Urban Green Space and Perinatal Health Inequities in the United States: A Literature Review

Abstract

Access to urban green space has been linked to positive health outcomes including enhanced perinatal health. The purpose of this article was to review, summarize, and synthesize what is known about the relationship between urban green space and perinatal health and outline implications for practice, policy, education, and research. Nineteen articles were included in this state-of-the-science review. Overall, it was found that limited access to green space is significantly related to adverse birth outcomes. These findings present an important opportunity for childbirth educators and other clinicians involved in the provision of prenatal and reproductive health care. Through education and intervention, poor perinatal outcomes may be mitigated. Clinical screening and education about the importance of access to and use of urban green space during pregnancy should be an essential component of preconception counseling and antenatal screening for at-risk populations. Policy makers should be made aware of these findings so that impactful change can be made in order to reduce disparities and promote health equity.

INTRODUCTION

As awareness of climate change and its negative effects on perinatal and reproductive health is increasing, access to urban green space is becoming an emerging area of research and policy to address environmental health disparities. Urban green spaces are public or private land covered by vegetation, such as parks, playgrounds, cemeteries, and urban forests as well as waterfronts (Abelt & McLafferty, 2017).

Current literature supports that urban green space is associated with numerous positive outcomes. Green spaces in urban communities have been shown to have numerous positive health benefits such as improving air quality and reducing stress and social isolation (Kruize et al., 2019). Urban access to green space encourages physical activity and has also been shown to reduce crime (Yang et al., 2021). Green space mitigates the harmful environmental exposures caused by air pollution and noise and provides shade during warm seasons in urban neighborhoods (Park et al., 2017; Sun et al., 2020b). Access to green space is associated with risk reduction for chronic health conditions such as obesity, hypertension, diabetes, and depression (Dorsen & Aktan, 2022).

Increased access to urban green space has also been associated with positive improvements in mental health and well-being (Barton & Rogerson, 2017). In fact, improved childhood learning and enhanced cognition as well as improved immune function have been linked to community members with access to trees (Dorsen & Aktan, 2022). In addition, urban green space is associated with improvements in perinatal health including a reduction in preterm birth, low birth weight, and other adverse birth outcomes (Abelt & McLafferty, 2017; Dadvand et al., 2012).

However, there are significant disparities in access to urban green space. Historically, racial discrimination denied predominantly Brown and Black communities’ access to urban green spaces (Dorsen & Aktan, 2022). Repercussions of this form of structural racism and classism are still felt today and continue to perpetuate racial and socioeconomic health disparities. For example, limited investment in development of urban green spaces in historically minoritized communities starting in the 1930s has resulted in a decreased tree canopy in many poor neighborhoods and resultant health inequities in cardiopulmonary health and psychological well-being (Nguyen et al., 2021).

Research has begun to emerge regarding the effects of climate change on health and well-being and the ways in which environmental equity contributes to health disparities. This growing body of literature, which includes perinatal and reproductive health inequities associated with environmental injustice, is of significant interest to childbirth educators and other clinicians involved in the provision of perinatal care. The purpose of this review is to summarize and synthesize what is known about the relationship between urban green space and perinatal and reproductive health and outline implications for practice, policy, education, and research.

METHODS

This interdisciplinary team reviewed existing literature to explore what is known about the relationship between urban green space and perinatal and reproductive health, with an emphasis on environmental inequity. A search strategy was developed in consultation with research librarians that included the following keywords and MESH terms: green space, parks, pregnancy, pregnancy outcome, and health inequities. An electronic search was conducted using the following databases: PubMed, MEDLINE, Embase, CINAHL, PsychINFO, and EBSCOhost.

Inclusion criteria included peer-reviewed articles published in English during the past 10 years that expressly referred to green space and the antepartum, intrapartum, or postpartum experience. Research completed outside of the United States was excluded due to historical and current sociopolitical realities that are unique to the United States regarding environmental injustice and racialized health disparities. Literature that explored the relationship of urban green space along with “blue space” (proximity to fresh or saltwater bodies) was not excluded, as this may be an additional factor to consider related to perinatal health (Glazer et al., 2018).

