social services and healthcare domains, adjusting for state-level covariates. All analyses were completed in 2021–2022. Results: State and local government spending on transportation was associated with 11% lower overall pregnancy-related mortality (adjusted rate ratio=0.89, 95% CI=0.83, 0.96) and 9%–12% lower pregnancy-related mortality among the racial/ethnic groups. Among spending subdomains, expenditures on higher education, highways and roads, and parks and recreation were associated with lower pregnancy-related mortality rates in the total population (adjusted rate ratio=0.90, 95% CI=0.86, 0.94; adjusted rate ratio=0.87, 95% CI=0.81, 0.94; and adjusted rate ratio=0.68, 95% CI=0.49, 0.95, respectively). These results were consistent among the racial/ethnic groups, but patterns of associations with pregnancy-related mortality and other spending subdomains differed notably between racial/ethnic groups. Conclusions: Investing more in local- and state-targeted spending in social services may decrease the risk for pregnancy-related mortality, particularly among Black women.
• Chaparro, M. P., Cruthirds, S., Bell, C. N., & Wallace, M. E. (2022). State-Level Socioeconomic Racial Inequity and Food Insecurity in the U.S.. American Journal of Preventive Medicine, 63(Issue 6). doi:10.1016/j.amepre.2022.06.019
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  Introduction: Racial inequities in food insecurity have been documented for the past 2 decades in the U.S., with the prevalence of food insecurity among Black households being 2–3 times higher than that among White households across time. The purpose of this study was to determine the association between socioeconomic indicators of structural racism at the state level and food insecurity among White and Black households in the U.S. Methods: This study is a secondary analysis of pooled, cross-sectional data from the Current Population Survey and the American Community Survey, 2015–2019 (N=158,551 Black and White households). Data analysis occurred in 2021–2022. The outcome was household food insecurity, and the exposure was structural racism indicators, operationalized as state-level racial inequities in income, earnings, education, unemployment, and home ownership. Individual-, household-, and state-level sociodemographic covariates were included. Results: Among Black households, state-level racial inequities in income, unemployment, and home ownership were associated with 34% (OR=1.34; 95% CI=1.05, 1.70), 14% (OR=1.14; 95% CI=1.02, 1.28), and 11% (OR=1.11; 95% CI=1.05, 1.16) higher odds of food insecurity, respectively. For White households, state-level racial inequities in income, education, unemployment, and home ownership were associated with 21% (OR=0.79; 95% CI=0.63, 0.98), 27% (OR=0.73; 95% CI=0.66, 0.85), 10% (OR=0.90; 95% CI=0.82, 0.98), and 8% (OR=0.92; 95% CI=0.89, 0.95) lower odds of food insecurity, respectively. Conclusions: Structural racism may be a key driver of food insecurity among Black households and may be protective against food insecurity among White households. Implementing policies addressing state-level racial inequity in socioeconomic indicators could be effective at reducing racial inequities in food insecurity.
• Dyer, L., Bell, C., Perez, S., Crear-Perry, J., Theall, K., & Wallace, M. (2022). US county-level prevalence and spatial distribution of optimal birth outcomes 2018–2019. Scientific Reports, 12(Issue 1). doi:10.1038/s41598-022-20517-9
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  A shift in focus towards healthy reproductive outcomes may reveal opportunities for novel interventions and strategies to promote optimal health. Using variables from the National Center for Health Statistics restricted use natality files, we calculated Empirical Bayes smoothed (EBS) rates of optimal birth for the all live births—both overall and by maternal race/ethnicity—by applying the smoothing tool in GeoDa version 1.18.0.10 We defined counties achieving greater racial birth equity as those where the overall EBS optimal birth rate was greater than the national 75th percentile and the absolute difference between maternal racial/ethnic categories was smaller than the national 25th percentile difference. During the study period, 49.80% of overall births could be classified as an optimal birth according to the study definition. Of the 3140 US counties, only 282 (8.98%) appeared to advance White-Black equity in optimal births, and 205 (6.53%) appeared to advance White-Hispanic equity in optimal births. In the effort improve maternal health, we should focus not only on the absence of negative outcomes, but also the occurrence of positive outcomes. Our analytic results suggest that optimal births can be measured and that geographic inequities by race occur.
• Dyer, L., Chambers, B. D., Crear-Perry, J., Theall, K. P., & Wallace, M. (2022). The Index of Concentration at the Extremes (ICE) and Pregnancy-Associated Mortality in Louisiana, 2016–2017. Maternal and Child Health Journal, 26(Issue 4). doi:10.1007/s10995-021-03189-1
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  Objectives: Social and contextual factors underlying the continually disproportionate and burdensome risk of adverse health outcomes experienced by Black women in the US are underexplored in the literature. The aim of this study was to use an index based on area-level population distributions of race and income to predict risk of death during pregnancy and up to 1 year postpartum among women in Louisiana. Methods: Using vital records data provided by the Louisiana Department of Health 2016–2017 (n = 125,537), a modified Poisson model was fit with generalized estimating equations to examine the risk of pregnancy-associated death associated with census tract-level values of the Index of Concentration at the Extremes (ICE)—grouped by tertile—while adjusting for both individual and tract-level confounders. Results: Analyses resulted in an estimated 1.73 (95% CI 1.02–2.93) times increased risk for pregnancy-associated death for those in areas which were characterized by concentrated deprivation (high proportions of Black and low-income residents) relative to those in areas of concentrated privilege (high proportions of white and high-income residents), independent of other factors. Conclusions for Practice: In addition to continuing to consider the deeply entrenched racism and economic inequality that shape the experience of pregnancy-associated death, we must also consider their synergistic effect on access to resources, maternal population health, and health inequities.
• Fleckman, J. M., Tokarz, S., Claire Craig-Kuhn, M., Wallace, M. E., & Theall, K. P. (2022). Neighborhood matters: Neighborhood violence, collective efficacy, and social emotional development in early childhood. Children and Youth Services Review, 143. doi:10.1016/j.childyouth.2022.106700
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  Exposure to community violence has been associated with a range of negative behavioral outcomes among school-age children and adolescents; yet there is limited evidence in the preschool setting. In the current study we examined the association between objective and parent-perceived neighborhood safety, and perceived collective efficacy, on behavioral concerns of children aged 3–5 enrolled at an early childhood school in New Orleans, Louisiana, from 2014 to 19 (n = 165). Teachers collected data on outcome measures of child social emotional well-being in the classroom setting. A parent survey included data on residential address, how safe they felt in their neighborhood, and perceived collective efficacy. Addresses were geocoded and linked by Census tract number to data on violent crime rates (per 1,000 tract residents). Associations between neighborhood violent crime, perceived safety, perceived collective efficacy, and child social emotional development were assessed with generalized estimating equations. After mutually adjusting for perceived neighborhood safety and violent crime rate, children of parents with the lowest perceived neighborhood collective efficacy had similar findings: children of parents that perceive the neighborhood as unsafe had a lower attachment (β = −6.55, 95 % CI 1.44, 11.66) and protective score (β = −4.51, 95 % CI 0.89–8.13) and a 10-unit increase in violent crime was associated with a decrease in attachment score (β = −2.77, 95 % CI −4.22, −1.32). Overall, child attachment and protective scores were significantly associated with perceived unsafe neighborhoods and violent crime, and the relationship was moderated by perceived neighborhood efficacy. These findings suggest a negative impact of perceived neighborhood safety and protective impact of collective efficacy on early childhood social emotional development.
• Goldin Evans, M., Wallace, M., Theall, K. P., Mahoney, A. M., Richardson, L., & Daniel, C. M. (2022). State-Level Recommendations to Reduce Inequities in Sexually Transmitted Infections. Women's Health Issues, 32(Issue 5). doi:10.1016/j.whi.2022.07.002
• Harville, E. W., Grady, S. K., Langston, M., Juarez, P. J., Vilda, D., & Wallace, M. E. (2022). The public health exposome and pregnancy-related mortality in the United States: a high-dimensional computational analysis. BMC Public Health, 22(Issue 1). doi:10.1186/s12889-022-14397-x
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  Background: Racial inequities in maternal mortality in the U.S. continue to be stark. Methods: The 2015–2018, 4-year total population, county-level, pregnancy-related mortality ratio (PRM; deaths per 100,000 live births; National Center for Health Statistics (NCHS), restricted use mortality file) was linked with the Public Health Exposome (PHE). Using data reduction techniques, 1591 variables were extracted from over 62,000 variables for use in this analysis, providing information on the relationships between PRM and the social, health and health care, natural, and built environments. Graph theoretical algorithms and Bayesian analysis were applied to PHE/PRM linked data to identify latent networks. Results: PHE variables most strongly correlated with total population PRM were years of potential life lost and overall life expectancy. Population-level indicators of PRM were overall poverty, smoking, lack of exercise, heat, and lack of adequate access to food. Conclusions: In this high-dimensional analysis, overall life expectancy, poverty indicators, and health behaviors were found to be the strongest predictors of pregnancy-related mortality. This provides strong evidence that maternal death is part of a broader constellation of both similar and unique health behaviors, social determinants and environmental exposures as other causes of death.
• Harville, E. W., Wallace, M. E., & Theall, K. P. (2022). Eviction as a social determinant of pregnancy health: County-level eviction rates and adverse birth outcomes in the United States. Health and Social Care in the Community, 30(Issue 6). doi:10.1111/hsc.13983
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  Access to housing is an important manifestation of structural racism and discrimination, and birth outcomes show wide health disparities, but few studies have examined eviction and birth outcomes. This multilevel study merged data from the Eviction Lab on 2015 eviction judgements and records with the National Center for Health Statistics natality dataset. The analytic sample included 2,950,965 births across 5924 counties in 45 states. Outcomes of interest were low birthweight (
• Harville, E. W., Wallace, M. E., He, H., & Bazzano, L. A. (2022). Lifetime cardiovascular risk factors and maternal and offspring birth outcomes: Bogalusa Babies. PLoS ONE, 17(Issue 1). doi:10.1371/journal.pone.0260703
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  Both cardiovascular and reproductive complications may have origins in utero or in early life. Women in the Bogalusa Heart Study (n = 1401) had been linked to birth certificates for birthweight and gestational data, which were examined relative to childhood (ages 4-16) cardiometabolic indicators, indicated by mean levels overall and total risk factor burden as estimated by area under the curve (AUC) computed from longitudinal quadratic randomeffects growth models. Women reported the birthweight and gestational age of each of their own pregnancies, and delivery medical records were linked to interview data where possible. Path analyses were conducted to examine the relationships among a woman's own birth outcomes, childhood and preconception adult cardiovascular health, and birth outcomes. Mean blood pressure (systolic blood pressure (SBP) adjusted relative risk (aRR) per 1-SD increase, 1.27, 95% CI 1.04-1.57) and low-density lipoprotein (aRR 1.21, 95% CI 1.02-1.44) in childhood predicted preterm birth (PTB), while mean SBP (aRR 1.33, 95% CI 1.02-1.74) predicted term low birthweight. The AUC data suggested an association between blood pressure and PTB (aRR for SBP top 10%, 1.86, 95% CI 1.08-3.21). Prepregnancy total cholesterol was negatively associated with gestational age. In path analyses, positive associations were found for each step between own birthweight, childhood BMI, pre-pregnancy BMI, and child's birthweight. Childhood levels of some, though not all, cardiovascular risk factors may predict adverse birth outcomes (preterm birth and reduced fetal growth). Copyright:
• Mullen, A. J., O’connor, D. L., Hanley, A. J., Piedimonte, G., Wallace, M., & Ley, S. H. (2022). Associations of Metabolic and Obstetric Risk Parameters with Timing of Lactogenesis II. Nutrients, 14(Issue 4). doi:10.3390/nu14040876
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  Lactogenesis II is the onset of copious milk production following parturition. Delayed onset of lactogenesis II (DLII) often contributes to poorer lactation performance, which may adversely affect maternal and child health. The present study aims to identify the metabolic and obstetric risk factors for DLII in a secondary analysis of a prospective cohort study following pregnant women through postpartum. We defined the onset of lactogenesis II as delayed if it occurred ≥72 h postpartum. Multiple logistic regression analyses were conducted to evaluate the associations of metabolic and obstetric variables with DLII. Median onset of lactogenesis II was 72.4 h (IQR 60.4–91.6) postpartum, and 55.4% (98 of 177) of women experienced DLII. Time to first breast contact ≥ 2 h postpartum compared to ≤1 h postpartum was associated with DLII (OR 2.71 95% CI 1.12–6.53) with adjustment for age, race, pregravid BMI, primiparity, and mode of delivery, while metabolic variables were not significantly associated with DLII. In this comprehensive examination of potential metabolic and obstetric parameters, earlier timing of putting the infant to the breast remained significantly associated with earlier onset of milk coming in after consideration of the other potential risk factors. Obstetrical practices, including putting the baby to the breast later, may have an important impact on the timing of lactation, and interventions are needed to address this concern.
