ArticleO&G open2026
Multilevel Intersectional Social Drivers of Health and Nulliparous Term, Singleton, Vertex Cesarean Delivery.
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15 authors.
Jameaka L HamiltonDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
William A GrobmanDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Jiqiang WuDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Lynn M YeeDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
David M HaasDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Becky McneilDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Jessica WilderDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Hyagriv SimhanDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Uma M ReddyDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Robert M SilverDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Lisa LevineDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
George SaadeDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Jun WuDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Courtney D LynchDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Kartik K VenkateshDepartment of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island; Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois; Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana; RTI International, Durham, North Carolina; Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio; Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Yale University, New Haven, Connecticut; Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah; Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Obstetrics and Gynecology, EVMS, Norfolk, Virginia; and Department of Environmental and Occupational Health, University of California, Irvine, Orange, California.
Funding
Indiana Clinical and Translational Sciences InstituteUL1TR001108 · NCATS · INDIANA UNIVERSITY INDIANAPOLIS · PI DENNE, SCOTT C., SHEKHAR, ANANTHA · 2013 to 2017
$23.3MPreterm Birth in Nulliparous Women: An Understudied Population at Great RiskU10HD063036 · NICHD · RESEARCH TRIANGLE INSTITUTE · PI PARKER, CORETTE BREEDEN · 2010 to 2015
$19.5MInstitute for Clinical and Translational ScienceUL1TR000153 · NCATS · UNIVERSITY OF CALIFORNIA-IRVINE · PI COOPER, DAN M · 2012 to 2015
$12.1MPrevention of Preterm Birth in high Risk Nulliparous PatientsU10HD063047 · NICHD · COLUMBIA UNIVERSITY HEALTH SCIENCES · PI WAPNER, RONALD · 2010 to 2014
$1.9MPreterm Birth in Nulliparous Women: An Understudied Population at Great RiskU10HD063053 · NICHD · UNIVERSITY OF UTAH · PI SILVER, ROBERT M. · 2010 to 2014
$1.7MPreterm Birth in Nulliparous Women: An Understudied Population at Great Risk U10HD063020 · NICHD · NORTHWESTERN UNIVERSITY AT CHICAGO · PI GROBMAN, WILLIAM ADAM · 2010 to 2014
$1.6MPreterm Birth in Nulliparous Women: An Understudied Population at Great RiskU10HD063046 · NICHD · UNIVERSITY OF CALIFORNIA-IRVINE · PI WING, DEBORAH A · 2010 to 2014
$1.6MPreterm Birth in Nulliparous Women: An Understudied Population at Great RiskU10HD063041 · NICHD · MAGEE-WOMEN'S RES INST AND FOUNDATION · PI SIMHAN, HYAGRIV N · 2010 to 2014
$1.5MPreterm Birth in Nulliparous Women: An Understudied Population at Great RiskU10HD063048 · NICHD · UNIVERSITY OF PENNSYLVANIA · PI PARRY, SAMUEL I. · 2010 to 2014
$1.5MDissecting the Genetic Etiology of Preterm Birth in Nulliparous WomenU10HD063037 · NICHD · INDIANA UNIVERSITY INDIANAPOLIS · PI HAAS, DAVID M. · 2010 to 2014
$1.2MAdverse Outcomes in Nulliparous Pregnancies: The Ohio CollaborativeU10HD063072 · NICHD · CASE WESTERN RESERVE UNIVERSITY · PI MERCER, BRIAN M. · 2010 to 2014
$1.2MNCATS NIH HHS UL1 TR000153NCATS NIH HHS UL1 TR001108NICHD NIH HHS U10 HD063020NICHD NIH HHS U10 HD063036NICHD NIH HHS U10 HD063037NICHD NIH HHS U10 HD063041NICHD NIH HHS U10 HD063046NICHD NIH HHS U10 HD063047NICHD NIH HHS U10 HD063048NICHD NIH HHS U10 HD063053NICHD NIH HHS U10 HD063072
Abstract
objectiveTo examine the intersectionality of three frequently measured neighborhood social determinants during pregnancy-socioeconomic disadvantage, food access, and walkability-and their collective association with nulliparous term, singleton, vertex (NTSV) cesarean delivery.
methodsThis was a secondary analysis of data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be observational cohort. Home addresses in the first trimester were geocoded at the census-tract level to define three adverse neighborhood measures: 1) socioeconomic disadvantage by the Area Deprivation Index (in tertiles), 2) low food access by the U.S. Department of Agriculture
resultsAmong 8,010 nulliparous individuals with NTSV deliveries, 27.3% lived in a neighborhood in the top tertile of socioeconomic disadvantage, 24.5% with low food access, and 66.4% with low walkability. The risk of NTSV cesarean delivery was higher only among individuals living in neighborhoods with low walkability (adjusted relative risk [RR] 1.17, 95% CI, 1.06-1.28). Individuals exposed to one (adjusted RR 1.14, 95% CI, 1.01-1.27) or two or more (adjusted RR 1.19, 95% CI, 1.06-1.34) compared with no adverse neighborhood social determinants had a higher risk of cesarean delivery. Individuals living in neighborhoods with low walkability and high socioeconomic disadvantage (adjusted RR 1.21, 95% CI, 1.03-1.41) or low walkability and low food access (adjusted RR 1.20, 95% CI, 1.05-1.37) had a higher risk of cesarean delivery. The frequency of all three adverse neighborhood social determinants was higher for non-Hispanic Black and Hispanic individuals compared with non-Hispanic White individuals (
conclusionIn a prospective U.S. cohort, living in a neighborhood with low walkability, alone and in combination with socioeconomic disadvantage and food access, was associated with an increased risk of NTSV cesarean delivery.
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