摘要：Objectives. We assessed the longitudinal association between housing transitions and pregnancy outcomes in a sample of public housing residents. Methods. A cohort of 2670 Black women residing in Atlanta, Georgia, housing projects with 1 birth occurring between 1994 and 2007 was created from maternally linked longitudinal birth files and followed for subsequent births. Traditional regression and marginal structural models adjusting for time-varying confounding estimated the risk of preterm low birth weight (LBW) or small for gestational age LBW by maternal housing transition patterns. Results. Women moving from public to private housing as a result of housing project demolition were at elevated risk for preterm LBW (risk ratio = 1.74; 95% confidence interval = 1.00–3.04) compared with women not affected by project demolition. Other non–policy-related housing transition patterns were not associated with pregnancy outcomes. Conclusions. Further longitudinal study of housing transitions among public housing residents is needed to better understand the relationship between housing, neighborhoods, housing policy, and perinatal outcomes. Under the auspices of Roosevelt’s New Deal in 1936, Atlanta, Georgia, led the nation by establishing Techwood Homes as the first public housing project in the United States. 1 Initially envisioned as a tool for economic development, public housing evolved nationally into a critical and often criticized component of the social safety net. Although meeting demands for affordable housing, the location, design, and regulation of some high-density public housing projects in US metropolitan areas have also contributed to persistent racial residential segregation and the concentration of poverty. 2,3 In 1992, Congress passed the Housing Opportunities for People Everywhere initiative to support, in part, the redevelopment and deconcentration of traditional public housing projects. Before the 1996 Summer Olympics in Atlanta, the Atlanta Housing Authority (AHA) once again led the nation by initiating a decommissioning and demolition process for 29 of Atlanta’s distressed family occupied public housing projects, 4 replacing them with mixed-income housing developments and transitioning most public housing recipients to Housing Choice Vouchers (formerly Section 8) for use in the private rental market. 5 Residence in high poverty neighborhoods has been associated with poor health outcomes, 6,7 but it is not clear whether the voluntary or involuntary transition of individuals out of traditional housing projects results in lower poverty destination neighborhoods, and if so, whether this improves health. There are mixed findings with regards to health following voluntary residential mobility interventions such as Moving to Opportunity. 8–10 The persistence of racial and economic disparities in pregnancy outcomes, including the 2 main components of infant low birth weight (LBW)—preterm birth (< 37 weeks’ gestation) and fetal growth restriction—have been widely described. Such disparities are hypothesized to exist in part because of the sensitivity of pregnancy to acute and cumulative social exposures and determinants. 11–13 In particular, residential neighborhood characteristics, including violent crime, income inequality, residential segregation, and deprivation, explain some of the racial disparities in poor pregnancy outcomes. 14–18 Social, behavioral, and medical risk factors for poor outcomes may interact through various pathways, including access to preconceptional primary care and perinatal care, accessibility of healthy foods and safe environments for physical activity, physiologic effects of accumulated exposure to stressors, or behavioral response (e.g., smoking) to stressors and targeted tobacco and alcohol marketing. Women residing in public housing projects generally have high health burdens 19 and may be exposed to chronic stress from high crime and poverty rates. However, residence in housing project communities could also be a source of social support networks and result in access to targeted social and health services. There are similarities in the identified risk factors for preterm birth and fetal growth restriction (commonly operationalized as small for gestational age or < 10th percentile of weight for gestational age 20 ). However, the relative importance of hypothesized etiologic factors such as smoking, stress, and reproductive tract infection differs for each outcome. For instance, smoking, low maternal weight gain, and pregnancy-induced hypertension may be more important population drivers of small for gestational age risk, whereas inflammation or infection and chronic stress may be relatively more important for preterm birth. 21 These factors could be variably influenced by housing and neighborhood characteristics, including local access to health services and healthy foods, local social networks and support, and exposure to stressful environments. This study aims to take advantage of a unique longitudinal data set and a significant change in public housing policy to answer 2 research questions. (1) Are housing transition patterns of women ever residing in public housing projects associated with subsequent pregnancy outcomes? (2) Is housing transition resulting from public housing project decommissioning associated with subsequent pregnancy outcomes?