• Theall, K. P., Morrison, C. N., Jacoby, S. F., Tucker, A., Wallace, M. E., Kondo, M. C., Branas, C. C., & Gustat, J. (2022). Neighborhood Blighted Property Removal and 311 Calls for Non-Emergency Services: A Test of a Marker of Social Control. Geographical Analysis, 54(Issue 2). doi:10.1111/gean.12286
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  Many studies have demonstrated that collective efficacy is associated with positive health outcomes, lower crime, and violence in urban communities, and residents’ emotional connection to their community. Remediation of blighted properties has been theoretically linked to increases in collective efficacy. The purpose of this study was to examine the impact of blighted property remediation on city non-emergency 311 calls for public incivilities and deterioration, as potential markers of collective efficacy. We used a quasi-experimental design to test whether 311 calls for service changed around remediated vacant lots in New Orleans, Louisiana, United States, many of which were left vacant after Hurricane Katrina in 2005. In six city neighborhoods eligible for blighted property remediation as part of a city program, 203 treated vacant lots were matched 1:3 without replacement to control lots that were eligible for but did not receive treatment. This yielded a total of 812 vacant lots partitioned within 48 months, or 38,976 lot-months. Controls were in the same New Orleans neighborhoods as their matched treatment lots but were at least 250 feet away to minimize contamination. Overall difference-in-differences models detected postintervention declines in calls related to dumping and garbage, and slight but mostly non-significant changes in calls between intervention and control lots in all but calls for dumping and vehicles. Blighted property remediation may have an impact on dumping and garbage, which is important. Despite being geographically specific, low-cost and longitudinal, the nature of 311 calls and structural and historic factors at play in both the concentration of vacant properties in communities and residents’ willingness to call must be considered. Further analyses of changes in 311 data and additional qualitative inquiry are warranted to more fully determine the utility of these data.
• Wallace, M. E. (2022). Trends in Pregnancy-Associated Homicide, United States, 2020. American Journal of Public Health, 112(Issue 9). doi:10.2105/ajph.2022.306937
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  Objectives. To estimate the national pregnancy-associated homicide rate in 2020 and to characterize patterns of victimization. Methods. Using a retrospective analysis of the 2020 US national mortality file, I identified all homicides of women who were pregnant or within 1 year of the end of pregnancy. Descriptive statistics characterized these victims, and I calculated annual pregnancy-associated homicide rates (deaths per 100 000 live births) for comparisons with 2018 and 2019. I estimated the added risk conferred by pregnancy in 2020 by comparing the pregnancy-associated homicide rate to homicide in the nonpregnant, nonpostpartum population of females aged 10 to 44 years. Results. There were 5.23 pregnancy-associated homicides per 100 000 live births in 2020, a notable increase from previous years. Rates were highest among adolescents and non-Hispanic Black women. Eighty percent of incidents involved firearms. The risk of homicide was 35% greater for pregnant and postpartum women than for their nonpregnant, nonpostpartum counterparts, who did not experience as large an increase from previous years. Conclusions. Pregnancy-associated homicide substantially increased in 2020.
• Wallace, M., Gillispie-Bell, V., Cruz, K., Davis, K., & Vilda, D. (2022). In Reply. Obstetrics and Gynecology, 139(Issue 4). doi:10.1097/aog.0000000000004738
• Anderson, C. E., Broyles, S. T., Wallace, M. E., Bazzano, L. A., & Gustat, J. (2021). Association of the Neighborhood Built Environment with Incident and Prevalent Depression in the Rural South. Preventing Chronic Disease, 18. doi:10.5888/pcd18.200605
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  Introduction A neighborhood’s built environment is associated with physical activity among its residents, and physical activity is associated with depression. Our study aimed to determine whether the built environment was associated with depression among residents of the rural South and whether observed associations were mediated by physical activity. Methods We selected 2,000 participants from the Bogalusa Heart Study who had a valid residential address, self-reported physical activity (minutes/week), and a complete Center for Epidemiologic Study–Depression (CES-D) scale assessment from 1 or more study visits between 1998 and 2013. We assessed the built environment with the Rural Active Living Assessment street segment audit tool and developed built environment scores. The association between built environment scores and depression (CES-D ≥16) in geographic buffers of various radii were evaluated by using modified Poisson regression, and mediation by physical activity was evaluated with mixed-effects models. Results Depression was observed in 37% of study participants at the first study visit. One-point higher physical security and aesthetic scores for the street segment of residence were associated with 1.07 times higher (95% CI, 1.02–1.11) and 0.96 times lower (95% CI, 0.92–1.00) baseline depression prevalence. One-point higher destination scores (ie, more commercial and civic facilities) in radius buffers of 0.25 miles or more were associated with 1.06 times (95% CI, 1.00–1.13) the risk of depression during follow-up. Neighborhood poverty (defined as percentage of residents with incomes below the federal poverty level and dichotomized at 28.3%) modified cross-sectional and longitudinal associations. Associations were not mediated by physical activity. Conclusion The built environment was associated with prevalence and risk of depression, and associations were stronger in high-poverty neighborhoods. Built environment improvements to promote physical activity should take neighborhood context into consideration to minimize negative side effects on mental health in high-poverty communities.
• Crear-Perry, J., Correa-De-Araujo, R., Lewis Johnson, T., Mclemore, M. R., Neilson, E., & Wallace, M. (2021). Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women's Health, 30(Issue 2). doi:10.1089/jwh.2020.8882
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  Since the World Health Organization launched its commission on the social determinants of health (SDOH) over a decade ago, a large body of research has proven that social determinants - defined as the conditions in which people are born, grow, live, work, and age - are significant drivers of disease risk and susceptibility within clinical care and public health systems. Unfortunately, the term has lost meaning within systems of care because of misuse and lack of context. As many disparate health outcomes remain, including higher risk of maternal mortality among Black women, a deeper understanding of the SDOH - and what forces underlie their distribution - is needed. In this article, we will expand our review of social determinants of maternal health to include the terms "structural determinants of health"and "root causes of inequities"as we assess the literature on this topic. We hypothesize that the addition of structural determinants and root causes will identify racism as a cause of inequities in maternal health outcomes, as many of the social and political structures and policies in the United States were born out of racism, classism, and gender oppression. We will conclude with proposed practice and policy solutions to end inequities in maternal health outcomes.
• Karletsos, D., Stoecker, C., Vilda, D., Theall, K. P., & Wallace, M. E. (2021). Association of State Gestational Age Limit Abortion Laws With Infant Mortality. American Journal of Preventive Medicine, 61(Issue 6). doi:10.1016/j.amepre.2021.05.022
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  Introduction: A growing number of state legislatures have passed laws that restrict access to abortion care after a specified gestational age (gestational age limit laws). The impact of these laws on maternal and child population health outcomes and inequities is unknown. The objective of this study is to determine whether states that implement gestational age limit laws experience subsequent changes in rates of infant mortality. Methods: Using U.S. population‒based data from the National Center for Health Statistics Linked Infant Birth-Death Files (2005–2017), difference-in-differences models were estimated using multivariable linear regressions to compare the trends in infant mortality (all-cause and cause-specific rates) in states with gestational age limit laws with the trends in states without such laws. Models stratified by maternal racial/ethnic group explored racial heterogeneity in the law's impact. Data were analyzed in 2020. Results: This study included 16,232,133 births in states that enacted a gestation age limit abortion law and 36,472,309 births in states that did not from 2005 to 2017. In difference-in-difference analyses, gestational age limit laws were associated with 0.23 excess infant deaths per 1,000 live births (95% CI=0.09, 0.37, p
• Vilda, D., Hardeman, R., Dyer, L., Theall, K. P., & Wallace, M. (2021). Structural racism, racial inequities and urban–rural differences in infant mortality in the US. Journal of Epidemiology and Community Health, 75(Issue 8). doi:10.1136/jech-2020-214260
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  While evidence shows considerable geographic variations in county-level racial inequities in infant mortality, the role of structural racism across urban–rural lines remains unexplored. The objective of this study was to examine the associations between county-level structural racism (racial inequity in educational attainment, median household income and jail incarceration) and infant mortality and heterogeneity between urban and rural areas. Using linked live birth/infant death data provided by the National Center for Health Statistics, we calculated overall and race-specific 2013–2017 5-year infant mortality rates (IMRs) per 1000 live births in every county. Racially stratified and area-stratified negative binomial regression models estimated IMR ratios and 95% CIs associated with structural racism indicators, adjusting for county-level confounders. Adjusted linear regression models estimated associations between structural racism indicators and the absolute and relative racial inequity in IMR. In urban counties, structural racism indicators were associated with 7%–8% higher black IMR, and an overall structural racism score was associated with 9% greater black IMR; however, these findings became insignificant when adjusting for the region. In white population, structural racism indicators and the overall structural racism score were associated with a 6% decrease in urban white IMR. Both absolute and relative racial inequity in IMR were exacerbated in urban counties with greater levels of structural racism. Our findings highlight the complex relationship between structural racism and population health across urban–rural lines and suggest its contribution to the maintenance of health inequities in urban settings.
• Vilda, D., Wallace, M. E., Daniel, C., Evans, M. G., Stoecker, C., & Theall, K. P. (2021). State Abortion Policies and Maternal Death in the United States, 2015–2018. American Journal of Public Health, 111(Issue 9). doi:10.2105/ajph.2021.306396
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  Objectives. To examine associations between state-level variation in abortion-restricting policies in 2015 and total maternal mortality (TMM), maternal mortality (MM), and late maternal mortality (LMM) from 2015 to 2018 in the United States. Methods. We derived an abortion policy composite index for each state based on 8 state-level abortion-restricting policies. We fit ecological state-level generalized linear Poisson regression models with robust standard errors to estimate 4-year TMM, MM, and LMM rate ratios and 95% confidence intervals (CIs) associated with a 1-unit increase in the abortion index, adjusting for state-level covariates. Results. States with the higher score of abortion policy composite index had a 7% increase in TMM (adjusted rate ratio [ARR] 5 1.07; 95% CI 5 1.02, 1.12) compared with states with lower abortion policy composite index, after we adjusted for state-level covariates. Among individual abortion policies, states with a licensed physician requirement had a 51% higher TMM (ARR 5 1.51; 95% CI 5 1.15, 1.99) and a 35% higher MM (ARR 5 1.35; 95% CI 5 1.09, 1.67), and states with restrictions on Medicaid coverage of abortion care had a 29% higher TMM (ARR 5 1.29; 95% CI 5 1.03, 1.61). Conclusions. Restricting access to abortion care at the state level may increase the risk for TMM.
• Wallace, M. E., Vilda, D., Theall, K. P., & Stoecker, C. (2021). Firearm Relinquishment Laws Associated With Substantial Reduction In Homicide Of Pregnant And Postpartum Women. Health Affairs, 40(Issue 10). doi:10.1377/hlthaff.2021.01129
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  Homicide is a leading cause of death among women who are pregnant and up to one year postpartum in the United States. Most incidents are perpetrated by an intimate partner with a firearm. Some states have implemented laws that prohibit firearm possession by perpetrators of domestic violence and, in some instances, include explicit statutory language mandating relinquishment of firearms once a person has become prohibited from possessing them. We examined the impact of these policies on state-level rates of homicide among pregnant and postpartum women during the period 2011–19. We found that state laws prohibiting possession of firearms and requiring relinquishment of firearms by people convicted of domestic violence–related misdemeanors were associated with substantial reductions in homicide of pregnant and postpartum women. State policy makers should consider further strengthening domestic violence–related firearm regulations and their enforcement to prevent homicide of pregnant and postpartum women.
• Wallace, M., Dyer, L., Felker-Kantor, E., Benno, J., Vilda, D., Harville, E., & Theall, K. (2021). Maternity Care Deserts and Pregnancy-Associated Mortality in Louisiana. Women's Health Issues, 31(Issue 2). doi:10.1016/j.whi.2020.09.004
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  Background: Maternal mortality is an issue of growing concern in the United States, where the incidence of death during pregnancy and postpartum seems to be increasing. The purpose of this analysis was to explore whether residing in a maternity care desert (defined as a county with no hospital offering obstetric care and no OB/GYN or certified nurse midwife providers) was associated with risk of death during pregnancy and up to 1 year postpartum among women in Louisiana from 2016 to 2017. Methods: Data provided by the March of Dimes were used to classify Louisiana parishes by level of access to maternity care. Using data on all pregnancy-associated deaths verified by the Louisiana Department of Health (n = 112 from 2016 to 2017) and geocoded live births occurring in Louisiana during the same time period (n = 101,484), we fit adjusted modified Poisson regression models with generalized estimating equations and exploratory spatial analysis to identify significant associations between place of residence and risk of death. Results: We found that the risk of death during pregnancy and up to 1 year postpartum owing to any cause (pregnancy-associated mortality) and in particular death owing to obstetric causes (pregnancy-related mortality) was significantly elevated among women residing in maternity care deserts compared with women in areas with greater access (adjusted risk ratio [aRR] for pregnancy-associated mortality, 1.91; 95% confidence interval [CI], 1.15–3.18; aRR for pregnancy-related mortality, 3.37; 95% CI, 1.71–6.65). A large racial inequity in risk persisted above and beyond differences in geographic access to maternity care (non-Hispanic Black vs. non-Hispanic White aRR for pregnancy-associated mortality, 2.22; 95% CI, 1.39–3.56; aRR for pregnancy-related mortality, 2.66; 95% CI, 1.16–6.12). Conclusions: Ensuring access to maternity care may be an important step toward maternal mortality prevention, but may alone be insufficient for achieving maternal health equity.
