Abstract
Objectives. To measure neighborhood exposure to proactive policing as a manifestation of structural racism and its association with preterm birth.
Methods. We linked all birth records in New Orleans, Louisiana (n = 9102), with annual census tract rates of proactive police stops using data from the New Orleans Police Department (2018–2019). We fit multilevel Poisson models predicting preterm birth across quintiles of stop rates, controlling for several individual- and tract-level covariates.
Results. Nearly 20% of Black versus 8% of White birthing people lived in neighborhoods with the highest rates of proactive police stops. Fully adjusted models among Black birthing people suggest the prevalence of preterm birth in the neighborhoods with the highest proactive policing rates was 1.41 times that of neighborhoods with the lowest rates (95% confidence interval = 1.04, 1.93), but associations among White birthing people were not statistically significant.
Conclusions. Taken together with previous research, high rates of proactive policing likely contribute to Black‒White inequities in reproductive health.
Public Health Implications. Proactive policing is widely implemented to deter violence, but alternative strategies without police should be considered to prevent potential adverse health consequences. (Am J Public Health. 2023;113(S1):S21–S28. https://doi.org/10.2105/AJPH.2022.307079)
Proactive policing is widely implemented in urban contexts and involves stopping and searching individuals and surveilling communities.1 Although there are several definitions for this type of police activity, it is broadly characterized by pursuing a suspect not as a result of a citizen request but rather because of officer discretion.1,2 Proactive stops can occur frequently and are often intentionally concentrated in specific, disproportionately Black, neighborhoods, contributing to racial inequities in arrests.2,3 Proactive policing, therefore, perpetuates structural racism in the criminal legal system and is rooted in legacies of racist neighborhood disinvestment and dispossession.2,4
Residents and scholars have critiqued proactive policing and the ways it harms Black communities and serves as a chronic stressor to residents.3,5–8 A growing body of research suggests that the public health implications of proactive policing extend beyond individuals directly involved in police stops.7,9 Living in a neighborhood with high levels of proactive policing could contribute to racialized hypervigilance and chronic stress, particularly for Black caregivers concerned for their own and their family’s well-being and safety from police violence.10–12 The impact of living in a neighborhood with high levels of police contact on adolescent and adult mental health has been explored in several studies.7,12–14 However, to our knowledge, fewer studies have examined health effects of proactive policing during pregnancy,11 a life-course period in which individuals are particularly at risk for deleterious effects of stressful residential contexts.15
Previous research has also identified related neighborhood-level manifestations of structural racism including historical redlining and persistent neighborhood disinvestment and racial inequities in perinatal health and adverse birth outcomes.16–18 These and other factors including gentrification have dictated where Black people live and controlled the flow of material goods and resources into or out of certain communities, contributing to racially disparate policing practices.2,17,19
Preterm birth is a leading cause of infant mortality,20 and, nationally, the racial inequity in preterm birth persists with rates 1.5 times higher among Black infants compared with White infants.21 This racialized patterning is mirrored in New Orleans, Louisiana—a majority Black city—where the preterm birth rate is consistently 2-fold higher among Black residents compared with White residents.22 Over a number of years, the US Department of Justice documented a persistent pattern of frequent and racially biased police stops in New Orleans, with evidence of harassment and disrespectful treatment of Black and lesbian, gay, bisexual, and transgender individuals during police stops.23 This report prompted a federal consent decree to address unconstitutional police conduct in New Orleans that is ongoing and began in 2013.23 Federal investigations have identified unconstitutional patterns of police stops in several other US cities including Newark, NJ24; Los Angeles, CA; Ferguson, MO; and Baltimore, MD.25
Our study thus had 2 aims: first, to examine whether New Orleanians who lived in neighborhoods with more frequent proactive police stops during their pregnancy were at increased risk of preterm birth and, second, to assess the degree to which neighborhood police stops might contribute to the Black‒White racial inequity in preterm birth. We hypothesized that living in a neighborhood where people are frequently stopped or searched by police operates as chronic stressor to pregnant people, and Black pregnant people in particular, that increases the risk of preterm birth.
