Associations between neighborhood violence during pregnancy and birth outcomes: evidence from Sao Paulo's Western Region Birth Cohort

BACKGROUND: Low birth weight and prematurity remain leading causes of infant mortality and morbidity globally. Although extensive literature has highlighted the importance of socioenvironmental characteristics for birth outcomes, the role of indirect violence on health remains fairly understudied. METHODS: Using geocoded birth records from the ongoing Western Region Birth Cohort (Regiao Oeste Coorte - ROC-Cohort) of infants born between 2012 and 2014 and geocoded crime reports, we assessed the associations between exposure to violent crimes during pregnancy within a 1-km radius of the mother's residence and low birth weight, preterm delivery, and being born small-for-gestational-age. Violent crime exposure was categorized into quintiles. Multivariate logistic regressions were used to examine the associations between violence exposure and birth outcomes. Models were adjusted for sex, maternal age and education, socioeconomic status, and risk factors such as hypertension, diabetes, smoking, and drinking during pregnancy. RESULTS: Among the 5268 children included, the average crime exposure during the first two trimesters of pregnancy ranged from 0.44 violent crimes in the least exposed quintile to 12.74 crimes in the most exposed. Compared to children with the lowest violence exposure, children in the highest exposure quintile had higher odds of being born small-for-gestational-age (1.41[1.06-1.89]), preterm (1.35[1.01-1.80]), and low birth weight (1.42[1.03-1.98]). While socioeconomic status and maternal education were positively associated with lower violence exposure, no associations were found between these characteristics and birth outcomes. CONCLUSIONS: Higher exposure to violent crimes in the close vicinity of pregnant women's residence is associated with substantial increases in the odds of adverse birth outcomes. Policies to improve neighborhood safety can potentially contribute not only to the short-term wellbeing of populations but may also have large social, economic, and health benefits in the long term.