title: Neighborhood contextual factors, maternal smoking, and birth outcomes: multilevel analysis of the South Carolina PRAMS survey, 2000-2003.
abstract: BACKGROUND
  Previous studies investigating relationships among neighborhood contexts, maternal smoking behaviors, and birth outcomes (low birth weight [LBW] or preterm births) have produced mixed results.
  
  
  METHODS
  We evaluated independent effects of neighborhood contexts on maternal smoking behaviors and risks of LBW or preterm birth outcomes among mothers participating in the South Carolina Pregnancy Risk Assessment and Monitoring System (PRAMS) survey, 2000-2003. The PRAMS data were geocoded to 2000 U.S. Census data to create a multilevel data structure. We used a multilevel regression analysis (SAS PROC GLIMMIX) to estimate odds ratios (OR) and corresponding 95% confidence intervals (CI).
  
  
  RESULTS
  In multivariable logistic regression models, high poverty, predominantly African American neighborhoods, upper quartiles of low education, and second quartile of neighborhood household crowding were significantly associated with LBW. However, only mothers resident in predominantly African American Census tract areas were statistically significantly at an increased risk of delivering preterm (OR 2.2, 95% CI 1.29-3.78). In addition, mothers resident in medium poverty neighborhoods remained modestly associated with smoking after adjustment for maternal-level covariates. The results also indicated that maternal smoking has more consistent effects on LBW than preterm births, particularly for mothers living in deprived neighborhoods.
  
  
  CONCLUSIONS
  Interventions seeking to improve maternal and child health by reducing smoking during pregnancy need to engage specific community factors that encourage maternal quitting behaviors and reduce smoking relapse rates. Inclusion of maternal-level covariates in neighborhood models without careful consideration of the causal pathway might produce misleading interpretation of the results.
authors.affiliation: School of Human Sciences/Colorado School of Public Health, University of Northern Colorado, Greeley, Colorado 80639, USA. snamankrasc@lycos.com
authors.forename: Stephen
authors.initials: S
authors.lastname: Nkansah-Amankra
mesh_terms: D000328:Adult; D019352:Censuses; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D006306:Health Surveys; D006801:Humans; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D016015:Logistic Models; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000208:ethnology; D047928:Premature Birth / Q000208:ethnology; D012111:Residence Characteristics; D018570:Risk Assessment; D012907:Smoking / Q000009:adverse effects* / Q000208:ethnology; D013022:South Carolina; D011795:Surveys and Questionnaires; D055815:Young Adult