• Wallace, M., Gillispie-Bell, V., Cruz, K., Davis, K., & Vilda, D. (2021). Homicide During Pregnancy and the Postpartum Period in the United States, 2018-2019. Obstetrics and Gynecology, 138(Issue 5). doi:10.1097/aog.0000000000004567
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  OBJECTIVE:To estimate the national pregnancy-associated homicide mortality ratio, characterize pregnancy-associated homicide victims, and compare the risk of homicide in the perinatal period (pregnancy and up to 1 year postpartum) with risk among nonpregnant, nonpostpartum females aged 10-44 years.METHODS:Data from the National Center for Health Statistics 2018 and 2019 mortality files were used to identify all female decedents aged 10-44 in the United States. These data were used to estimate 2-year pregnancy-associated homicide mortality ratios (deaths/100,000 live births) for comparison with homicide mortality among nonpregnant, nonpostpartum females (deaths/100,000 population) and to mortality ratios for direct maternal causes of death. We compared characteristics and estimated homicide mortality rate ratios and 95% CIs between pregnant or postpartum and nonpregnant, nonpostpartum victims for the total population and with stratification by race and ethnicity and age.RESULTS:There were 3.62 homicides per 100,000 live births among females who were pregnant or within 1 year postpartum, 16% higher than homicide prevalence among nonpregnant and nonpostpartum females of reproductive age (3.12 deaths/100,000 population, P
• Gustat, J., Anderson, C. E., Chukwurah, Q. C., Wallace, M. E., Broyles, S. T., & Bazzano, L. A. (2020). Cross-sectional associations between the neighborhood built environment and physical activity in a rural setting: The Bogalusa Heart Study. BMC Public Health, 20(Issue 1). doi:10.1186/s12889-020-09509-4
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  Background: Insufficient physical activity (PA) is a common health risk and more prevalent in rural populations. Few studies have assessed relationships between the built environment and PA in rural settings, and community policy guidance to promote PA through built environment interventions is primarily based on evidence from urban studies. Methods: Participants in the Bogalusa Heart Study, a longitudinal study in rural Louisiana, with International Physical Activity Questionnaire data from 2012 to 2013 and a valid residential address (N = 1245) were included. PA was summarized as the number of weekly metabolic equivalent (MET)-minutes of total, transportation, and leisure time PA. The Rural Active Living Assessment street segment audit tool and Google Street View were used to assess features of the built environment overall and in six categories (path features, pedestrian safety features, aesthetics, physical security, destinations and land use) that influence PA. Scores for street segment built environment (overall and in categories) were calculated, for segments and buffers of 0.25, 0.50, 1.00 and 1.50 miles. Associations between built environment scores and PA were assessed with generalized estimating equations. Results: Participants reported little weekly total, leisure time, and transportation PA (mean 470, 230 and 43 MET-minutes per week, respectively). A 1-point increase in the overall built environment score was associated with 10.30 additional weekly leisure time MET-minutes within a 1.50 mile buffer (p-value 0.05), with a similar magnitude observed for a 1.00-mile buffer. A 1-point increase in the aesthetic score was associated with significantly higher leisure time PA for all geographic units (from 22.21 to 38.75 MET-minutes weekly) when adjusted for individual covariates, but was attenuated and only significant for the segment of the residence after accounting for other neighborhood characteristics. Conclusions: Significant associations between features of the environment (overall and aesthetic scores) with leisure time PA were observed among adults in this rural population. Built environment interventions in rural settings face additional barriers of lower population density and greater distances for infrastructure projects, and it is important to identify approaches that are both feasible for rural communities and can promote PA.
• Kajeepeta, S., Theall, K. P., Kondo, M. C., Branas, C. C., Wallace, M. E., Jacoby, S. F., & Morrison, C. N. (2020). The association between blighted property remediation and domestic crime by alcohol availability. Health and Place, 64. doi:10.1016/j.healthplace.2020.102364
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  There is increasing evidence that place-based interventions reduce crime and interpersonal violence in urban settings. However, evidence concerning the impacts of these neighborhood interventions on domestic crime (crime between intimate partners, family, or household members) is inconclusive. We used data from a New Orleans, Louisiana, place-based blighted property remediation intervention to test the hypothesis that the intervention was associated with changes in domestic crime. Because there is evidence that alcohol availability is related to domestic crime, we also assessed whether this association was moderated by alcohol outlet density. We assessed overall associations using a difference-in-difference approach and assessed moderation using a triple-difference approach. The analytic sample consisted of 204 remediated lots and 612 non-remediated matched control lots over 84 months (2011–2017), for a total of 68,544 lot-months. In difference-in-differences analyses, the place-based intervention was associated with additional domestic crime incidence (β = 0.311, 95% CI: 0.016, 0.605; p = 0.039). In triple-difference analyses, on-premise bar density modified this association (β = −0.119, 95%CI: −0.147, −0.092; p < 0.001): in areas with higher bar density, increases in domestic crime were lower near remediated lots compared with control lots. Place-based interventions to reduce blighted properties may have contributed to fewer domestic crime incidents in areas with more bars.
• Mehta, P. K., Kieltyka, L., Bachhuber, M. A., Smiles, D., Wallace, M., Zapata, A., & Gee, R. E. (2020). Racial Inequities in Preventable Pregnancy-Related Deaths in Louisiana, 2011–2016. Obstetrics and Gynecology, 135(Issue 2). doi:10.1097/aog.0000000000003591
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  OBJECTIVE: To examine preventable pregnancy-related deaths in Louisiana by race and ethnicity and maternal level of care to inform quality improvement efforts. METHODS: We conducted a retrospective observational descriptive analysis of Louisiana Pregnancy-Associated Mortality Review data of 47 confirmed pregnancy-related deaths occurring from 2011 to 2016. The review team determined cause of death, preventability, and contributing factors. We compared preventability by race–ethnicity and maternal level of care of the facility where death occurred (from level I: basic care to level IV: regional perinatal health center) using odds ratios (ORs) and 95% CIs. RESULTS: The rate of pregnancy-related death among non-Hispanic black women (22.7/100,000 births, 95% CI 15.5–32.1, n532/140,785) was 4.1 times the rate among non-Hispanic white women (5.6/100,000, 95% CI 2.8–10.0, n511/197,630). Hemorrhage (n58/47, 17%) and cardiomyopathy (n58/47, 17%) were the most common causes of pregnancy-related death. Among non-Hispanic black women who experienced pregnancy-related death, 59% [n519] of deaths were deemed potentially preventable, compared with 9% (n51) among non-Hispanic white women (OR 14.6, 95% CI 1.7–128.4). Of 47 confirmed pregnancy-related deaths, 58% (n527) occurred at level III or IV birth facilities. Compared with those at level I or II birth facilities (n52/4, 50%), pregnancy-related deaths occurring at level III or IV birth facilities (n514/27, 52%) were not less likely to be categorized as preventable (OR 2.0, 95% CI 0.5–8.0). CONCLUSION: Compared with non-Hispanic white women, pregnancy-related deaths that occurred among non-Hispanic black women in Louisiana from 2011 to 2016 were more likely to be preventable. The proportion of deaths that were preventable was similar between lower and higher level birth facilities. Hospital-based quality improvement efforts focused on addressing hemorrhage, hypertension, and associated racial inequities may prevent pregnancy-related deaths in Louisiana.
• Sudhinaraset, M., Vilda, D., Gipson, J. D., Bornstein, M., & Wallace, M. E. (2020). Women's Reproductive Rights Policies and Adverse Birth Outcomes: A State-Level Analysis to Assess the Role of Race and Nativity Status. American Journal of Preventive Medicine, 59(Issue 6). doi:10.1016/j.amepre.2020.07.025
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  Introduction: Reproductive rights policies can potentially support or inhibit individuals’ abilities to attain the highest standard of reproductive and sexual health; however, research is limited on how broader social policies may differentially impact women of color and immigrants in the U.S. This study examines the associations among state-level reproductive rights policies, race, and nativity status with preterm birth and low birth weight in the U.S. Methods: This was a retrospective, cross-sectional analysis of all births occurring within all the 50 states and the District of Columbia using vital statistics birth record data in 2016 (N=3,945,875). Modified log-Poisson regression models with generalized estimating equations were fitted to estimate the RR of preterm birth and low birth weight associated with tertiles of the reproductive rights policies index. Analyses were conducted between 2019 and 2020. Results: Compared with women in states with the most restrictive reproductive rights policies, women living in the least restrictive states had a 7% lower low birth weight risk (adjusted RR=0.93, 95% CI=0.88, 0.99). In particular, low birth weight risk was 8% lower among Black women living in the least restrictive states than among their counterparts living in the most restrictive states (adjusted RR=0.92, 95% CI=0.86, 0.99). In addition, low birth weight risk was 6% lower among U.S.-born Black women living in the least restrictive states than among those living in the most restrictive states, but this was marginally significant (adjusted RR=0.94, 95% CI=0.89, 1.00). No other significant associations were found for race–nativity-stratified models. Conclusions: Women living in states with fewer restrictions related to reproductive rights have lower rates of low birth weight, especially for Black women.
• Wallace, M. E., Crear-Perry, J., Mehta, P. K., & Theall, K. P. (2020). Homicide during Pregnancy and the Postpartum Period in Louisiana, 2016-2017. JAMA Pediatrics, 174(Issue 4). doi:10.1001/jamapediatrics.2019.5853
• Wallace, M. E., Friar, N., Herwehe, J., & Theall, K. P. (2020). Violence As a Direct Cause of and Indirect Contributor to Maternal Death. Journal of Women's Health, 29(Issue 8). doi:10.1089/jwh.2019.8072
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  Death during pregnancy and postpartum in the United States is an issue of urgent and growing concern. Mortality from obstetric-related causes is on the rise, and pregnancy-associated homicide remains a leading cause of death. It is unknown how the context in which women live contributes to their risk of obstetric or violent death during pregnancy and the postpartum period. This study aimed to quantify incidence of mortality from obstetric-related causes and violent death during pregnancy and up to 1-year postpartum, and to identify associations between state-level violent crime rates and incidence of pregnancy-related mortality and pregnancy-associated homicide. Materials and Methods: We conducted a retrospective, ecologic analysis of all pregnancy-associated homicides in 17 states participating in the National Violent Death Reporting System from 2011 to 2015. Pregnancy-related mortality was identified by International Classification of Diseases-10 code for underlying cause of death in death records issued in the same states and years, data provided by the National Center for Health Statistics. We characterized decedents of both violent and nonviolent maternal death (n = 174 and 1,617, respectively). Five-year mortality ratios (deaths per 100,000 live births) were estimated for both pregnancy-related mortality and pregnancy-associated homicide in every state. Poisson regression models estimated associations between violent crime and maternal death, adjusting for area-level socioeconomic conditions. Results: Both pregnancy-related mortality and pregnancy-associated homicide ratios were higher in states with higher rates of violent crime (relative risk [RR] = 1.05, 95% confidence interval [CI] = 1.01-1.12; RR = 1.17, 95% CI = 1.01-1.34, respectively). Conclusion: Broad population-wide violence prevention efforts may help reduce incidence of maternal mortality from both obstetric and violent causes.
• Wallace, M., Felker-Kantor, E., Madkour, A., Ferguson, T., Welsh, D., Molina, P., & Theall, K. P. (2020). Adverse Childhood Experiences, Smoking and Alcohol Use, and Allostatic Load Among People Living with HIV. AIDS and Behavior, 24(Issue 6). doi:10.1007/s10461-019-02684-5
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  Allostatic load is an indicator of multisystem physiologic dysregulation that may arise from prolonged or accumulated exposure to stress, including adverse childhood experiences (ACEs) and chronic stressors persisting into adulthood. People living with HIV (PLWH) may be particularly vulnerable given their high burdens of adversity across the life course. Using data from a cohort of middle aged PLWH, we examined associations between ACEs and two measures of allostatic load. In order to determine whether the negative impact of ACEs on allostatic load operates through increasing the adoption of adverse coping behaviors, we tested for mediation by smoking and alcohol use. PLWH who had experienced 4 or more ACEs had on average higher allostatic load in adulthood compared to those who experienced fewer. Neither smoking nor alcohol use mediated this relationship, however, suggesting alternative mechanisms may be at play.
