title: Using an External Exposome Framework to Examine Pregnancy-Related Morbidities and Mortalities: Implications for Health Disparities Research.
abstract: OBJECTIVE
  We have conducted a study to assess the role of environment on the burden of maternal morbidities and mortalities among women using an external exposome approach for the purpose of developing targeted public health interventions to decrease disparities.
  
  
  METHODS
  We identified counties in the 48 contiguous USA where observed low birthweight (LBW) rates were higher than expected during a five-year study period. The identification was conducted using a retrospective space-time analysis scan for statistically significant clusters with high or low rates by a Discrete Poisson Model.
  
  
  RESULTS
  We observed statistically significant associations of LBW rate with a set of predictive variables. However, in one of the two spatiotemporal models we discovered LBW to be associated with five predictive variables (teen birth rate, adult obesity, uninsured adults, physically unhealthy days, and percent of adults who smoke) in two counties situated in Alabama after adjusting for location changes. Counties with higher than expected LBW rates were similarly associated with two environmental variables (ozone and fine particulate matter).
  
  
  CONCLUSIONS
  The county-level predictive measures of LBW offer new insights into spatiotemporal patterns relative to key contributory factors. An external framework provides a promising place-based approach for identifying "hotspots" with implications for designing targeted interventions and control measures to reduce and eliminate health disparities.
authors.affiliation: Research Center on Health Disparities, Equity &amp; the Exposome, Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA. toyana@uthsc.edu.
authors.forename: Tonny J
authors.initials: TJ
authors.lastname: Oyana
authors.affiliation: Pediatrics, Infectious Disease and Microbiology, Immunology &amp; Biochemistry, University of Tennessee Health Science Center, Le Bonheur Children's Medical Center, Memphis, TN 36163, USA. pmatthews-juarez@mmc.edu.|Department of Family and Community Medicine, Meharry Medical College, Nashville, TN 37208, USA. pmatthews-juarez@mmc.edu.
authors.forename: Patricia
authors.initials: P
authors.lastname: Matthews-Juarez
authors.affiliation: Pediatrics, Infectious Disease and Microbiology, Immunology &amp; Biochemistry, University of Tennessee Health Science Center, Le Bonheur Children's Medical Center, Memphis, TN 36163, USA. scormier@uthsc.edu.
authors.forename: Stephania A
authors.initials: SA
authors.lastname: Cormier
authors.affiliation: Pediatrics, Infectious Disease and Microbiology, Immunology &amp; Biochemistry, University of Tennessee Health Science Center, Le Bonheur Children's Medical Center, Memphis, TN 36163, USA. xxu24@uthsc.edu.
authors.forename: Xiaoran
authors.initials: X
authors.lastname: Xu
authors.affiliation: Pediatrics, Infectious Disease and Microbiology, Immunology &amp; Biochemistry, University of Tennessee Health Science Center, Le Bonheur Children's Medical Center, Memphis, TN 36163, USA. pjuarez@mmc.edu.|Department of Family and Community Medicine, Meharry Medical College, Nashville, TN 37208, USA. pjuarez@mmc.edu.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Juarez
mesh_terms: D000293:Adolescent; D000328:Adult; D000407:Alabama / Q000453:epidemiology; D005260:Female; D054625:Healthcare Disparities / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D007234:Infant, Premature; D009017:Morbidity; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology* / Q000401:mortality*; D011256:Pregnancy Outcome / Q000453:epidemiology*; D037841:Pregnant People; D047928:Premature Birth / Q000453:epidemiology; D015995:Prevalence; D012111:Residence Characteristics; D012189:Retrospective Studies; D012307:Risk Factors; D012959:Socioeconomic Factors; D055815:Young Adult
keywords: discrete Poisson model; external exposome; geographic information systems; health disparities; infant mortality; low birthweight; maternal mortality; pregnancy outcomes; premature birth