Abstract
BACKGROUND: While there is growing evidence of the negative impact of neighborhood segregation on maternal and infant health, the evidence for stillbirth is limited. METHODS: A retrospective cohort study of live births and stillbirths for 2007-2020 was conducted in greater Houston, TX, to examine the associations of racialized economic segregation, assessed using the Index of Concentrations at the Extremes (ICE), with stillbirth. Here, ICE contrasted census tract-level racial and economic privilege with disadvantage (i.e., high-income non-Hispanic White persons vs. low-income Persons of Color). Additionally, Oaxaca-Blinder decomposition methods were applied to examine the degree to which segregation and maternal risk factors explained observed racial disparities in stillbirth. RESULTS: The prevalence of stillbirth was highest among non-Hispanic Black mothers (9.1/1000) compared with Hispanic mothers (4.7/1000), non-Hispanic White mothers (3.8/1000), and mothers whose race or ethnicity was unknown or classified as other (3.7/1000). In models adjusted for age, pre-pregnancy body mass index (BMI), smoking during pregnancy, and education, odds of stillbirth were reduced for non-Hispanic White mothers living in the most privileged neighborhoods (OR = 0.82, 95% CI 0.60, 1.12 for ICE tertile 3 vs. ICE tertile 1). In contrast, residing in more privileged neighborhoods did not confer the same benefit for mothers of other racial and ethnic groups. Based on the decomposition analysis, maternal age, education, pre-pregnancy BMI, smoking, and ICE explained 21.2% of the disparity in stillbirth between non-Hispanic Black and non-Hispanic White mothers; of which, having a high school education or less (12.3%), living in the most privileged neighborhoods (9.7%), and being obese (7.2%) contributed the most. CONCLUSIONS: Neighborhood privilege appears to confer benefits for White mothers but not for non-White mothers, potentially due to experiences of racial discrimination that offset economic advantages. While racialized economic segregation contributed modestly to Black-White disparities in stillbirth, much of the disparity remains unexplained by the factors examined. Future research should explore additional individual- and neighborhood-level contributors to these disparities while addressing inequities to reduce stillbirth risks across all populations.