The initial search found 71 articles. Duplicates were removed and based on a review of titles and abstracts, 32 articles were found to be eligible for full-text review. Of these, 13 articles were excluded after a full-text review because they did not meet the inclusion criteria (most commonly, the study did not expressly include the antepartum, intrapartum, or postpartum experience). This resulted in 19 articles for inclusion in this review (Table 1). Table 2 includes a presentation of the measures of green space, measures of perinatal health, and whether race and ethnicity, maternal education level, and/or socioeconomic status (SES) of the sample was reported in the 17 original research articles.

TABLE 1. Summary of Included Studies.

Author(s)	Study purpose	Method and sample	Location	Key findings	Strengths	Limitations
Abelt and McLafferty (2017)	To explore the relationship between exposure to green and blue spaces and adverse birth outcomes	Quantitative analysis using a data set of 111,754 pregnant persons	New York	People in poorer neighborhoods suffer from higher rates of adverse birth outcomes and lower levels of residential greenness.	Sample size and diversity	Measures of residential greenness may not reflect actual exposure or access
				A significant inverse association between nearby street trees and the odds of preterm birth was found.		Vital statistics do not account for physical activity, social capital, or psychological well-being
Banay et al. (2017)	To examine the association between greenness and maternal or infant health	Review of 14 studies	United States	Studies showed positive associations between greenness and birth weight and maternal depression.	Synthesis of recent findings on greenness and maternal/infant health outcomes with some studies presented meeting inclusion criteria for this review	Studies may not incorporate the latest evidence as some studies presented were published over 10 years ago
				Few found evidence for an association between greenness and gestational age or other birth outcomes or between greenness and preeclampsia or gestational diabetes.
				Several assessed socioeconomic status (SES) and found that effects of limited access to greenness were stronger among those of lower SES.
Casey et al. (2016)	To evaluate the association between prenatal residential greenness and birth outcomes (term birth weight, small for gestational age, preterm birth, and low 5 min Apgar score) across a range of community types using electronic health record data	Quantitative review of 20,569 delivery events and 20,598 neonates	Pennsylvania	Higher greenness was protective for both preterm (odds ratio [OR] = 0.78, 95% confidence interval [CI]: 0.61–0.99) and small for gestational age birth (OR = 0.73, 95% CI: 0.58–0.97), but not birth weight or Apgar score.	Medical record provided detailed patient data and accurate outcome ascertainment	Methodology prevented testing interactions between community type and greenness
					Normalized difference vegetation index (NDVI) × exposure summarized exposure across pregnancy by trimester	Misclassification of exposure and other covariates since the medical record only maintains mother’s most recent address
						Medical record lacked other relevant data on maternal nutrition and exercise
						Did not fully adjust for SES
						Cannot describe qualitatively how mothers interacted with green space
						Calculated NDVI around the participants’ homes but did not around workplaces or other natural exposures
Choe et al. (2018)	To quantify the impact of features of the maternal residential natural and built environments on risk of gestational diabetes and hypertensive disorders of pregnancy	Quantitative analysis of 61,640 births	Rhode Island	Second-trimester particulate matter exposures (OR = 1.08, 95% CI: 1.00, 1.15 per interquartile range increase in PM 2.5) and living close to a major roadway (OR = 1.09, 95% CI: 1.00, 1.19) were associated with higher odds of gestational diabetes, while living 1 km from the coast was associated with lower odds of gestational diabetes (OR = 0.87, 95% CI: 0.78, 0.96).	Large sample	Prescence of confounding variables such as body mass index (BMI) and weight gain during pregnancy is not controlled and these may influence risk for gestational diabetes and hypertension
				Living 500 m from a recreational facility was associated with lower odds of gestational hypertension (OR = 0.89, 95% CI: 0.80, 0.99).
Cusack et al. (2017)	To examine the relationships between multiple urban green space and associations with term birth weight	Quantitative analysis using vital statistics data on 90,265 and 88,807 births from two cities	Maine and Texas	Consistent protective effects of NDVI, % green space, % tree cover, and % street tree buffering for most buffer sizes on birth weight.	Large sample from two cities	Tested multiple hypotheses
				Maternal race, ethnicity and education had the largest association with green space and birth weight.	Multiple green space metrics	Inconsistencies between birth and census data