METHODS
We conducted this secondary, multilevel, cross-sectional study with publicly available data from the New Orleans Police Department and state vital statistics data. We geocoded birth records for every birth occurring in New Orleans from 2018 to 2019 (n = 9102) to identify Federal Information Processing System codes for census tract of residence. We identified cases of preterm birth as those occurring at less than 37 weeks gestation and excluded 12 births missing gestational age. The vital statistics data do not include information on gender identity, and we therefore use gender-inclusive language when discussing attributes of the birthing parent in our study population. We also hypothesized that any contextual effects of proactive policing would similarly impact the pregnancies of cisgender women and transgender and gender-nonconforming people.
Exposure Measures
We constructed our neighborhood proactive policing variable by using publicly available field interview data from the New Orleans Police Department (2018–2019). We considered proactive stops to be those classified by police as because of a “suspicious person” or “suspicious vehicle.” We calculated annual rates of average daily census tract total and proactive police stops per 100 000 residents by using census tract population denominator data from the 5-Year American Community Survey (ACS 2015–2019) and categorized these rates into quintiles. We similarly calculated rates of Black and White total and proactive stops to examine racially concordant associations with preterm birth for Black and White birthing people, respectively. Sample size limited our ability to assess additional racial/ethnic groups. We merged rates of total and proactive police stops to birth records by census tract Federal Information Processing System code.
Additional Covariates
Birth records also contained data on several important individual-level variables that are known to be associated with preterm birth and neighborhood mobility, including age (continuous years), highest level of educational attainment at the time of birth (< 9th grade, 9th‒12th grade no diploma, high-school diploma or general educational development (GED), some college, associate degree, bachelor’s degree, master’s degree, doctorate or professional degree), and whether the birth was financed by Medicaid. Our effect modification analyses used birthing person race and ethnicity as self-reported on the birth certificate (non-Hispanic White, Black, American Indian/Alaska Native, Asian, Native Hawaiian or other Pacific Islander, multiracial, other race, Hispanic).
To address neighborhood differences in other contextual drivers of adverse birth outcomes and proactive policing, we used census tract data from the ACS. Census tract measures included quintiles of the following: percentage of working-age unemployed adults, percentage with less than high-school education, percentage of households with child poverty, and population density per square mile. We additionally adjusted for an annual rate of 911 calls related to violence (i.e., aggravated assault and battery, rape, homicide, armed robbery) using public data from the New Orleans Police Department.
Statistical Analyses
To assess our study’s first aim, to determine whether New Orleanians who lived in neighborhoods with higher rates of proactive police stops were at increased risk of preterm birth, we first examined the rates of proactive police stops across term and preterm births, along with our other individual and census tract‒level variables (Table 1). We then mapped the census-tract rates of proactive police stops for 2018 and 2019 (Figure 1), as well as census-tract prevalence of preterm birth.