• Dyer, L., Hardeman, R., Vilda, D., Theall, K., & Wallace, M. (2019). Mass incarceration and public health: The association between black jail incarceration and adverse birth outcomes among black women in Louisiana. BMC Pregnancy and Childbirth, 19(Issue 1). doi:10.1186/s12884-019-2690-z
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  Background: A growing body of evidence is beginning to highlight how mass incarceration shapes inequalities in population health. Non-Hispanic blacks are disproportionately affected by incarceration and criminal law enforcement, an enduring legacy of a racially-biased criminal justice system with broad health implications for black families and communities. Louisiana has consistently maintained one of the highest rates of black incarceration in the nation. Concurrently, large racial disparities in population health persist. Methods: We conducted a cross-sectional analysis of all births among non-Hispanic black women in Louisiana in 2014 to identify associations between parish-level (county equivalent) prevalence of jail incarceration within the black population and adverse birth outcomes (N = 23,954). We fit a log-Poisson model with generalized estimating equations to approximate the relative risk of preterm birth and low birth weight associated with an interquartile range increase in incarceration, controlling for confounders. In sensitivity analyses, we additionally adjusted for the parish-level index crime prevalence and analyzed regression models wherein white incarceration was used to predict the risk of adverse birth outcomes in order to quantify the degree to which mass incarceration may harm health above and beyond living in a high crime area. Results: There was a significant 3% higher risk of preterm birth among black women associated with an interquartile range increase in the parish-level incarceration prevalence of black individuals, independent of other factors. Adjusting for the prevalence of index crimes did not substantively change the results of the models. Conclusion: Due to the positive significant associations between the prevalence of black individuals incarcerated in Louisiana jails and estimated risk of preterm birth, mass incarceration may be an underlying cause of the persistent inequities in reproductive health outcomes experienced by black women in Louisiana. Not only are there economic and social impacts stemming from mass incarceration, but there may also be implications for population health and health inequities, including the persistence of racial disparities in preterm birth and low birth weight.
• Felker-Kantor, E. A., Wallace, M. E., Madkour, A. S., Duncan, D. T., Andrinopoulos, K., & Theall, K. (2019). HIV Stigma, Mental Health, and Alcohol Use Disorders among People Living with HIV/AIDS in New Orleans. Journal of Urban Health, 96(Issue 6). doi:10.1007/s11524-019-00390-0
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  Evidence suggests that HIV-related stigma is a contributing factor to mental health and substance use problems among people living with HIV (PLWH). Limited research, however, has examined the differential effects that multiple stigma constructs, specifically, anticipated, enacted, and internalized stigma may have on mental health and alcohol use disorders among PLWH. Furthermore, no studies have examined this relationship within the larger context of urban life stressors. The purpose of this study was to examine associations of an overall HIV-related stigma measure and four HIV stigma subscales on depression, anxiety, and hazardous drinking among a sample of 380 PLWH in New Orleans. Log-Poisson models with generalized estimating equations were used to estimate relative risks (RR) and 95% confidence intervals (CI). A test of interaction was used to determine presence of effect modification by urban life stressors. Overall, higher levels of HIV-stigma were associated with depressive symptoms (RR 1.67, 95% CI 1.25, 2.23), anxiety symptoms (RR 1.91, 95% CI 1.17, 3.12), and hazardous drinking (RR 1.45, 95% CI 1.02, 2.05). Internalized HIV-stigma (measured using the negative self-image subscale) was associated with all three outcomes and had the highest magnitude point estimates across the four stigma subscales. Urban life stressors, measured by the Urban Life Stressors Scale (ULSS), modified the association between HIV-related stigma and mental health and alcohol use disorders (P < 0.2), highlighting the importance for examining the larger urban environmental context. Findings from this study may inform interventions to reduce HIV-related stigma operating at the individual and structural level.
• Harville, E. W., Jacobs, M., Shu, T., Breckner, D., & Wallace, M. (2019). Comparison of reproductive history gathered by interview and by vital records linkage after 40 years of follow-up: Bogalusa Babies. BMC Medical Research Methodology, 19(Issue 1). doi:10.1186/s12874-019-0758-0
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  Background: To examine the consistency and likely degree of bias in a study of cardiovascular health, linked with reproductive data over 40 years. Methods: Linkage of vital statistics data of births to female Bogalusa Heart Study participants was compared to interviewing of female participants. The characteristics of participants, the agreement, and demographic, study-related, and medical predictors of discrepancy were analyzed, using kappa statistics, mean and median differences, and logistic regression. Results: Overall, 3944 (66.7%) of participants were located by one or both sources. The strongest predictor of either linkage or interview was recent and/or frequent participation in the parent study. Agreement between the two sources was generally good (kappa > 0.9 for birthweight and 0.8 for gestational age). Black race, older age, and time since pregnancy were associated with greater discrepancy in reporting of outcomes, but cardiovascular risk factors generally were not. Conclusions: Combining information from multiple sources to increase sample size and outcome ascertainment may be valid, which will increase population health sciences' ability to leverage the many existing, large-scale sources to answer previously unexplored questions, even those that the data were not initially collected to answer.
• Harville, E. W., Knoepp, L. R., Wallace, M. E., & Miller, K. S. (2019). Cervical pathways for racial disparities in preterm births: the Preterm Prediction Study. Journal of Maternal-Fetal and Neonatal Medicine, 32(Issue 23). doi:10.1080/14767058.2018.1484091
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  Purpose: Racial disparities in preterm birth have been long recognized, but the social and biological mechanisms for these differences are unclear. Our analysis had three goals: (1) to determine the relation between race and other social risk factors and cervical structure; (2) to determine whether social factors mediate the relation between race and cervical structure; and (3) to determine whether racial disparities in preterm birth (PTB) are mediated through changes in cervical structure observed earlier in pregnancy. Materials and methods: Data from the Maternal Fetal Medicine Unit network Preterm Prediction Study were used to examine the relation between race and other social factors and cervical properties throughout pregnancy in 2920 black and white women. Outcomes included cervical length and dilation; cervical score (cervical length–internal dilation); and whether membranes protruded at 22–24 and 26–29 weeks. Race, education, income, insurance type, and marital status were examined as predictors of the outcomes using linear and logistic regression, adjusting for age, BMI, parity, and smoking. Mediation analysis was used to examine whether (a) any social factors explained racial differences in cervical properties, and (b) whether cervical properties mediated racial differences in risk for preterm birth. Results: Shorter cervical length, especially at a subject’s first visit, was associated with black race (adjusted beta −1.56 mm, p
• Madkour, A. S., Felker-Kantor, E., Wallace, M., Ferguson, T., Welsh, D. A., Molina, P. E., & Theall, K. P. (2019). Latent Alcohol Use Typologies and Health Status among a Cohort of Adults Living with HIV. Alcohol and Alcoholism, 54(Issue 6). doi:10.1093/alcalc/agz071
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  Aims: To characterize latent typologies of alcohol use among persons living with human immunodeficiency virus (HIV) (PLWH) and test their relationship with physical and mental health status. Methods: Baseline data from 365 adult in-care PLWH enrolled in the New Orleans Alcohol Use in HIV study were analyzed. Indicators of current and former heavy drinking, intoxication, withdrawal and dependence symptoms, alcohol-related problems and past contact with alcohol use treatment were drawn from validated scales. Physical and mental health measures included SF-36 subscales, medication non-adherence and anxiety, depressive and post-traumatic stress disorder symptoms. Latent class analysis was conducted to characterize alcohol drinking typologies. Logistic and ordinary least-squares regression were employed to test associations between alcohol use and health status. Results: Four latent classes were identified: Heavy drinkers (36%), former heavy drinkers (14%), heavy drinkers with problems (12%) and low-risk drinkers/abstainers (38%). Controlling for background characteristics, low-risk drinkers/abstainers showed significantly better health compared to heavy drinkers with problems across most domains. Although current and former heavy drinkers without alcohol-related problems were similar to heavy drinkers with problems in most health domains, they presented worse mental health and energy compared to low-risk drinkers/abstainers. Conclusions: Heavy drinkers with alcohol-related problems evidenced the worst health status among PLWH, and should be considered for mental and physical health interventions. However, interventions to improve physical and mental health of PLWH should consider history of heavy alcohol use, as current alcohol use status alone may be insufficient for identifying groups at increased risk.
• Theall, K. P., Wallace, M., Felker-Kantor, E., Madkour, A. S., Brashear, M., Ferguson, T., Welsh, D., & Molina, P. (2019). Neighborhood Alcohol Environment: Differential Effects on Hazardous Drinking and Mental Health by Sex in Persons Living with HIV (PLWH). AIDS and Behavior, 23(Issue 12). doi:10.1007/s10461-019-02632-3
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  Despite greater mental health co-morbidities and heavier alcohol use among PLWH, few studies have examined the role of the neighborhood alcohol environment on either alcohol consumption or mental health. Utilizing cross-sectional data from a cohort study in a southern U.S. metropolitan area, we examine the association between neighborhood alcohol environments on hazardous drinking and mental health among 358 in-care PLWH (84% African American, 31% female). Multilevel models were utilized to quantify associations between neighborhood alcohol exposure on hazardous drinking and effect modification by sex. Neighborhood alcohol density was associated with hazardous drinking among men but not women. Women living in alcohol dense neighborhoods were nearly two-fold likely to report depression compared to those in less dense neighborhoods, with no association between neighborhood alcohol density and depression among men. Neighborhood alcohol environments may be an important contextual factor to consider in reducing heavy alcohol consumption and improving mental health among PLWH.
• Vilda, D., Wallace, M., Dyer, L., Harville, E., & Theall, K. (2019). Income inequality and racial disparities in pregnancy-related mortality in the US. SSM - Population Health, 9. doi:10.1016/j.ssmph.2019.100477
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  In this ecological study, we examined the associations between state-level income inequality and pregnancy-related mortality among non-Hispanic (NH) black and NH white populations across the US. We estimated total population and race-specific 5-year pregnancy-related mortality ratios in each state based on national death and live birth records from 2011 to 2015. We obtained data on Gini coefficients for income inequality and population-level characteristics from the US Census American Community Survey. Poisson regression with robust standard errors estimated pregnancy-related mortality rate ratios (RR) and 95% confidence intervals (CI) associated with a one unit increase in income inequality overall and separately within black and white populations. Adjusted linear regression models estimated the associations between income inequality and magnitude of the absolute and relative racial inequity in pregnancy-related mortality within states. Across all states, increasing contemporaneous income inequality was associated with a 15% and 5-year lagged inequality with 14% increase in pregnancy-related mortality among black women (aRR = 1.15, 95% CI = 1.05; 1.25 and aRR = 1.14, 95% CI = 1.04; 1.24, respectively) after controlling for states’ racial compositions and socio-economic conditions. In addition, both lagged and contemporaneous income inequality were associated with larger absolute and relative racial inequities in pregnancy-related mortality. These findings highlight the role of contextual factors in contributing to pregnancy-related mortality among black women and the persistent racial inequity in maternal death in the US.
• Wallace, M. E., Crear-Perry, J., Green, C., Felker-Kantor, E., & Theall, K. (2019). Privilege and deprivation in Detroit: Infant mortality and the Index of Concentration at the Extremes. International Journal of Epidemiology, 48(Issue 1). doi:10.1093/ije/dyy149
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  Background Enhanced understanding of spatial social polarization as a determinant of infant mortality is critical to efforts aimed at advancing health equity. Our objective was to identify associations between spatial social polarization and risk of infant death. Methods We conducted a cross-sectional analysis of all birth records issued to non-Hispanic (NH) Black and White women in Wayne County, MI, from 2010 to 2013 (n = 84 159), including linked death records for deaths occurring at less than 1 year of age. Spatial social polarization was measured in each Census tract of maternal residence (n = 599) using the Index of Concentration at the Extremes (ICE) - a joint measure of racial and economic segregation - estimated from American Community Survey 2009-2013 data. Log-Poisson regression models quantified relative risk (RR) of infant death (all-cause and cause-specific) associated with tertiles of the index, adjusting for maternal demographic characteristics and tract-level poverty. Results The crude infant-mortality rate was more than 2-fold higher among NH Black infants compared with NH Whites (14.0 vs 5.9 deaths per 1000 live births). Half of the 845 infant deaths (72% NH Black, 28% NH White) occurred in tracts in the lowest tertile of the ICE distribution, representing areas of relative deprivation. After adjustments, risk of death among infants in the lowest tertile was 1.46 times greater than those in the highest tertile (adjusted infant-mortality rate = 3.7 deaths per 1000 live births in highest tertile vs 5.4 deaths per 1000 live births in lowest tertile, relative risk = 1.46, 95% confidence interval = 1.02, 2.09). Patterns of associations with the index differed by cause of death. Conclusions These findings suggest efforts to support equitable community investments may reduce incidents of death and the disproportionate experience of loss among NH Black women.
