Neighborhood Safety Key SDOH in Maternal, Infant Outcomes

June 01, 2023 - In terms of maternal and infant outcomes, neighborhood is everything, with a new JAMA Network Open research note outlining poor perceived neighborhood safety can result in low birth weight, likelihood of perinatal depression, and lower prenatal care access.

Collectively, these poor maternal and infant outcomes could contribute to the nation’s maternal infant health crisis, the researchers said.

It’s already accepted that the United States does not perform well in maternal in infant health. Seminal research from The Commonwealth Foundation showed that the US has the worst maternal health outcomes in the developed world. And according to the JAMA researchers, neighborhood has something to do with that.

Previous data has shown that neighborhood-level exposure to certain risk factors can lead to low birth weight, preterm birth, smaller babies, perinatal depression, and inadequate prenatal care access. Neighborhood safety, an element of neighborhood as a social determinant of health, contributes to that, the researchers added.

Perceived neighborhood safety can affect certain clinical measures like blood pressure, stress levels, lower physical activity levels, smoking, and consumption of alcohol, all of which can impact the health of the baby and patient.

This latest study, which assessed survey responses about perceived neighborhood safety in the Pregnancy Risk Assessment Monitoring System and birth outcomes, found that neighborhood safety—plus interpersonal or domestic violence—is linked not just to certain clinical states, but to overall birth outcomes.

Overall, most (78 percent) survey respondents said they always felt safe in their neighborhoods and another 13.7 percent said they rarely felt unsafe.

But for the 5.3 percent who sometimes felt unsafe and the 3 percent who often or always felt unsafe, there were consequences for birth outcomes.

Indeed, birthing people responded with some adverse outcomes regardless of their perceived neighborhood safety; 6.5 percent had babies with low birth weights and nearly a fifth reported perinatal depression. But for those who said they always or often felt unsafe, those outcomes were more likely.

Folks reporting less perceived neighborhood safety were 23 percent more likely to have a baby with low birth weight and 100 percent more likely to experience perinatal depressive symptoms. Meanwhile, they were 10 percent less likely to have adequate prenatal care access, defined as attending more than 8 prenatal care visits.

Importantly, the researchers stressed that their study could not prove causation and did not posit what drives the link between perceived neighborhood safety and maternal or infant outcomes.

But they did note that improving patient access to trauma-informed care through tailored neighborhood-level approaches could offer up one solution.

Moreover, the team advocated for social determinants of health interventions, particularly those that target poverty and income, over clinical interventions.

“Social and economic interventions designed to combat neighborhood and domestic violence may be more beneficial in reducing adverse pregnancy outcomes than biomedical interventions,” they wrote in the study’s discussion. “To more effectively support the health of pregnant people and their families, we need to invest in strengthening low-income communities, including resources for community-based violence prevention and mental health support.”

Healthcare organizations may consider some of the social determinants of health screening tools validated for assessing intimate partner violence and neighborhood safety.

The American Academy of Family Physicians (AAFP) has cited a US Preventive Services Task Force (USPSTF) recommendation for screening women of reproductive age and older or vulnerable adults for intimate partner violence. USPSTF suggested using the following screenings for women of reproductive age:

• Humiliation, Afraid, Rape, Kick (HARK)
• Hurt/Insult/Threaten/Scream (HITS)
• Extended-Hurt/Insult/Threaten/Scream (E-HITS)
• Partner Violence Screen (PVS)
• Woman Abuse Screening Tool (WAST)

However, USPSTF acknowledged there are scant validated tools for older or vulnerable adults in primary care settings.

There are also a handful of screenings for neighborhood violence:

• HealthBegins Upstream Risk Screening Tool: This screening tool asks whether patients have concerns about safety in their neighborhood.
• PRAPARE: This screening asks if patients feel physically and emotionally safe where they currently live.
• Structural Vulnerability Assessment Tool: This screening asks multiple questions, including about perceived safety, exposure to violence, exposure to drug use or criminal activity, comfort walking around at night, and experiences being attacked or mugged.
• WellRx Toolkit: This screening asks whether patients feel unsafe in their daily lives.
• Kaiser Permanente’s Your Current Life Situation Survey: This screening asks whether patients have any concerns about their current living situation, including housing safety and costs.

Through screening, healthcare providers may begin individual-level SDOH interventions with the goal of improving infant and maternal health outcomes.