					Accounted for individual and neighborhood level confounding variables	Presence of mediating variables
						Green space exposure measures are based on residential addresses only
Ebisu et al. (2016)	To explore green and urban land-use effects on birth weight	Quantitative study of 239,811 pregnancies	Connecticut	Urban green spaces are associated with birth weight.	Associations are generally robust after controlling for air pollution and traffic exposures	Possibility of land use misclassification and the estimation of exposure based on the address at birth as pregnant persons could move during pregnancy
				Interquartile range (IQR) increase in green space was associated with 7.6% (2.6, 12.4) decreased risk of low birth weight.
				IQR increment in the fraction of green space within 250 m of residence was associated with 3.2 g (95% CI: 0.4, 6.0) higher birth weight.
				Exposure to urban space was negatively correlated with green space (r = −0.88), and negative association with birth outcomes.
				Increasing green space may reduce the risk of adverse birth outcomes such as low birth weight and small for gestational age.
				Increased exposure to green space was associated with higher birth weight.
Glazer et al. (2018)	To evaluate associations between green and blue spaces and birth outcomes in a coastal area	Quantitative analysis using 61,640 births	Rhode Island	Increase in NDVI was associated with 12% higher (95% CI: 4%, 20%) odds of preterm birth	Large sample	Address at the time of birth was used precluding consideration of residential mobility
				NDVI was associated with higher birth weight (7.4 g, 95% CI: 0.4–14.4 g) and lower odds of small gestational age (OR 0.92, 95% CI: 0.87–0.98)
Laurent et al. (2013)	To study the relationships between greenness exposure and pregnancy outcomes of birth weight, preterm birth, and preeclampsia	Quantitative exploration of 80,000 births	California	An increase in birth weight in term infants and a reduced risk of preterm birth was associated with an increase in NDVI.	Largest study of greenness and pregnancy outcomes ever conducted	Did not adjust for maternal smoking and BMI
				No significant association was observed between greenness and preeclampsia.
Lee et al. (2020)	To conduct a meta-analysis to assess the effects of greenness related to air pollution and pregnancy outcomes	Analysis of 89 studies which identified and included 10 in quantitative synthesis	N/A	Greenness of the environment within 100, 250, and 500 m buffers was positively associated with birth weight and a significant decrease in the incidence of poor pregnancy outcomes such as low birth weight, small of gestational age (OR = 0.94; 95% CI: 0.92, 0.97), and preterm delivery (OR = 0.98; 95% CI: 0.97, 0.99).	First meta-analysis to assess the effects of greenness with the context of the proximity to air pollution sources on the pregnancy outcomes with some studies presented meeting inclusion criteria for this review	Review was limited to 10 studies that met inclusion criteria
Margerison et al. (2021)	To examine whether changes in residential greenness are associated with preterm birth and low birth weight	Quantitative analysis of 1,730,424 births	Michigan	Each 0.1 unit change in NDVI was associated with 0.98 (95% CI: 0.97, 0.99) times lower odds of preterm birth and a 9.0 (95% CI: 8.1, 9.9) g increase in birth weight after adjusting for covariates.	Longitudinal design	Used single measure of greenness (NDVI) that does not account for quality/accessibility
					Controlled for time-invariant maternal characteristics	Unable to examine impact of green space on birth outcomes related to desire to use green space, income, occupation, and access
Runkle et al. (2022)	To examine the association between green space and pregnancy outcomes	Quantitative analysis of 238,922 births	South Carolina	Exposure to green space was associated with mental and depressive disorders and gestational diabetes.	Large sample	Did not have data on place of residence, using only zip codes taken from billing documentation
				Participants with the lowest access were more at risk for preeclampsia, preterm birth, and mental disorders.	Longitudinal, retrospective cohort design
South et al. (2021)	To pilot a program to increase green space among urban-dwelling postpartum persons	Quantitative analysis of 36 postpartum persons	Pennsylvania	Intervention was associated with three times higher nature visits compared to control (IRR = 3.1, 95% CI: 1.16–3.14, p = .025).	Randomized, control design	Small sample size
					Intervention study aimed to increase time in green space
					Used GPS rather than relying on subjective recall
Sun et al. (2020a)	To evaluate the relationships between green space and PTB, identify windows of susceptibility and explore potential interactions between green space and air pollution	Quantitative analysis using 3,753,799 births	California	A reduced risk of preterm birth was associated with increased residential NDVI exposure in 250 m, 500 m, 1,000 m, and 2,000 m.	Large, diverse sample	Differences in the actual use of and contact with green space might have different impacts on health
