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Racial Residential Segregation and Preterm Birth: Built Environment as a Mediator

Anthopolos, Rebeccaa; Kaufman, Jay S.b; Messer, Lynne C.c; Miranda, Marie Lynna,d

doi: 10.1097/EDE.0000000000000079

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.

Conclusion: 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.

Supplemental Digital Content is available in the text.

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.

The authors report no conflicts of interest.

Supported by the US Environmental Protection Act (grant number RD-83329301).

Supplemental digital content is available through direct URL citations in the HTML and PDF versions of this article ( This content is not peer-reviewed or copy-edited; it is the sole responsibility of the author.

Correspondence: Rebecca Anthopolos, School of Natural Resources and Environment, University of Michigan, 4036 Dana Building, Ann Arbor, MI 48109. E-mail:

© 2014 by Lippincott Williams & Wilkins, Inc