• Harville, E. W., Jacobs, M., Shu, T., Breckner, D., & Wallace, M. (2018). Feasibility of Linking Long-Term Cardiovascular Cohort Data to Offspring Birth Records: The Bogalusa Heart Study. Maternal and Child Health Journal, 22(Issue 6). doi:10.1007/s10995-018-2460-y
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  Introduction Researchers in perinatal health, as well as other areas, may be interested in linking existing datasets to vital records data when the existence or timing of births is unknown. Methods 5914 women who participated in the Bogalusa Heart Study (1973–2009), a long-running study of cardiovascular health in childhood, adolescence, and adulthood, were linked to vital statistics birth data from Louisiana, Mississippi, and Texas (1982–2010). Deterministic and probabilistic linkages based on social security number, race, maternal date of birth, first name, last name, and Soundex codes for name were conducted. Characteristics of the linked and unlinked women were compared using t-tests, Chi square tests, and multiple regression with adjustment for age and year of examinations. Results The Louisiana linkage linked 4876 births for 2770 women; Mississippi linked 791 births to 487 women; Texas linked 223 births to 153 women; After removal of duplicates and implausible dates, this left a total of 5922 births to 3260 women. This represents a successful linkage of 55% of all women ever seen in the larger study, and an estimated 65% of all women expected to have given birth. Those linked had more study visits, were more likely to be black, and had statistically lower BMIs than unlinked participants. Discussion Linking unrelated study data to vital records data was feasible to a degree. The linked group had a somewhat more favorable health profile and was less mobile than the overall study population.
• Harville, E. W., Myers, L., Shu, T., Wallace, M. E., & Bazzano, L. A. (2018). Pre-pregnancy cardiovascular risk factors and racial disparities in birth outcomes: The Bogalusa Heart Study. BMC Pregnancy and Childbirth, 18(Issue 1). doi:10.1186/s12884-018-1959-y
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  Background: Racial disparities in birth outcomes are mirrored in cardiovascular health. Recently there have been calls for more attention to preconception and interconceptional health in order to improve birth outcomes, including as a strategy to reduce black-white disparities. Methods: As part of a larger study of cardiovascular and reproductive health ("Bogalusa Babies"), female participants were linked to their children's birth certificates for Louisiana, Mississippi, and Texas births from 1982 to 2009. Three thousand and ninety-five women were linked to birth certificate data. Birth outcomes were defined as low birthweight (LBW) birthweight < 2500 g; preterm birth (PTB), > 3 weeks early; small for gestational age (SGA), 90th percentile for gestational age]. Cardiovascular measures (blood pressure, lipids, glucose, insulin) at the visit closest in time but prior to the pregnancy was examined as predictors of birth outcomes using logistic models adjusted for covariates. Results: Only a few cardiovascular risk factors were associated with birth outcomes. Triglycerides were associated with higher risk of LBW among whites (aOR 1.05, 95% 1.01-1.10). Higher glucose was associated with a reduction in risk of SGA for black women (aOR 0.85, 95% CI 0.76-0.95), but not whites (p for interaction = 0.02). Clear racial disparities were found, but they were reduced modestly (LBW/SGA) or not at all (PTB/LGA) after CVD risk factors were adjusted for. Conclusions: This analysis does not provide evidence for preconception cardiovascular risk being a strong contributor to racial disparities.
• Theall, K. P., Felker-Kantor, E., Wallace, M., Zhang, X., Morrison, C. N., & Wiebe, D. J. (2018). Considering high alcohol and violence neighborhood context using daily diaries and GPS: A pilot study among people living with HIV. Drug and Alcohol Dependence, 187. doi:10.1016/j.drugalcdep.2018.03.005
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  Our understanding of how community-level context impacts care of persons living with HIV (PLWH), including antiretroviral therapy (ART) adherence and retention in care, is limited. The objective of this study was to characterize the activity spaces of PLWH from an urban area in Southeastern U.S., where the epidemic is among the nation's highest, and to examine how such activity spaces are associated with daily mood and health behaviors. In this small, pilot study, 11 participants were tracked with a global positioning system (GPS)-enabled application on their smartphones for 2 weeks. Activity spaces were created by connecting GPS points sequentially and adding buffers. Contextual exposure data (e.g., alcohol outlets) were connected to activity spaces. Participants also completed daily diary entry through texts 3 times per day regarding outcomes of substance use behaviors, mood, and medication adherence. This yielded a total of 18,007 GPS polyline records that we aggregated into 258 person-days that captured discrete occasions of exposure to contextual factors and subjects’ behaviors and moods. On average, the participants spent 19% of their time awake during the 2-week periods in their residential census tract. Exposure to social and built environment factors such as alcohol outlets was greater when participants were outside versus inside their residential census tract. Exposures on daily routes were also significantly associated with ART adherence, alcohol consumption, and mood. Findings suggest substantial differences between activity spaces and residential contexts. Activity spaces are relevant for PLWH and may impact HIV care and behavioral outcomes such as ART adherence and substance use.
• Wallace, M. E., Bazzano, L., Zhang, C., & Harville, E. (2018). Fasting glucose concentrations and associations with reproductive history over 40 years of follow-up. Gynecological Endocrinology, 34(Issue 8). doi:10.1080/09513590.2018.1431771
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  Gestational diabetes mellitus (GDM) is the onset or first recognition of diabetes that occurs during pregnancy. We aimed to assess for trends in fasting blood glucose levels across the life-course among a cohort of women by reproductive history: nulligravid women, gravid women with and without a history of GDM. Women who had participated in the Bogalusa Heart Study as children were interviewed about their reproductive history, including GDM (n = 358). We compared fasting blood glucose (mg/dL) measured after last pregnancy (or after age 40 among nulligravid women) across reproductive history groups in linear models adjusted for prepregnancy fasting blood glucose, body mass index, race, parity, and age at outcome measure. We fit a log-Poisson model to estimate the associations with prediabetes risk after age 40. After adjustments, mean fasting glucose after age 40 was not different between gravid women without GDM history and nulligravid women. However, women with a history of GDM had mean fasting glucose 27 mg/dL greater than nulligravid women (95% CI = 12.35, 41.64). Heterogeneity by race indicated Black women with a history of GDM had disproportionately elevated mean fasting glucose after age 40. Fasting blood glucose trends over the life-course differ among women by reproductive history and race.
• Williams, A. D., Wallace, M., Nobles, C., & Mendola, P. (2018). Racial residential segregation and racial disparities in stillbirth in the United States. Health and Place, 51. doi:10.1016/j.healthplace.2018.04.005
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  We examined whether current and/or persistent racial residential segregation is associated with black-white stillbirth disparities among 49,969 black and 71,785 white births from the Consortium on Safe Labor (2002–2008). Black-white segregation was measured using the dissimilarity index and the isolation index, categorized into population-based tertiles. Using hierarchical logistic models, we found low and decreasing levels of segregation were associated with decreased odds of stillbirth, with blacks benefitting more than whites. Decreasing segregation may prevent approximately 900 stillbirths annually among U.S. blacks. Reducing structural racism, segregation in particular, could help reduce black-white stillbirth disparities.
• Felker-Kantor, E., Wallace, M., & Theall, K. (2017). Living in violence: Neighborhood domestic violence and small for gestational age births. Health and Place, 46. doi:10.1016/j.healthplace.2017.05.011
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  Objectives To determine the association between neighborhood domestic violence and small-for-gestational-age (SGA) birth and to examine if there is a differential impact of neighborhood domestic violence on SGA births by race in a high crime community. Methods This analysis includes all birth records issued in New Orleans, Louisiana from 2011 to 2012 geocoded by census tract (N=177 census tracts, N=8322 women). Hierarchical modeling and ecologic spatial analysis were used to examine the area-effect of neighborhood domestic violence on SGA births, independent of individual-level predictors and accounting for the propensity to live in high domestic violence neighborhoods. Results Tests for spatial autocorrelation reveled area-level clustering and overlap of SGA and domestic violent rates. Pregnant women living in high domestic violence areas were more likely to give birth to an SGA infant compared to women in low-domestic violence areas (OR=1.04, 95%CI: 1.01, 1.08), net of the effects of individual-level factors and propensity scores. Conclusion Neighborhood-level attributes including rates of domestic violence may increase women's risk for SGA birth, highlighting a policy-relevant and potentially amenable exposure.
• Jones, C. W., Gambala, C., Esteves, K. C., Wallace, M., Schlesinger, R., O'Quinn, M., Kidd, L., Theall, K. P., & Drury, S. S. (2017). Differences in placental telomere length suggest a link between racial disparities in birth outcomes and cellular aging. American Journal of Obstetrics and Gynecology, 216(Issue 3). doi:10.1016/j.ajog.2016.11.1027
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  Background Health disparities begin early in life and persist across the life course. Despite current efforts, black women exhibit greater risk for pregnancy complications and negative perinatal outcomes compared with white women. The placenta, which is a complex multi-tissue organ, serves as the primary transducer of bidirectional information between the mother and fetus. Altered placental function is linked to multiple racially disparate pregnancy complications; however, little is known about racial differences in molecular factors within the placenta. Several pregnancy complications, which include preeclampsia and fetal growth restriction, exhibit racial disparities and are associated with shorter placental telomere length, which is an indicator of cellular stress and aging. Cellular senescence and telomere dynamics are linked to the molecular mechanisms that are associated with the onset of labor and parturition. Further, racial differences in telomere length are found in a range of different peripheral tissues. Together these factors suggest that exploration of racial differences in telomere length of the placenta may provide novel mechanistic insight into racial disparities in birth outcomes. Objective This study examined whether telomere length measured in 4 distinct fetally derived tissues were significantly different between black and white women. The study had 2 hypotheses: (1) that telomere length that is measured in different placental tissue types would be correlated and (2) that across all sampled tissues telomere length would differ by race. Study Design In a prospective study, placental tissue samples were collected from the amnion, chorion, villus, and umbilical cord from black and white singleton pregnancies (N=46). Telomere length was determined with the use of monochrome multiplex quantitative real-time polymerase chain reaction in each placental tissue. Demographic and pregnancy-related data were also collected. Descriptive statistics characterized the sample overall and among black and white women separately. The overall impact of race was assessed by multilevel mixed-effects linear regression models that included empirically relevant covariates. Results Telomere length was correlated significantly across all placental tissues. Pairwise analyses of placental tissue telomere length revealed significantly longer telomere length in the amnion compared with the chorion (t=–2.06; P=.043). Overall telomere length measured in placenta samples from black mothers were significantly shorter than those from white mothers (β=–0.09; P=.04). Controlling for relevant maternal and infant characteristics strengthened the significance of the observed racial differences (β=–0.12; P=.02). Within tissue analyses revealed that the greatest difference by race was found in chorionic telomere length (t=–2.81; P=.007). Conclusion These findings provide the first evidence of racial differences in placental telomere length. Telomere length was significantly shorter in placental samples from black mothers compared with white mothers. Given previous studies that have reported that telomere length, cellular senescence, and telomere dynamics are molecular factors that contribute to the rupture of the amniotic sac, onset of labor, and parturition, our findings of shorter telomere length in placentas from black mothers suggest that accelerated cellular aging across placental tissues may be relevant to the increased risk of preterm delivery in black pregnancies. Our results suggest that racial differences in cellular aging in the placenta contribute to the earliest roots of health disparities.
• Latimer, J., Fleckman, J., Wallace, M., Rountree, M., & Theall, K. (2017). The Influence of Violence Victimization on Sexual Health Behaviors and Outcomes. AIDS Patient Care and STDs, 31(Issue 5). doi:10.1089/apc.2016.0265
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  This study examines the implications of a history of personal violence on health and health behaviors. A secondary analysis of cross-sectional data involving adults (n = 214) from a semirural area in southern Louisiana between October 2008 and December 2010 was conducted to ascertain the association between a personal history of violence victimization and indicators of sexual health behaviors and outcomes: communication with sexual partners about HIV status, consistent condom use, and sexually transmitted infection (STI). While violence victimization is widely accepted as a risk factor for high-risk sex behavior, the mechanisms underlying violence victimization's influence on sexual health outcomes remain unclear. Bivariate analyses demonstrated a significant positive association between experience of physical abuse and lifetime history of STI. Surprisingly, respondents reporting lifetime physical violence were more than two times more likely to ask sexual partners about HIV status [odds ratio (OR) for physical attack = 2.23, 95% confidence intervals (CI) = 1.00-4.97; OR for physical injury = 4.60, 95% CI = 1.79-11.85]. Consistent condom use was not significantly associated with violence exposure in adjusted models. There was no evidence that communication with sexual partners mediated the relationship between experiences of violence and condom use. The link between personal history of violence and condom use may be mediated through alternative pathways beyond communication.