				In the 2,000 m buffer, the association was strongest for very preterm birth (adjusted hazard ratio [HR] per IQR increase in NDVI = 0.959, 95% CI: 0.942–0.976), followed by moderate preterm birth (HR = 0.970, 95% CI: 0.962–0.978) and overall preterm birth (HR = 0.972, 95% CI: 0.966–0.978).	Applied time-to-event analysis to examine the association between residential surrounding green space and preterm birth
				Green space during the third to fifth gestational months had stronger associations with preterm birth than other time periods, especially during the fourth gestational month (NDVI 2000 m: HR = 0.970, 95% CI: 0.965–0.975).
				Consistent positive additive and multiplicative interactions between green space and air pollution.
Sun et al. (2020b)	To examine the combined effects of heatwaves, air pollution, and green space exposure on the risk of preterm birth	Quantitative analysis of 1,967,300 births	California	Combined effects of heatwaves and green space indicated negative interactions for less intense heatwaves (shorter duration or low temperature), whereas there were potential positive interactions for more intense heatwaves which have the potential to impact risk of preterm birth.	Large size and diversity of the population	Estimated exposures were assessed based on the zip code reported on the infant birth certificate without data on actual address
					Broad set of definitions that capture variables of interest
Tiako et al. (2021a)	To examine the association of urban residential tree canopy cover, which is associated with perception of green space, with perceived stress in pregnant women and explore whether this differed among participants with a history of anxiety and depression	Quantitative assessment of 1,294 pregnant persons	Pennsylvania	Residential tree canopy coverage was associated with reduced perceived stress among pregnant persons with a history of anxiety or depression.	Included a large sample of non-Hispanic Black women who are particularly at risk for greater perceived stress	Lack of an association between tree canopy cover and perceived stress may be due to some heterogeneity among participants
				Among pregnant people with a history of depression or anxiety, urban residential greenness was associated with lower perceived stress.		Single-center, tertiary care center in an urban setting
				An effect modification was detected among participants with a history of depression or anxiety, so that each standard deviation increase in tree canopy cover was associated with lower perceived stress.		Tree canopy cover is a static measure that does not necessarily reflect participants’ engagement and activity related to green spaces such as frequency or time spent outdoors
						Data related to treatment for anxiety or depression were not collected
Tiako et al. (2021b)	To examine the association between greenness and hypertensive disorders of pregnancy	Secondary quantitative analysis of 1,943 participants	Pennsylvania	Less residential tree canopy cover was significantly related to hypertensive disorders of pregnancy.	Prospective enrollment included a large non-White sample	Single-center, tertiary care
						Incidence of hypertensive disorders was larger than the general population
						Did not account for engagement and activity related to green space
Tvina et al. (2021)	To examine the association between the proximity of tree canopies to a prenatal residential address and the rates of preterm birth among non-Hispanic Black women	Quantitative analysis of 2771 Hispanic Black women	Wisconsin	Tree canopy coverage was significantly associated with preterm birth.	Detailed chart reviews	Did not collect data on usage of green space, time outdoors, and activity patterns or control for mediating variables such as air and noise and proximity to main roads
				After adjusting for sociodemographic and clinical risk factors, a 10% increase in tree canopy coverage was associated with lower preterm birth.	Interprofessional collaboration	Used residential address at onset of pregnancy only
				Closer proximity to green space played an important role in outcomes.	Elimination of multiple confounding variables
Weber et al. (2020)	To investigate whether residing near more green space might reduce the risk of preeclampsia	Quantitative analysis of 197,345 births	California	Significant inverse association in the 500 m buffer for people in the top quartile of NDVI and a positive association in the lowest quartile of NDVI with preeclampsia.	Included a large, diverse sample	Cannot determine direct exposure or utilization of green space, just proximity
Young et al. (2016)	To determine risk of gestational diabetes and preeclampsia related to proximity to green space	Quantitative analysis including 6,567,580 people (362,525 pregnancies)	California	Preeclampsia and gestational diabetes are not significantly associated with green space.	Google maps and birth certificate data were used to determine proximity to green space	Reliance on birth certificate data for reported health outcomes

