Influences of Housing on Maternal and Infant Health: 30-year Follow-up of a Randomized Trial - PROJECT SUMMARY/ABSTRACT Addressing maternal and infant health disparities is an urgent public health concern with profound implications for health equity across the life course. Causes of disparities in maternal morbidity and birth outcomes are multifactorial and arise from an accumulation of short- and long-term environmental, economic, social, behavioral, and biological processes that unfold across the life course. To understand and ultimately address pregnancy disparities, research needs to move beyond cross-sectional designs at one point in life, to examine upstream, place-based, and macrostructural determinants of health that occur much earlier in life, using rigorous designs. Neighborhood context is a particularly important macrostructural, distal exposure, which is influenced by residential segregation, but can be altered through housing policy. The proposed project aims to understand the impact of housing policy on neighborhood context and infant and maternal outcomes in the U.S. To study this critical public health problem, we will leverage data from the Moving to Opportunity (MTO) Study. MTO started as a randomized trial of 16,000 individuals (adults and their children) in 4,600 low-income families, living in public housing at baseline, in five U.S. cities. Volunteer families were randomized beginning in 1994 to receive one of three treatments: (1) a housing voucher that subsidized rent in apartments located in low-poverty neighborhoods (<10% poverty) plus housing counseling; (2) a housing voucher subsidizing rent in any neighborhood; or (3) an in-place control group that received no voucher but remained eligible for public housing. The original MTO study ran from 1994-2010. We propose to link the MTO study participants to population-based administrative data to extend the study for an additional 15 years until 2024. Linkage with universal data will enable us to analyze the long-term effects of this experiment on household heads, their (now adult) children, and their infant grandchildren. We have four specific aims: (1) Test if MTO treatment improves neighborhood quality (neighborhood opportunity) in 2024; (2) Test if MTO treatment affects maternal morbidity (e.g., hypertensive disorders of pregnancy, gestational diabetes, obesity); adverse birth events (low birthweight, preterm birth); or fertility (short birth interval, number of births) by 2024; (3) Identify subgroups that are more or less likely to benefit from the MTO housing voucher experiment, i.e., test heterogeneity of MTO effects on fertility, maternal morbidity and adverse birth outcomes by baseline demographic factors and their combinations (effect modification); and (4) Calculate the number of adverse maternal and infant related events avoided, and how the racial/ethnic health gap would be narrower, at the population level, if voucher-based housing policy were broadly implemented to promote opportunity moves (simulation). This rigorous, long-term population health research project aims to achieve health equity across multiple generations of families, by improving housing and neighborhood contexts early in life.