TABLE 1—
Individual- and Neighborhood-Level Characteristics of All Term and Preterm Births: New Orleans, LA, 2018–2019
| Characteristic | Total (n = 9102), No. (%) or Mean ±SD | Preterm Birthsa (n = 1190), No. (%) or Mean ±SD | Term Birthsa (n = 7900), No. (%) or Mean ±SD |
| Individual level | |||
| Race/ethnicity | |||
| Non-Hispanic White | 2458 (27.01) | 197 (16.55) | 2260 (28.61) |
| Non-Hispanic Black | 5334 (58.60) | 841 (70.67) | 4485 (56.77) |
| American Indian/Alaska Native | 39 (0.43) | 3 (0.25) | 36 (0.46) |
| Asian and Pacific Islander | 188 (2.07) | 27 (2.27) | 170 (2.15) |
| Multiracial | 86 (0.94) | 14 (1.18) | 77 (0.97) |
| Other race | 53 (0.58) | 104 (8.74) | 39 (0.49) |
| Hispanic | 920 (10.11) | 4 (0.34) | 814 (10.30) |
| Missing | 24 (0.26) | 0 | 19 (0.24) |
| Age at birth,a y | 29.21 ±5.92 | 29.59 ±6.06 | 29.15 ±5.89 |
| Education at birth | |||
| < 9th grade | 201 (2.21) | 25 (2.10) | 175 (2.22) |
| 9th‒12th grade, no diploma | 955 (10.49) | 140 (11.76) | 813 (10.29) |
| High school or GED | 2593 (28.49) | 399 (33.53) | 2193 (27.76) |
| Some college | 1555 (17.08) | 208 (17.48) | 1345 (17.03) |
| Associates degree | 418 (4.59) | 52 (4.37) | 366 (4.63) |
| Bachelor’s degree | 1636 (17.97) | 172 (14.45) | 1463 (18.52) |
| Master’s degree | 981 (10.78) | 102 (8.57) | 878 (11.11) |
| > master’s degree | 579 (6.36) | 53 (4.45) | 526 (6.66) |
| Missing | 184 (2.02) | 39 (3.28) | 141 (1.78) |
| Census tract level | |||
| Neighborhood stop rateb | 40.81 ±59.17 | 44.39 ±61.31 | 40.18 ±58.73 |
| Q1 (0‒11.0) | 2167 (23.81) | 253 (21.26) | 1913 (24.22) |
| Q2 (11.0–20.1) | 1961 (21.54) | 237 (19.92) | 1723 (21.81) |
| Q3 (20.1–32.8) | 1772 (19.47) | 235 (19.75) | 1534 (19.42) |
| Q4 (32.8–57.2) | 1729 (19.00) | 233 (19.58) | 1496 (18.94) |
| Q5 (> 57.2) | 1473 (16.18) | 232 (19.50) | 1234 (15.62) |
| Proactive stop rateb | 3.58 ±6.67 | 3.80 ±6.17 | 3.53 ±6.69 |
| Q1 (0‒0.8) | 1810 (19.89) | 193 (16.22) | 1616 (20.46) |
| Q2 (0.8–1.4) | 2125 (23.35) | 263 (22.10) | 1861 (23.56) |
| Q3 (1.4–2.3) | 1897 (20.84) | 246 (20.67) | 1649 (20.87) |
| Q4 (2.3–4.9) | 1811 (19.90) | 257 (21.60) | 1551 (19.63) |
| Q5 (> 4.9) | 1459 (16.03) | 231 (19.41) | 1223 (15.48) |
| % unemployment | 9.06 ±5.72 | 9.95 ±6.11 | 8.93 ±5.65 |
| % < high school | 14.94 ±9.58 | 16.30 ±9.36 | 14.73 ±9.60 |
| % child poverty | 33.53 ±23.99 | 37.40 ±23.42 | 32.93 ±24.02 |
| Rate of violence-related calls to policeb | 3.56 ±4.29 | 3.97 ±4.56 | 3.49 ±4.24 |
Note. GED = general educational development; Q = quintile.
There were no missing values for age at birth, and we excluded 12 births missing gestational age.
Annual census tract rates of police stops were calculated as the average daily number of stops per 100 000 population. Proactive stops were classified as those because of a “suspicious person” or “suspicious vehicle.” Quintiles of proactive stops were constructed using the distribution of neighborhood stops for 2018 and 2019.
FIGURE 1—
Census Tract Rates of Proactive Police Stops in (a) 2018 and (b) 2019: New Orleans, LA
Note. Annual census tract rates of proactive police stops were calculated as the average daily number of stops because of “suspicious person” or “suspicious vehicle” per 100 000 population. Quintiles of proactive stops were constructed using the distribution of neighborhood stops for 2018–2019.
