Exploring the Relationship Between Historical Redlining and Place-Based Reproductive Health Inequities: A Qualitative GIS Approach

Individual-level risk factors and characteristics do not fully explain racial, ethnic, and socioeconomic inequities in preterm birth in the United States, and evidence suggests that medical advancements, increased access to prenatal care, and high per-capita spending on health care have done little to reduce these inequities. Health inequities research has shifted its attention from individual-level factors that influence health outcomes to the social determinants of health. Neighborhoods, considered an important upstream social determinant of health, can influence health outcomes through their social, service, and physical environments, and have been consistently linked to birth outcomes. Despite increased attention to neighborhood influences on reproductive health, there is limited attention to the historical macrostructural determinants of neighborhood conditions and place-based reproductive health inequities. Guided by feminist neighborhood political ecology, this study used Qualitative GIS to explore the relationship between historical redlining, contemporary neighborhood conditions, and spatial clusters of preterm birth in Denver, Colorado. Using an explanatory sequential mixed methods design, the geospatial strand first examined the spatial distributions of live births (N = 45,307) and preterm births (n = 4,005), identified statistically significant high value (hot spot) and low value (cold spot) clusters of preterm birth, and examined the neighborhood-level sociodemographic and environmental characteristics for the most intensely clustered preterm birth hot spot and cold spot. The most intensely clustered preterm birth hot spot and cold spot identified in the geospatial strand were used to target neighborhoods for qualitative interview recruitment to explore maternal perceptions of neighborhood influences on their reproductive health. Due to the COVID-19 pandemic, no participants were successfully recruited for the qualitative strand, resulting in no qualitative or mixed methods analysis for this study. Overall, this study found that high value clusters of preterm birth did not overlap with historically redlined neighborhoods, but rather occurred in the geographically segregated area of the city characterized by a greater concentration of Black residents and poorer quality service and physical environments. Spatial analysis also indicated that most of Denver’s historically redlined neighborhoods are now gentrified. These findings suggest that spatial inequities in preterm birth may be related to the contemporary pattern of Black residential segregation and a lack of investment in health-promoting infrastructure and opportunities in segregated neighborhoods. This study’s findings point to the need for additional research to understand what specific neighborhood-level characteristics are associated with preterm birth hot spots and how spatiotemporal dynamics influence the spatial clustering of preterm birth in Denver. Implications for policy and practice are also discussed