• Mendola, P., Sundaram, R., Louis, G. M., Sun, L., Wallace, M. E., Smarr, M. M., Sherman, S., Zhu, Y., Ying, Q., & Liu, D. (2017). Proximity to major roadways and prospectively-measured time-to-pregnancy and infertility. Science of the Total Environment, 576(Issue). doi:10.1016/j.scitotenv.2016.10.038
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  We aimed to study the potential impact of proximity to major roadways on time-to-pregnancy and infertility in couples attempting pregnancy in the Longitudinal Investigation of Fertility and Environment (LIFE) study (2005–2009), a population-based, prospective cohort study. Couples attempting pregnancy (n = 500) were enrolled and followed prospectively until pregnancy or 12 months of trying and 393 couples (78%) had complete data and full follow-up. Time-to-pregnancy was based on a standard protocol using fertility monitors, tracking estrone-3-glucuonide and luteinizing hormone, and pregnancy test kits to detect human chorionic gonadotropin (hCG). The fecundability odds ratio (FOR) and 95% confidence interval (CI) were estimated using proportional odds models. Infertility was defined as 12 months of trying to conceive without an hCG pregnancy and the relative risk (RR) and 95% CI were estimated with log-binomial regression. Final models were adjusted for age, parity, study site, and salivary alpha-amylase, a stress marker. Infertile couples (53/393; 14%) tended to live closer to major roadways on average than fertile couples (689 m vs. 843 m, respectively) but the difference was not statistically significant. The likelihood of pregnancy was increased 3% for every 200 m further away the couples residence was from a major roadway (FOR = 1.03; CI = 1.01–1.06). Infertility also appeared elevated at moderate distances compared to 1000 m or greater, but estimates lacked precision. Our findings suggest that proximity to major roadways may be related to reductions in fecundity. Prospective data from larger populations is warranted to corroborate these findings.
• Theall, K. P., Shirtcliff, E. A., Dismukes, A. R., Wallace, M., & Drury, S. S. (2017). Association between neighborhood violence and biological stress in children. JAMA Pediatrics, 171(Issue 1). doi:10.1001/jamapediatrics.2016.2321
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  IMPORTANCE Exposure to violence continues to be a growing epidemic, particularly among children. An enhanced understanding of the biological effect of exposure to violence is critical. OBJECTIVE To examine the association between neighborhood violence and cellular and biological stress in children. DESIGN, SETTING, AND PARTICIPANTS A matched, cross-sectional study of 85 black children aged 5 to 16 years from 52 neighborhoods took place in the greater New Orleans, Louisiana, area between January 1, 2012, and July 31, 2013. EXPOSURES Density of businesses where individuals can purchase alcohol as measured by rates per capita of liquor or convenience stores, and violence as measured by reports of violent crime and reports of domestic violence, operationalized as reports per capita of crime and domestic violence. Rates of exposure within a 500-, 1000-, and 2000-m radius from the child's home were calculated. MAIN OUTCOMES AND MEASURES Primary biological outcomeswere telomere length and cortisol functioning. RESULTS Among the 85 children in the study, (mean [SD] age, 9.8 [3.1] years; 50 girls and 35 boys) significant variation in telomere length and cortisol functioning was observed at the neighborhood level, with intraclass correlation coefficients of 6%for telomere length, 3.4% for waking cortisol levels, and 5.5%for peak cortisol levels following a stressor. Density of liquor or convenience stores within a 500-m radius of a child's home was associated with a decrease in mean telomere length by 0.004 for each additional liquor store or convenience store (β [SE], -0.004 [0.002]; P = .02). The rate of domestic violence was significantly and inversely associated with a decrease in mean telomere length by 0.007 for each additional report of domestic violence in a 500-m radius of a child's home (β [SE], -0.007 [0.001]; P < .001). The rate of violent crime was significantly associated with a decrease in mean telomere length by 0.006 for each additional report of violent crime in a 500-m radius of a child's home (β [SE], -0.006 [0.002]; P < .001). Children exposed to more liquor and convenience stores within 500mof their home were significantly less likely to reduce cortisol levels after a reactivity test (β, 0.029; P = .047), as were children exposed to high rates of domestic violence (β, 0.088; P = .12) and violent crime (β, 0.029; P = .006). Children exposed to more liquor and convenience stores within 500mof their home had a steeper diurnal decline in cortisol levels during the day (β [SE], -0.002 [0.001]; P = .04), as did children exposed to more violent crime within 500mof their home (β [SE] -0.032 [0.014]; P = .02). CONCLUSIONS AND RELEVANCE Neighborhoods are important targets for interventions to reduce the effect of exposure to violence in the lives of children. These findings provide the first evidence that objective exposures to neighborhood-level violence influence both physiological and cellular markers of stress, even in children.
• Theall, K. P., Wallace, M., & Wesson, D. M. (2017). Zika: A Missed Opportunity to Protect Women's Health and Prevent Unwanted Pregnancies. Women's Health Issues, 27(Issue 1). doi:10.1016/j.whi.2016.10.005
• Wallace, M. E., Evans, M. G., & Theall, K. (2017). The Status of Women's Reproductive Rights and Adverse Birth Outcomes. Women's Health Issues, 27(Issue 2). doi:10.1016/j.whi.2016.12.013
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  Background Reproductive rights—the ability to decide whether and when to have children—shape women's socioeconomic and health trajectories across the life course. The objective of this study was to examine reproductive rights in association with preterm birth (PTB;
• Wallace, M. E., Green, C., Richardson, L., Theall, K., & Crear-Perry, J. (2017). “Look at the whole me”: A Mixed-Methods examination of black infant mortality in the us through women’s lived experiences and community context. International Journal of Environmental Research and Public Health, 14(Issue 7). doi:10.3390/ijerph14070727
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  In the US, the non-Hispanic Black infant mortality rate exceeds the rate among non-Hispanic Whites by more than two-fold. To explore factors underlying this persistent disparity, we employed a mixed methods approach with concurrent quantitative and qualitative data collection and analysis. Eighteen women participated in interviews about their experience of infant loss. Several common themes emerged across interviews, grouped by domain: individual experiences (trauma, grieving and counseling; criminalization); negative interactions with healthcare providers and the healthcare system; and broader contextual factors. Concurrently, we estimated the Black infant mortality rate (deaths per 1000 live births) using linked live birth-infant death records from 2010 to 2013 in every metropolitan statistical area in the US. Poisson regression examined how contextual indicators of population health, socioeconomic conditions of the Black population, and features of the communities in which they live were associated with Black infant mortality and inequity in Black-White infant mortality rates across 100 metropolitan statistical areas with the highest Black infant mortality rates. We used principal components analysis to create a Birth Equity Index in order to examine the collective impact of contextual indicators on Black infant mortality and racial inequity in mortality rates. The association between the Index and Black infant mortality was stronger than any single indicator alone: in metropolitan areas with the worst social, economic, and environmental conditions, Black infant mortality rates were on average 1.24 times higher than rates in areas where conditions were better (95% CI = 1.16, 1.32). The experiences of Black women in their homes, neighborhoods, and health care centers and the contexts in which they live may individually and collectively contribute to persistent racial inequity in infant mortality.
• Wallace, M. E., Mendola, P., Kim, S. S., Epps, N., Chen, Z., Smarr, M., Hinkle, S. N., Zhu, Y., & Grantz, K. L. (2017). Racial/ethnic differences in preterm perinatal outcomes. American Journal of Obstetrics and Gynecology, 216(Issue 3). doi:10.1016/j.ajog.2016.11.1026
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  Background Racial disparities in preterm birth and infant death have been well documented. Less is known about racial disparities in neonatal morbidities among infants who are born at
• Wallace, M., Bazzano, L., Chen, W., & Harville, E. (2017). Maternal childhood cardiometabolic risk factors and pregnancy complications. Annals of Epidemiology, 27(Issue 7). doi:10.1016/j.annepidem.2017.06.002
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  Purpose The influence of childhood health on later-life health outcomes is increasingly hypothesized but rarely tested. We examined the relationship between cardiometabolic indicators in childhood and risk of pregnancy-induced hypertension, preeclampsia, and gestational diabetes. Methods Childhood measurements from 755 women in the Bogalusa Heart Study included body mass index, systolic and diastolic blood pressure (SBP and DBP), low- and high-density lipoprotein cholesterol, total cholesterol, triglycerides, insulin, and glucose. Average childhood values were estimated by area under the curve computed from longitudinal quadratic random-effects growth models to account for the unequally spaced repeated measures. Women reported pregnancy complications, and medical records were linked to interview data where possible. Log-Poisson models predicted adjusted risk associated with an interquartile range increase in cardiometabolic indicators. Results Elevated childhood insulin was associated with 10%–15% increased risk across the three outcomes. Elevated childhood SBP was associated with preeclampsia (SBP RR = 1.50, 95% CI: 1.13, 2.01) and SBP, DBP, and body mass index predicted pregnancy-induced hypertension (SBP RR = 2.15, 95% CI: 1.65, 2.82; DBP RR = 1.83, 95% CI: 1.38, 2.43; BMI RR = 1.67, 95% CI: 1.41, 1.98). Blood pressure mediated the association between childhood body mass index and pregnancy-induced hypertension. Conclusions Results suggest the potential long-term impact of early-life cardiometabolic profiles on complications of pregnancy.
• Wallace, M., Crear-Perry, J., Richardson, L., Tarver, M., & Theall, K. (2017). Separate and unequal: Structural racism and infant mortality in the US. Health and Place, 45. doi:10.1016/j.healthplace.2017.03.012
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  We examined associations between state-level measures of structural racism and infant mortality among black and white populations across the US. Overall and race-specific infant mortality rates in each state were calculated from national linked birth and infant death records from 2010 to 2013. Structural racism in each state was characterized by racial inequity (ratio of black to white population estimates) in educational attainment, median household income, employment, imprisonment, and juvenile custody. Poisson regression with robust standard errors estimated infant mortality rate ratios (RR) and 95% confidence intervals (CI) associated with an IQR increase in indicators of structural racism overall and separately within black and white populations. Across all states, increasing racial inequity in unemployment was associated with a 5% increase in black infant mortality (RR=1.05, 95% CI=1.01, 1.10). Decreasing racial inequity in education was associated with an almost 10% reduction in the black infant mortality rate (RR=0.92, 95% CI=0.85, 0.99). None of the structural racism measures were significantly associated with infant mortality among whites. Structural racism may contribute to the persisting racial inequity in infant mortality.
• Backonja, U., Robledo, C. A., Wallace, M. E., Flores, K. F., & Kiely, M. (2016). Reproductive Health Knowledge among African American Women Enrolled in a Clinic-Based Randomized Controlled Trial to Reduce Psychosocial and Behavioral Risk: Project DC-HOPE. Women's Health Issues, 26(Issue 4). doi:10.1016/j.whi.2016.03.005
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  Background Washington, DC, has among the highest rates of sexually transmitted infections and unintended pregnancy in the United States. Increasing women's reproductive health knowledge may help to address these reproductive health issues. This analysis assessed whether high-risk pregnant African American women in Washington, DC, who participated in an intervention to reduce behavioral and psychosocial risks had greater reproductive health knowledge than women receiving usual care. Methods Project DC-HOPE was a randomized, controlled trial that included pregnant African American women in Washington, DC, recruited during prenatal care (PNC). Women in the intervention group were provided reproductive health education and received tailored counseling sessions to address their psychosocial and behavioral risk(s) (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence). Women in the control group received usual PNC. Participants completed a 10-item reproductive knowledge assessment at baseline (n = 1,044) and postpartum (n = 830). Differences in total reproductive health knowledge scores at baseline and postpartum between groups were examined via χ2 tests. Differences in postpartum mean total score by group were assessed via multiple linear regression. Results Women in both groups and at both time points scored approximately 50% on the knowledge assessments. At postpartum, women in the intervention group had higher total scores compared with women receiving usual care (mean 5.40 [SD 1.60] vs. 5.03 [SD 1.53] out of 10, respectively; p < .001). Conclusions Although intervention participants increased reproductive health knowledge, overall scores remained low. Development of interventions designed to impart accurate, individually tailored information to women may promote reproductive health knowledge among high-risk pregnant African American women residing in Washington, DC.
• Kaplan, K. C., Hormes, J. M., Wallace, M., Rountree, M., & Theall, K. P. (2016). Racial discrimination and HIV-related risk behaviors in Southeast Louisiana. American Journal of Health Behavior, 40(Issue 1). doi:10.5993/ajhb.40.1.15
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  Objectives: We examined the relationship between cumulative experiences of racial discrimination and HIV-related risk taking, and whether these relationships are mediated through alcohol use among African Americans in semi-rural southeast Louisiana. Methods: Participants (N = 214) reported on experiences of discrimination, HIV sexual risk-taking, history of sexually transmitted infection (STI), and health behaviors including alcohol use in the previous 90 days. Experiences of discrimination (scaled both by frequency of occurrence and situational counts) as a predictor of a sexual risk composite score as well as a history of STI was assessed using multivariate linear and logistic regression, respectively, including tests for mediation by alcohol use. Results: Discrimination was common in this cohort, with respondents confirming their experience on average 7 of the 9 potential situations and on more than 34 separate occasions. After adjustment, discrimination was significantly associated with increasing sexual risk-taking and lifetime history of STI when measured either by frequency of occurrence or number of situations, although there was no evidence that these relationships were mediated through alcohol use. Conclusions: Cumulative experiences of discrimination may play a significant role in sexual risk behavior and consequently increase vulnerability to HIV and other STIs.