We fit multilevel Poisson models with tract-level random intercepts and robust standard errors to estimate risk or prevalence ratios for preterm birth across quintiles of neighborhood proactive stops.26 We stratified our models across birthing person race and ethnicity to assess whether proactive policing as a manifestation of anti-Black structural racism was more strongly associated with preterm birth among Black birthing people. We additionally examined associations between total police stops and preterm birth to determine whether our findings for proactive stops were reflective of a broad relationship between neighborhood policing and preterm birth (Table 2). All models adjust for age, education, Medicaid status, and year, and tract-level unemployment, education, poverty, population density, and rate of 911 calls for violence. Birth records were geocoded in ArcGIS Pro 2.9.0 (Esri, Redlands, CA), and all statistical analyses, mapping, and visualizations were done in R version 4.2.1 (R Foundation for Statistical Computing, Vienna, Austria).
TABLE 2—
Preterm Births Associated With Census Tract Total and Proactive Police Stops Stratified by Non-Hispanic Black and White Race and Ethnicity: New Orleans, LA, 2018–2019
| Neighborhood Police Stop Rate | All Births, ARR (95% CI) | Black Births, ARR (95% CI) | White Births, ARR (95% CI) |
| Proactive stops | |||
| Q1 (0‒0.8; Ref.) | 1 | 1 | 1 |
| Q2 (0.8–1.4) | 1.06 (0.87, 1.29) | 1.07 (0.83, 1.39) | 0.98 (0.65, 1.49) |
| Q3 (1.4–2.3) | 1.05 (0.85, 1.28) | 1.10 (0.84, 1.43) | 0.92 (0.58, 1.47) |
| Q4 (2.3–4.9) | 1.15 (0.93, 1.42) | 1.25 (0.95, 1.63) | 0.85 (0.53, 1.36) |
| Q5 (> 4.9) | 1.24 (0.97, 1.59) | 1.41 (1.04, 1.93) | 0.74 (0.33, 1.66) |
| Total stops | |||
| Q1 (0‒11.0; Ref.) | 1 | 1 | 1 |
| Q2 (11.0–20.1) | 0.98 (0.81, 1.19) | 0.88 (0.69, 1.13) | 1.44 (0.92, 2.27) |
| Q3 (20.1–32.8) | 1.05 (0.87, 1.27) | 1.01 (0.79, 1.28) | 1.36 (0.84, 2.19) |
| Q4 (32.8–57.2) | 1.03 (0.84, 1.27) | 1.08 (0.83, 1.40) | 1.14 (0.67, 1.94) |
| Q5 (> 57.2) | 1.14 (0.89, 1.45) | 1.18 (0.87, 1.60) | 1.09 (0.54, 2.21) |
Note. ARR = adjusted risk ratio; CI = confidence interval; Q = quintile. Annual census tract rates of police stops were calculated as the average daily number of stops per 100 000 population. Proactive stops were classified as those because of a “suspicious person” or “suspicious vehicle.” Quintiles of proactive stops were constructed using the distribution of neighborhood stops for 2018 and 2019. Estimates are from multilevel Poisson models with census tract random intercepts and robust SEs that adjusted for age, education, Medicaid status, year, and tract-level unemployment, education, poverty, population density, and rate of calls to police for violence. Covariate ARRs and 95% CIs are available in Table A (available as a supplement to the online version of this article at https://ajph.org).
To examine our study’s second aim, to assess the degree to which neighborhood police stops exacerbate racial inequities in preterm birth, we used the method described by Ward et al.27 that considers the prevalence of the exposure and outcome across groups as well as the relationship between exposure and outcome across groups. To do so, we fit an interaction model to test for effect modification by race and ethnicity and plotted the racial differences in the predicted prevalence of preterm birth across racial groups, as well as the proportion of births in the lowest and highest quintiles of neighborhood proactive police stops (Figure 2). Because of sample size limitations, we only present results for Black and White individuals.
FIGURE 2—
Prevalence of Preterm Birth Among Black and White Individuals Across Levels of Census Tract Police Stops: New Orleans, LA, 2018–2019
Note. Q = quintile. Circles in this figure are scaled by the percentage of births that were exposed to low and high neighborhood proactive police stops within each racial/ethnic group.