Note. GPS = global positioning system

TABLE 2. Variables Examined in Included Studies.

Author(s)	Measure(s) of green space	Measure(s) of perinatal health	Included and reported race and ethnicity	Included and reported maternal education level or SES
Abelt and McLafferty (2017)	NDVI	Term/low/preterm birth weight, small for gestational age	Yes	Yes
Casey et al. (2016)	NDVI	Term birth weight, small for gestational age, preterm birth, and low 5 min Apgar score	Yes	Yes
Choe et al. (2018)	Residential levels of fine particulate matter, black carbon, neighborhood green/blue space	Gestational diabetes, gestational hypertension, preeclampsia	Yes	Yes
Cusack et al. (2017)	NDVI, % tree cover, % green space, % street tree buffering, access to parks	Term birth weight	Yes	Yes
Ebisu et al. (2016)	Land use data through National Land Cover Database to determine urbanicity	Birth weight	Yes	Yes
Glazer et al. (2018)	NDVI, distance to recreational facilities, freshwater and coastal water	Gestational age/preterm birth	Yes	Yes
Laurent et al. (2013)	NDVI	Birth weight, preeclampsia	Yes	Yes
Margerison et al. (2021)	NDVI	Preterm birth/birth weight	Yes	Yes
Runkle et al. (2022)	Percent of green space per person in each county (included parks, recreation areas, and historic/cultural areas)	Gestational diabetes, gestational hypertension, severe maternal morbidity, preeclampsia, mental disorders, depressive disorders, preterm birth	Yes	Yes
South et al. (2021)	Nature visit frequency and duration using smartphone GPS data	Postnatal depression	Yes	Yes
Sun et al. (2020a)	Heatwaves, air pollution, NDVI	Preterm birth	Yes	Yes
Sun et al. (2020b)	NDVI	Preterm birth	Yes	Yes
Tiako et al. (2021a)	Residential tree canopy cover	Perceived stress	Yes	Yes
Tiako et al. (2021b)	Residential tree canopy cover	Gestational hypertension, preeclampsia	Yes	Yes
Tvina et al. (2021)	Tree canopy cover in proximity to residential address using geospatial database/software	Preterm birth	Yes	No
Weber et al. (2020)	NDVI	Preeclampsia	Yes	Yes
Young et al. (2016)	Google Maps Extractor to extract location data	Gestational diabetes, preeclampsia	Yes	Yes

Note. GPS = global positioning system; NVDI = normalized difference vegetation index; SES = socioeconomic status.

FINDINGS

The literature describing the relationship between urban green space and perinatal health is evolving. Most studies included in this review were quantitative in nature. No articles were identified that used qualitative or mixed-method approaches. Sixteen studies limited to a single state in a specific region: northeast (n = 8), west (n = 5), mid-west (n = 2), and south (n = 1). Two studies included samples from multiple states (Cusack et al., 2017; Glazer et al., 2018). Study sample size ranged widely, from 36 to 3,753,799. Nine of the studies included in this review measured green space using the Normalized Difference Vegetation Index (NDVI), a geospatial measure of tree canopy that uses infrared technology to determine green spaces (Abelt & McLafferty, 2017). All studies included and reported data on participants’ race and ethnicity, and all but one (Tvina et al., 2021) reported educational level and SES. Other demographic variables reported included tobacco use, alcohol use, and insurance status as potential confounding factors.

Studies examined a variety of perinatal and reproductive health outcomes. Preterm birth (n = 5) and infant birth weight (n = 6) were the most common, followed by gestational diabetes (n = 3), gestational hypertension (n = 3), mood disorders (n = 3), and preeclampsia (n = 6). Of the studies reviewed, 10 looked specifically at adverse birth outcomes (Abelt & McLafferty, 2017; Banay et al., 2017; Casey et al., 2016; Ebisu et al., 2016; Glazer et al., 2018; Laurent et al., 2013; Margerison et al., 2021; Runkle et al., 2022; Tiako et al., 2021a; Young et al., 2016). Eleven studies demonstrated a positive association between access to green space and infant birth weight (Abelt & McLafferty, 2017; Banay et al., 2017; Cusack et al., 2017; Ebisu et al., 2016; Laurent et al., 2013; Lee et al., 2020; Margerison et al., 2021; Runkle et al., 2022; Sun et al., 2020a,b; Tvina et al., 2021). A higher incidence of preeclampsia was found among populations with less access to green space in three studies (Banay et al., 2017; Choe et al., 2018; Weber et al., 2020). Four studies analyzed gestational diabetes in relation to urban green space (Banay et al., 2017; Choe et al., 2018; Runkle et al., 2022; Young et al., 2016). Low SES was also found to be a factor in perinatal outcomes in several of the studies included in this review (Abelt & McLafferty, 2017; Banay et al., 2017; Margerison et al., 2021; Tvina et al., 2021).