• Kim, S. S., Zhu, Y., Grantz, K. L., Hinkle, S. N., Chen, Z., Wallace, M. E., Smarr, M. M., Epps, N. M., & Mendola, P. (2016). Obstetric and neonatal risks among obese women without chronic disease. Obstetrics and Gynecology, 128(Issue 1). doi:10.1097/aog.0000000000001465
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  OBJECTIVE: To investigate whether prepregnancy obesity is associated with adverse pregnancy outcomes among women without chronic disease. METHODS: Singleton deliveries (N112,309) among mothers without chronic diseases in the Consortium on Safe Labor, a retrospective U.S. cohort, were analyzed using Poisson regression with robust variance estimation. Relative risks and 95% confidence intervals (CIs) estimated perinatal risks in relation to prepregnancy obesity status adjusted for age, race-ethnicity, parity, insurance, smoking and alcohol use during pregnancy, and study site. RESULTS: Obstetric risks were variably (and mostly marginally) increased as body mass index (BMI) category and obesity class increased. In particular, the risk of gestational hypertensive disorders, gestational diabetes, cesarean delivery, and induction increased in a dose-response fashion. For example, the percentage of gestational diabetes among obese class III women was 14.6% in contrast to 2.8% among women with normal BMIs (corresponding relative risks [95% CI] 1.99 [1.86-2.13], 2.94 [2.73-3.18], 3.97 [3.61-4.36], and 5.47 [4.96-6.04] for overweight, obese class I, obese class II, and obese class III women, respectively) compared with women with normal BMIs. Similarly, neonatal risks increased in a dose-response fashion with maternal BMI status including preterm birth at less than 32 weeks of gestation, large for gestational age (LGA), transient tachypnea, sepsis, and intensive care unit admission. The percentage of LGA neonates increased from 7.9% among women with normal BMIs to 17.3% among obese class III women and relative risks increased to 1.52 (1.45-1.58), 1.74 (1.65-1.83), 1.93 (1.79-2.07), and 2.32 (2.14-2.52) as BMI category increased. CONCLUSION: Prepregnancy obesity is associated with increased risks of a wide range of adverse pregnancy and neonatal outcomes among women without chronic diseases.
• Mendola, P., Wallace, M., Hwang, B. S., Liu, D., Robledo, C., Männistö, T., Sundaram, R., Sherman, S., Ying, Q., & Grantz, K. L. (2016). Preterm birth and air pollution: Critical windows of exposure for women with asthma. Journal of Allergy and Clinical Immunology, 138(Issue 2). doi:10.1016/j.jaci.2015.12.1309
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  Background Ambient air pollutants may increase preterm birth (PTB) risk, but critical exposure windows are uncertain. The interaction of asthma and pollutant exposure is rarely studied. Objective We sought to assess the interaction of maternal asthma and air pollutant exposures in relation to PTB risk. Methods Electronic medical records for 223,502 US deliveries were linked with modified Community Multiscale Air Quality model outputs. Logistic regression with generalized estimating equations estimated the odds ratio and 95% CIs for PTB on the basis of the interaction of maternal asthma and particulate matter with aerodynamic diameter of less than 2.5 microns and particulate matter with aerodynamic diameter of less than 10 microns, ozone (O3), nitrogen oxides (NOx), sulfur dioxide (SO2), and carbon monoxide (CO) per interquartile range. For each gestational week 23 to 36, exposures among women who delivered were compared with those remaining pregnant. Three-month preconception, whole pregnancy, weeks 1 to 28, and the last 6 weeks of gestation averages were also evaluated. Results On assessing PTB by gestational week, we found that significant asthma interactions were sporadic before 30 weeks but more common during weeks 34 to 36, with higher risk among mothers with asthma for NOx, CO, and SO2 exposure and an inverse association with O3 in week 34. Odds of PTB were significantly higher among women with asthma for CO and NOx exposure preconception and early in pregnancy. In the last 6 weeks of pregnancy, PTB risk associated with particulate matter with aerodynamic diameter of less than 10 microns was higher among women with asthma. Conclusions Mothers with asthma may experience a higher risk for PTB after exposure to traffic-related pollutants such as CO and NOx, particularly for exposures 3-months preconception and in the early weeks of pregnancy.
• Mendola, P., Wallace, M., Liu, D., Robledo, C., Mӓnnistӧ, T., & Grantz, K. L. (2016). Air pollution exposure and preeclampsia among US women with and without asthma. Environmental Research, 148. doi:10.1016/j.envres.2016.04.004
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  Maternal asthma and air pollutants have been independently associated with preeclampsia but rarely studied together. Our objective was to comprehensively evaluate preeclampsia risk based on the interaction of maternal asthma and air pollutants. Preeclampsia and asthma diagnoses, demographic and clinical data came from electronic medical records for 210,508 singleton deliveries. Modified Community Multiscale Air Quality models estimated preconception, first and second trimester and whole pregnancy exposure to: particulate matter (PM)
• Schliep, K. C., Mumford, S. L., Johnstone, E. B., Peterson, C. M., Sharp, H. T., Stanford, J. B., Chen, Z., Backonja, U., Wallace, M. E., & Buck Louis, G. M. (2016). Sexual and physical abuse and gynecologic disorders. Human Reproduction, 31(Issue 8). doi:10.1093/humrep/dew153
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  STUDY QUESTION Is sexual and/or physical abuse history associated with incident endometriosis diagnosis or other gynecologic disorders among premenopausal women undergoing diagnostic and/or therapeutic laparoscopy or laparotomy regardless of clinical indication? SUMMARY ANSWER No association was observed between either a history of sexual or physical abuse and risk of endometriosis, ovarian cysts or fibroids; however, a history of physical abuse was associated with a higher likelihood of adhesions after taking into account important confounding and mediating factors. WHAT IS KNOWN ALREADY Sexual and physical abuse may alter neuroendocrine-immune processes leading to a higher risk for endometriosis and other noninfectious gynecologic disorders, but few studies have assessed abuse history prior to diagnosis. STUDY DESIGN, SIZE, DURATION The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at 1 of the 14 surgical centers located in Salt Lake City, UT, USA or San Francisco, CA, USA. Women with a history of surgically confirmed endometriosis were excluded. PARTICIPANTS/MATERIALS, SETTING AND METHODS Prior to surgery, women completed standardized abuse questionnaires. Relative risk (RR) of incident endometriosis, uterine fibroids, adhesions or ovarian cysts by abuse history were estimated, adjusting for age, race/ethnicity, education, marital status, smoking, gravidity and recruitment site. We assessed whether a history of chronic pelvic pain, depression, or STIs explained any relationships via mediation analyses. MAIN RESULTS AND ROLE OF CHANCE 43 and 39% of women reported experiencing sexual and physical abuse. No association was observed between either a history of sexual or physical abuse, versus no history, and risk of endometriosis (aRR: 1.00 [95% confidence interval (CI): 0.80-1.25]); aRR: 0.83 [95% CI: 0.65-1.06]), ovarian cysts (aRR: 0.67 [95% CI: 0.39-1.15]); aRR: 0.60 [95% CI: 0.34-1.09]) or fibroids (aRR: 1.25 [95% CI: 0.85-1.83]); aRR: 1.36 [95% CI: 0.92-2.01]). Conversely, a history of physical abuse, versus no history, was associated with higher risk of adhesions (aRR: 2.39 [95% CI: 1.18-4.85]). We found no indication that the effect of abuse on women's adhesion risk could be explained by a history of chronic pelvic pain, depression or STIs. LIMITATIONS, REASONS FOR CAUTION Limitations to our study include inquiries on childhood physical but not sexual abuse. Additionally, we did not inquire about childhood or adulthood emotional support systems, found to buffer the negative impact of stress on gynecologic health. WIDER IMPLICATIONS OF THE FINDINGS Abuse may be associated with some but not all gynecologic disorders with neuroendocrine-inflammatory origin. High prevalence of abuse reporting supports the need for care providers to screen for abuse and initiate appropriate follow-up. STUDY FUNDING/COMPETING INTERESTS Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.
• Wallace, M. E., Grantz, K. L., Liu, D., Zhu, Y., Kim, S. S., & Mendola, P. (2016). Exposure to ambient air pollution and premature rupture of membranes. American Journal of Epidemiology, 183(Issue 12). doi:10.1093/aje/kwv284
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  Premature rupture of membranes (PROM) is a major factor that predisposes women to preterm delivery. Results from previous studies have suggested that there are associations between exposure to air pollution and preterm birth, but evidence of a relationship with PROM is sparse. Modified Community Multiscale Air Quality models were used to estimate mean exposures to particulate matter less than 10 μm or less than 2.5 μm in aerodynamic diameter, nitrogen oxides, carbon monoxide, sulfur dioxide, and ozone among 223,375 singleton deliveries in the Air Quality and Reproductive Health Study (2002-2008). We used log-linear models with generalized estimating equations to estimate adjusted relative risks and 95% confidence intervals for PROM per each interquartile-range increase in pollutants across the whole pregnancy, on the day of delivery, and 5 hours before delivery. Whole-pregnancy exposures to carbon monoxide and sulfur dioxide were associated with an increased risk of PROM (for carbon monoxide, relative risk (RR) = 1.09, 95% confidence interval (CI): 1.04, 1.14; for sulfur dioxide, RR = 1.15, 95% CI: 1.06, 1.25) but not preterm PROM. Ozone exposure increased the risk of PROM on the day of delivery (RR = 1.06, 95% CI: 1.02, 1.09) and 1 day prior (RR = 1.04, 95% CI: 1.01, 1.07). In the 5 hours preceding delivery, there were 3%-7% increases in risk associated with exposure to ozone and particulate matter less than 2.5 μm in aerodynamic diameter and inverse associations with exposure to carbon monoxide and nitrogen oxides. Acute and long-term air pollutant exposures merit further study in relation to PROM.
• Wallace, M. E., Hoyert, D., Williams, C., & Mendola, P. (2016). Pregnancy-associated homicide and suicide in 37 US states with enhanced pregnancy surveillance. American Journal of Obstetrics and Gynecology, 215(Issue 3). doi:10.1016/j.ajog.2016.03.040
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  Background Pregnant and postpartum women may be at increased risk of violent death including homicide and suicide relative to nonpregnant women, but US national data have not been reported since the implementation of enhanced mortality surveillance. Objective The objective of the study was to estimate homicide and suicide ratios among women who are pregnant or postpartum and to compare their risk of violent death with nonpregnant/nonpostpartum women. Study Design Death certificates (n = 465,097) from US states with enhanced pregnancy mortality surveillance from 2005 through 2010 were used to compare mortality among 4 groups of women aged 10–54 years: pregnant, early postpartum (pregnant within 42 days of death), late postpartum (pregnant within 43 days to 1 year of death), and nonpregnant/nonpostpartum. We estimated pregnancy-associated mortality ratios and compared with nonpregnant/nonpostpartum mortality ratios to identify differences in risk after adjusting for potential levels of pregnancy misclassification as reported in the literature. Results Pregnancy-associated homicide victims were most frequently young, black, and undereducated, whereas pregnancy-associated suicide occurred most frequently among older white women. After adjustments, pregnancy-associated homicide risk ranged from 2.2 to 6.2 per 100,000 live births, depending on the degree of misclassification estimated, compared with 2.5–2.6 per 100,000 nonpregnant/nonpostpartum women aged 10–54 years. Pregnancy-associated suicide risk ranged from 1.6–4.5 per 100,000 live births after adjustments compared with 5.3–5.5 per 100,000 women aged 10–54 years among nonpregnant/nonpostpartum women. Assuming the most conservative published estimate of misclassification, the risk of homicide among pregnant/postpartum women was 1.84 times that of nonpregnant/nonpostpartum women (95% confidence interval, 1.71–1.98), whereas risk of suicide was decreased (relative risk, 0.62, 95% confidence interval, 0.57–0.68). Conclusion Pregnancy and postpartum appear to be times of increased risk for homicide and decreased risk for suicide among women in the United States.
