title: The joint influence of area income, income inequality, and immigrant density on adverse birth outcomes: a population-based study.
abstract: BACKGROUND
  The association between area characteristics and birth outcomes is modified by race. Whether such associations vary according to social class indicators beyond race has not been assessed.
  
  
  METHODS
  This study evaluated effect modification by maternal birthplace and education of the relationship between neighbourhood characteristics and birth outcomes of newborns from 1999-2003 in the province of Québec, Canada (N = 353,120 births). Areas (N = 143) were defined as administrative local health service delivery districts. Multi-level logistic regression was used to model the association between three area characteristics (median household income, immigrant density and income inequality) and the two outcomes preterm birth (PTB) and small-for-gestational age (SGA) birth. Effect modification by social class indicators was evaluated in analyses stratified according to maternal birthplace and education.
  
  
  RESULTS
  Relative to the lowest tertile, high median household income was associated with SGA birth among Canadian-born mothers (odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06, 1.20) and mothers with high school education or less (OR 1.13, 95% CI 1.02, 1.24). Associations between median household income and PTB were weaker. Relative to the highest tertile, low immigrant density was associated with a lower odds of PTB among foreign-born mothers (OR 0.79, 95% CI 0.63, 1.00) but a higher odds of PTB among Canadian-born mothers (OR 1.14, 95% CI 1.07, 1.21). Associations with income inequality were weak or absent.
  
  
  CONCLUSIONS
  The association between area factors and birth outcomes is modified by maternal birthplace and education. Studies have found that race interacts in a similar manner. Public health policies focussed on perinatal health must consider the interaction between individual and area characteristics.
authors: Unité Etudes et Analyses de l'Etat de Santé de la Population, Institut National de Santé Publique du Québec, Montréal, Québec, Canada. nathalie.auger@inspq.qc.ca
authors: Nathalie
authors: N
authors: Auger
authors: Julie
authors: J
authors: Giraud
authors: Mark
authors: M
authors: Daniel
mesh_terms: D000328:Adult; D004522:Educational Status; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data*; D005260:Female; D054624:Health Status Disparities; D006801:Humans; D007182:Income; D007231:Infant, Newborn; D007236:Infant, Small for Gestational Age; D016015:Logistic Models; D008297:Male; D009035:Mothers; D016017:Odds Ratio; D011156:Population Density; D047928:Premature Birth / Q000453:epidemiology*; D011792:Quebec / Q000453:epidemiology; D012111:Residence Characteristics; D012923:Social Class; D055815:Young Adult