DISCUSSION

Although existing research into the relationship between urban green space and perinatal health is limited, the results of existing studies are compelling regarding associations between urban green space and specific perinatal health outcomes. Findings can be drawn as a result of this review. These significant results should be of interest to the childbirth educator and perinatal clinicians while planning for and providing high-quality perinatal care.

Overall, the strengths of this review include positive associations found between access to urban green space and perinatal and reproductive health outcomes. Access to and use of urban green space were associated with decreased risk for low birth weight and small for gestational age neonates (Glazer et al., 2018; Margerison et al., 2021; Sun et al., 2020a; Tvina et al., 2021; Weber et al., 2020). Similarly, studies found that limited access to green space may be associated with negative perinatal outcomes. These include preterm birth, perinatal depression, preeclampsia, and increased birth weight neonates (Abelt & McLafferty, 2017). Limited vicinity to green space in urban settings is correlated with health disparities that may increase risk of other adverse birth outcomes (Runkle et al., 2022). Additionally, it has also been found that pregnant people with limited access to urban green space experience higher rates of gestational diabetes and hypertensive disorders, although these relationships were not consistent across studies (Tiako et al., 2021b).

Overall, when examining the association between access to green space and perinatal outcomes, those of lower SES suffered the greatest impact, with maternal race, ethnicity, and education being most significant (Banay et al., 2017; Choe et al., 2018; Cusack et al., 2017). Therefore, as a result of this review, the association between access to green space and perinatal health is important to childbirth educators and other clinicians involved in the provision of perinatal care. Limited vicinity to green space in urban settings is correlated with health disparities including increased rates of adverse birth outcomes (Runkle et al., 2022). Providers must use and apply this knowledge to promote health equity.

LIMITATIONS

There are several limitations to this review. First, most studies included used the NDVI to measure green space. This standardized measure allows for comparison between studies; however, it has been criticized for lacking nuance in that it fails to account for social context. Access to green space by at-risk populations is essential to understand given the close relationship between green space and structural racism. Second, most studies included in this review relied on data collected from a single location or state. Generalizability of study findings to other cities, states, regions, or on a global scale may be limited. Finally, none of the identified studies presented qualitative data. This leaves a significant gap in existing knowledge that might elucidate nuances related to access and use of urban green space.

IMPLICATIONS

These findings present an important and unique opportunity for childbirth educators and other clinicians involved in the provision of perinatal care to engage in advocacy for access to green space. Nursing actions in the community should be multilevel models of intervention in order to be most effective. For example, efforts to advocate may include informing elected officials of the relationship of green space to health outcomes for pregnant people leading to impactful change at the policy level. Similarly, childbirth educators and other clinicians involved in the provision of perinatal care could include the importance of access to and use of urban green space in health promotion education activities. Given the historic racism that informed policy making leading to inequities of lived environment in the United States, there is an opportunity for restitution in neighborhoods with negligible green space. Future research should consider the effect of urban green space on outcomes related to both maternal and infant health and the impact on populations at greatest risk for health disparities.

CONCLUSIONS

The current evidence suggests that access to urban green space has the potential to contribute to factors that positively impact overall health, including increasing physical activity and decreasing stress. Conversely, limited proximity to green space in urban settings is associated with poorer health, notably including increased rates of adverse perinatal and reproductive outcomes. Due to public policy shaped by racism, there are inequities in access to green space in urban settings with corresponding disparities in perinatal health that need be considered in the provision of childbirth education as well as by those providing perinatal and reproductive health services. This literature review highlights that despite existing evidence of the relationship between urban green space and perinatal health, research must be considered and applied to inform decisions. Understanding the implications that lack of green space may play in increasing health inequities and furthering health disparities, the need for population-based approach to change is imminent.

Current research suggests that access to urban green space is associated with positive perinatal outcomes. Childbirth educators as well as other perinatal and reproductive health providers should advocate for increased access to green space to optimize perinatal health outcomes. Inequities in access to green space may lead to disparities in perinatal health. Awareness of the relationship between green space and perinatal health outcomes is necessary to inform policy and address maternal health inequities with emphasis on the reduction of health disparities.

Funding Statement

FUNDING The authors received no specific grant or financial support for the research, authorship, and/or publication of this article.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.