• Wallace, M. E., Mendola, P., Chen, Z., Hwang, B. S., & Grantz, K. L. (2016). Preterm Birth in the Context of Increasing Income Inequality. Maternal and Child Health Journal, 20(Issue 1). doi:10.1007/s10995-015-1816-9
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  Objective: Preterm birth is a leading cause of infant morbidity and mortality. Little is known about the contextual effect of US income inequality on preterm birth, an issue of increasing concern given that the current economic divide is the largest since 1928. Methods: We examined changes in inequality over time in relation to preterm birth among singleton deliveries from an electronic medical record-based cohort (n = 223,512) conducted in 11 US states and the District of Columbia from 2002 to 2008. Increasing income inequality was defined as a positive change in state-level Gini coefficient from the year prior to birth. Multi-level models estimated the independent effect of increasing inequality on preterm birth (>22 and
• Solivan, A. E., Wallace, M. E., Kaplan, K. C., & Harville, E. W. (2015). Use of a resiliency framework to examine pregnancy and birth outcomes among adolescents: A qualitative study. Families, Systems and Health, 33(Issue 4). doi:10.1037/fsh0000141
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  Introduction: Adolescent childbearing has been viewed as a social, political, and public health priority since the 1970s. Research has primarily focused on the negative consequences of teen pregnancy; less research has explored factors associated with healthy pregnancy and birth experiences in this population. Method: Using open-ended and qualitative techniques, researchers performed individual interviews with 15 adolescent mothers (15 to 19 years of age) recruited from a Women's and Children's Clinic in Southern Louisiana, who had experienced a healthy pregnancy and bore a full-term, normal birth weight infant. We used a resiliency framework to identify factors that may have supported positive health outcomes despite risks associated with low-income and/or marginalized minority status. Results: A total of 15 mothers of multiple racial/ethnic identities were included in the analysis. Mothers discussed potential protective factors that we classified as either assets (internal factors) or resources (external factors). Mothers demonstrated strong assets including self-efficacy and self-acceptance and important resources including familial support and partner support during pregnancy which may have contributed to their resiliency. Discussion: Ensuring access to social and structural supports as well as supporting adolescent-friendly health and social policies may be key to promoting healthy maternal and infant outcomes among young women who become pregnant.
• Wallace, M. E., Mendola, P., Liu, D., & Grantz, K. L. (2015). Joint effects of structural racism and income inequality on small-for-gestational-age birth. American Journal of Public Health, 105(Issue 8). doi:10.2105/ajph.2015.302613
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  Objectives. We examined potential synergistic effects of racial and socioeconomic inequality associated with small-for-gestational-age (SGA) birth. Methods. Electronic medical records from singleton births to White and Black women in 10 US states and the District of Columbia (n = 121 758) were linked to state-level indicators of structural racism, including the ratios of Blacks to Whites who were employed, were incarcerated, and had a bachelor's or higher degree. We used state-level Gini coefficients to assess income inequality. Generalized estimating equations models were used to quantify the adjusted odds of SGA birth associated with each indicator and the joint effects of structural racism and income inequality. Results. Structural racism indicators were associated with higher odds of SGA birth, and similar effects were observed for both races. The joint effects of racial and income inequality were significantly associated with SGA birth only when levels of both were high; in areas with high inequality levels, adjusted odds ratios ranged from 1.81 to 2.11 for the 3 structural racism indicators. Conclusions. High levels of racial inequality and socioeconomic inequality appear to increase the risk of SGA birth, particularly when they co-occur.
• Zhu, Y., Zhang, C., Liu, D., Grantz, K. L., Wallace, M., & Mendola, P. (2015). Maternal ambient air pollution exposure preconception and during early gestation and offspring congenital orofacial defects. Environmental Research, 140. doi:10.1016/j.envres.2015.06.002
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  Background: Maternal air pollution exposure has been related to orofacial clefts but the literature is equivocal. Potential chronic preconception effects have not been studied. Objectives: Criteria air pollutant exposure during three months preconception and gestational weeks 3-8 was studied in relation to orofacial defects. Methods: Among 188,102 live births and fetal deaths from the Consortium on Safe Labor (2002-2008), 63 had isolated cleft palate (CP) and 159 had isolated cleft lip with or without cleft palate (CL ±CP). Exposures were estimated using a modified Community Multiscale Air Quality model. Logistic regression with generalized estimating equations adjusted for site/region and maternal demographic, lifestyle and clinical factors calculated the odds ratio (OR) and 95% CI per interquartile increase in each pollutant. Results: Preconception, carbon monoxide (CO; OR=2.24; CI: 1.21, 4.16) and particulate matter (PM) ≤10μm (OR=1.72; CI: 1.12, 2.66) were significantly associated with CP, while sulfur dioxide (SO2) was associated with CL ±CP (OR=1.93; CI: 1.16, 3.21). During gestational weeks 3-8, CO remained a significant risk for CP (OR=2.74; CI: 1.62, 4.62) and nitrogen oxides (NOx; OR=3.64; CI: 1.73, 7.66) and PM ≤2.5μm (PM2.5; OR=1.74; CI: 1.15, 2.64) were also related to the risk. Analyses by individual week revealed that positive associations of NOx and PM2.5 with CP were most prominent from weeks 3-6 and 3-5, respectively. Conclusions: Exposure to several criteria air pollutants preconception and during early gestation was associated with elevated odds for CP, while CL ±CP was only associated with preconception SO2 exposure.
• Wallace, M. E., & Harville, E. W. (2013). Allostatic load and birth outcomes among white and black women in New Orleans. Maternal and Child Health Journal, 17(Issue 6). doi:10.1007/s10995-012-1083-y
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  As a marker of chronic stress, allostatic load has been theoretically recognized as a potential contributor to racial disparities in birth outcomes. The purpose of this investigation was to identify associations between allostatic load and birth outcomes and to assess differences in allostatic load and its relation to birth outcomes between white and black women. Blood samples from 123 women at 26-28 weeks gestation were assayed for cholesterol, glycosylated hemoglobin, dehydroepiandrosterone-sulfate, and cortisol, with 42 women having complete data on all biomarkers and birth outcomes. Together with systolic blood pressure, these biomarkers were combined to create an allostatic load index. Multiple linear regression models were used to evaluate associations between allostatic load index and gestational age, birth weight, birth weight ratio, birth length, and head circumference. Black women had a significantly lower allostatic load index than white women (P < 0.05). Gestational age was the only outcome significantly associated with allostatic load in both unadjusted and adjusted models (P < 0.05). Gestational age decreased significantly with increasing allostatic load (adjusted β -0.18, 95 % CI -0.35, 0.00). A significant interaction with age indicated that the effect was less strong at higher maternal ages (adjusted interaction β 0.04, 95 % CI 0.00, 0.08). There was no racial difference in the effect of allostatic load on birth outcomes. These findings represent possible evidence of the effect of stress age on gestational age. As a measure of cumulative disadvantage, allostatic load may prove to be a contributor to the racial disparities in birth outcomes. © 2012 Springer Science+Business Media, LLC.
• Wallace, M., & Saurel-Cubizolles, M. J. (2013). Returning to work one year after childbirth: Data from the mother-child cohort EDEN. Maternal and Child Health Journal, 17(Issue 8). doi:10.1007/s10995-012-1147-z
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  The amount of time women spend out of work postpartum has implications for both health and economic trajectories which may result in long-term social inequities or exacerbate those already existing. The purpose of this investigation was to describe the characteristics of women who return to work within the first year postpartum and to identify specific occupational and health factors associated with returning to work among women who worked during pregnancy. The EDEN cohort is comprised of pregnant women recruited in two French university hospitals before 24 weeks gestation with a singleton pregnancy. Questionnaires were administered at 4, 8, and 12 months after birth. Multivariate logistic regression was used to model the odds of returning to work within 1 year of childbirth with inclusion of sociodemographic, health, and occupational variables that were significantly related to returning to work at the level of p < 0.05 in bivariate analysis. Eighty percent of the women who worked during pregnancy in our sample had resumed work before their infant's first birthday. After adjustment, occupational level, full-time work, standing position, job reward, desire to change job, education, and father's occupational level remained significantly associated with returning to work. Women's perception of their work as rewarding was the strongest predictor of resuming employment (OR comparing high reward to low reward: 2.48, 95 % CI: 1.60-3.83 for women with parity 0 or 1). Experiencing an adverse birth outcome had no relation to returning to work within 1 year postpartum. Across all indicator variables, women of higher socioeconomic status or with greater resources had greater odds of returning to work compared to those of lower status. This suggests that the crucial period of employment transition around the time of childbirth may intensify preexisting social inequalities. © 2012 Springer Science+Business Media New York.
• Wallace, M., Harville, E., Theall, K., Webber, L., Chen, W., & Berenson, G. (2013). Neighborhood poverty, allostatic load, and birth outcomes in African American and white women: Findings from the Bogalusa Heart Study. Health and Place, 24. doi:10.1016/j.healthplace.2013.10.002
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  As a biologically-mediated pathway between adversity and declines in physical health, allostatic load has been frequently hypothesized as a potential contributor to racial disparities in birth outcomes, but an empirical evidence is lacking. The purpose of this study was to examine the relationships between maternal preconception allostatic load, race, and adverse birth outcomes within the context of neighborhood-level poverty using data from the Bogalusa Heart Study. Allostatic load was quantified as a count of regulatory biomarkers falling in the highest risk quartile of the sample distribution as measured from a physical examination that took place prior to conception. Consistent with previous findings, African American women resided in more impoverished neighborhoods and had higher allostatic load scores compared to whites; however, allostatic load was not associated with preterm birth or low birth weight in fully adjusted models. These results underscore a need for further refinement of both biologic and contextual measures that capture holistically the way in which stressful conditions and experiences encountered across the life-course influence health potentials and engender inequities in reproductive health outcomes. © 2013 Elsevier Ltd.
• Wallace, M., Harville, E., Theall, K., Webber, L., Chen, W., & Berenson, G. (2013). Preconception biomarkers of allostatic load and racial disparities in adverse birth outcomes: The Bogalusa heart study. Paediatric and Perinatal Epidemiology, 27(Issue 6). doi:10.1111/ppe.12091
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  Background Large disparities in adverse birth outcomes persist between African American and white women in the US despite decades of research, policy, and public health intervention. Allostatic load is an index of dysregulation across multiple physiologic systems that results from chronic exposure to stress in the physical and socio-cultural environment which may lead to earlier health deterioration among racially or socio-economically disadvantaged groups. The purpose of this investigation was to examine relationships between maternal biomarkers of allostatic load prior to conception and the occurrence of preterm birth and small for gestational age infants among a cohort of white and African American women participants in the Bogalusa Heart Study. Methods Data from women participants were linked to the birth record of their first-born infant. Principal components analysis was used to construct an index of allostatic load as a summary of the weighted contribution of nine biomarkers representing three physiologic domains: cardiovascular, metabolic, and immune systems. A series of Poisson regression models based on samples ranging from 1467 to 375 women were used to examine race, individual biomarkers of allostatic load, and quartiles of the allostatic load index as predictors of preterm birth (n = 150, 10.2%) and small for gestational age (n = 135, 9.2%). Results There was no evidence of a relationship between maternal preconception allostatic load and either adverse birth outcome in this sample. Further, there was no evidence of effect modification of by race or education. Conclusions More work is needed in understanding the biological mechanisms linking social inequities to racial disparities in adverse birth outcomes. © 2013 John Wiley & Sons Ltd.
• Wallace, M. E., & Harville, E. W. (2012). Predictors of Healthy Birth Outcome in Adolescents: A Positive Deviance Approach. Journal of Pediatric and Adolescent Gynecology, 25(Issue 5). doi:10.1016/j.jpag.2012.05.010
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  Study Objective: Pregnant adolescents experience elevated rates of adverse birth outcomes compared to older mothers. Positive deviance inquiry is the identification of uncommon behaviors and traits that result in better health outcomes for individuals in a population that shares similar risks. The purpose of our study was to utilize a positive deviance framework to identify sociodemographic and behavioral characteristics associated with a healthy birth outcome among adolescents. Design: This is a retrospective cohort study design. Setting: We performed a secondary data analysis of vital records data from the State of Louisiana between January 1, 1995 and December 31, 2007. Participants: Data included birth certificates from 35,013 Louisiana mothers age ≤19. Main Outcome Measure: A healthy birth was defined as having an infant of weight between 2500 g and 4000 g, delivered vaginally without induction or instrumented delivery and in the absence of pregnancy, obstetric, or neonatal complications and anomalies. Results: Twenty-one percent of the study population was classified as positive deviants with healthy births. Multivariate log-linear regression was used to model predictors of healthy birth. Adolescents who were older, non-black, multiparous, non-smoking, married, gained a medium amount of weight, had a longer inter-pregnancy interval or received adequate prenatal care were most likely to experience a healthy pregnancy and birth. Ethnicity, alcohol use, father's information on the birth certificate and paternal characteristics did not significantly predict a positive birth outcome. Conclusion: Characterizing positive deviant adolescents may help identify special populations for targeted intervention and important modifiable behaviors for the promotion of better birth outcomes in all young mothers. © 2012 North American Society for Pediatric and Adolescent Gynecology.