Public housing in the United States is an oft-criticized component of the nation’s social fabric. The high-density public housing projects in metropolitan areas have contributed to persistent racial residential segregation and concentration of poverty. Residence in high-poverty neighborhoods has been associated with poor health outcomes, but it is not clear whether the voluntary or involuntary transition of individuals out of housing projects results in lower poverty destination neighborhoods and whether this improves health. This retrospective study was undertaken to determine whether housing transition patterns of women ever residing in public housing projects are associated with subsequent pregnancy outcomes and whether housing transitions resulting from public housing project decommissioning are associated with subsequent pregnancy outcomes.
A retrospective cohort of women residing in Atlanta public housing at the time of at least 1 birth was followed up for subsequent births, with pregnancy outcomes contrasted among women with different interpregnancy residential transitions. Maternal longitudinally linked birth data were obtained for all live births to Georgia residents from 1994 to 2007. Geocoded birth records were combined with maps of all family-type public housing projects administered by the Atlanta Housing Authority to identify every birth event recorded to a mother residing in public housing between 1994 and 2007. Cohort eligibility was established with a woman’s first measured birth in traditional projects, and each woman was followed up for all subsequent births and residences. The main focus was the effect of longitudinal housing change, that is, public → public, public → private, or private → private, on later pregnancy outcomes. Women were considered “exposed” to a policy-induced housing transition if they had a birth while living in public housing within 1 year before that project was closed and then another birth while living in a different project or private housing. Outcomes were defined as preterm low birth weight (LBW; <37 weeks’ gestation, <2500 g) and small-for-gestational-age (SGA) LBW (<10th percentile weight for age, <2500 g).
The final analysis included 4616 birth transition pairs to 2670 unique women, of whom 36% had 1 follow-up birth after the baseline birth, and 49% had 2 or 3 follow-up births. The risks of preterm LBW and SGA LBW were 8.6% and 6.4%, respectively. For housing transitions, 37%, 39%, and 21% of births occurred to mothers with public → public, public → private, and private → private transitions, respectively. Preterm LBW occurred most often among women with the private → private pattern (11.6%), whereas women with the public → public pattern had the highest risk for SGA LBW (7.8%). Compared with women not exposed to policy-induced housing transition, exposed women had a higher risk for preterm LBW (P = 0.011) but not SGA LBW (P = 0.71). Residents of public housing projects lived in tracts with high segregation (mean tract = 91.5% black) and poverty (mean tract poverty rate = 42%). Women who moved from the public to the private market housing had an average 31% decrease in neighborhood poverty rate but only a 0.1% decrease in tract percentage black. A consistently null association was found between preterm LBW and women with public → private patterns compared with public → public patterns, whereas women who had 2 consecutive births in the private market had a modestly elevated risk compared with public → public patterns. For SGA LBW, public → private and private → private patterns showed lower risk than did public → public patterns.
Recognizing the importance of structural and social determinants of population health and the role of residential place in the distribution of health-related exposures suggests that greater attention should be paid to residential mobility and housing policy as health determinants. Further examination of the health impact of housing policy is needed. Understanding residential mobility and housing policies and their effects on discrimination in poverty concentration and residential segregation could ultimately lead to better interventions to reduce health disparities.
Departments of Epidemiology (M.R.K., C.R.H.) and Biostatistics and Bioinformatics (L.A.W.), Rollins School of Public Health; and Department of Family and Preventive Medicine (A.L.D.), School of Medicine, Emory University, Atlanta, GA