title: Racial residential segregation and preterm birth: built environment as a mediator.
abstract: BACKGROUND
  Racial residential segregation has been associated with preterm birth. Few studies have examined mediating pathways, in part because, with binary outcomes, indirect effects estimated from multiplicative models generally lack causal interpretation. We develop a method to estimate additive-scale natural direct and indirect effects from logistic regression. We then evaluate whether segregation operates through poor-quality built environment to affect preterm birth.
  
  
  METHODS
  To estimate natural direct and indirect effects, we derive risk differences from logistic regression coefficients. Birth records (2000-2008) for Durham, North Carolina, were linked to neighborhood-level measures of racial isolation and a composite construct of poor-quality built environment. We decomposed the total effect of racial isolation on preterm birth into direct and indirect effects.
  
  
  RESULTS
  The adjusted total effect of an interquartile increase in racial isolation on preterm birth was an extra 27 preterm events per 1000 births (risk difference = 0.027 [95% confidence interval = 0.007 to 0.047]). With poor-quality built environment held at the level it would take under isolation at the 25th percentile, the direct effect of an interquartile increase in isolation was 0.022 (-0.001 to 0.042). Poor-quality built environment accounted for 35% (11% to 65%) of the total effect.
  
  
  CONCLUSIONS
  Our methodology facilitates the estimation of additive-scale natural effects with binary outcomes. In this study, the total effect of racial segregation on preterm birth was partially mediated by poor-quality built environment.
authors.affiliation: From the aSchool of Natural Resources and Environment, University of Michigan, Ann Arbor, MI; bDepartment of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; cSchool of Community Health, Portland State University, Portland, OR; and dDepartment of Pediatrics, University of Michigan, Ann Arbor, MI.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Anthopolos
authors.forename: Jay S
authors.initials: JS
authors.lastname: Kaufman
authors.forename: Lynne C
authors.initials: LC
authors.lastname: Messer
authors.forename: Marie Lynn
authors.initials: ML
authors.lastname: Miranda
mesh_terms: D001719:Birth Certificates; D016001:Confidence Intervals; D016208:Databases, Factual; D004777:Environment; D005260:Female; D054624:Health Status Disparities; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D009657:North Carolina; D011247:Pregnancy; D047928:Premature Birth / Q000453:epidemiology / Q000208:ethnology*; D063505:Racism / Q000706:statistics & numerical data*; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012934:Social Isolation; D012959:Socioeconomic Factors