As a sensitivity analysis, we removed census tracts in the French Quarter, which is a largely nonresidential area that we observed had very high levels of police stops. We reconstructed quintile measures of annual rates of total and proactive police stops removing the French Quarter to evaluate bias in our main estimates. We repeated our main models using these measures, excluding births in the French Quarter (Figure C, available as a supplement to the online version of this article at https://ajph.org).
RESULTS
There were 9102 births in New Orleans during 2018 to 2019, of which 1190 (13%) were preterm. There was a large Black‒White racial gap in preterm birth with prevalences of 15.8% among Black people and 8.0% among White people. This racial inequity is also meaningful on the absolute scale; there were 841 Black preterm births and 197 White preterm births. Those who had preterm births were less likely to have attained greater than a bachelor’s degree and more likely to have had their birth financed by Medicaid compared with those who had full-term births (Table 1).
There were notable differences in the neighborhood rate of police stops across Black and White birthing people. Black birthing people (n = 4485; 58.4% of births) were exposed to an annual average of 43.7 proactive stops per 100 000 population occurring in their neighborhood of residence, compared with 30.7 stops, on average, in neighborhoods where White birthing people (n = 2458; 26.9% of births) lived. The neighborhood contexts in which Black and White birthing people resided also differed in their percentage of residents with less than high-school education (Black mean = 17.9%; White mean = 7.7%), households with child poverty (Black mean = 41.9%; White mean = 15.4%), and unemployment (Black mean = 10.7%; White mean = 5.5%). The maps displayed in Figure 1 show that the concentration of neighborhood proactive policing was largely consistent across both years included in our analysis. Police stops were highest in neighborhoods with larger proportions of Black residents including Central City and parts of the West Bank.
Fully adjusted models among Black birthing people suggest that the prevalence of preterm birth in neighborhoods with the highest rates of proactive policing was 1.41 times that of neighborhoods with the lowest rates (quintile [Q] 5 vs Q1; 95% confidence interval [CI] = 1.04, 1.93). The associations between Black preterm births and quintiles of neighborhood proactive police stops showed a monotonic increasing pattern with the strength of the association increasing at higher quintiles of neighborhood proactive policing, although CIs comparing rates in the lowest quintile to the second and third quintiles crossed the null (Table 2, covariate estimates in Table A, available as a supplement to the online version of this article at https://ajph.org).
By contrast, we observed a monotonic decreasing trend in the association between proactive policing rates and preterm births to White people, and CIs for all point estimates included the null (Table 2). When we additionally examined the risk of preterm birth across quintiles of total police stops, we observed similar monotonic increasing and decreasing patterns among Black and White people, respectively, although these associations were not statistically significant (Table 2). The diverging Black‒White patterns were largely masked in models among birthing people of all racial and ethnic groups, which showed slight increases in the association between preterm birth and quintiles of neighborhood proactive police stops, although point estimates were more attenuated compared with models among Black individuals alone, and all CIs included the null (Table 2). These results were unchanged in our sensitivity analysis that excluded stops and births in the French Quarter (Figure C, available as a supplement to the online version of this article at https://ajph.org).
We also tested for racially concordant associations using neighborhood rates of total and proactive police stops of Black and White people in models stratified by birthing person race and ethnicity. Neighborhood rates of total and proactive stops of Black people were not significantly associated with preterm birth in the full sample or among Black or White birthing people, with the exception that White birthing people living in neighborhoods with the second-lowest versus lowest rates of stops of Black people had an increased risk of preterm birth (Q2 vs Q1 risk ratio = 2.00; 95% CI = 1.10, 3.68; Figure A, available as a supplement to the online version of this article at https://ajph.org). Neighborhood rates of total and proactive stops of White people were also not significantly associated with preterm birth overall or among Black or White birthing people (Figure B, available as a supplement to the online version of this article at https://ajph.org).
We next assessed the degree to which neighborhood proactive police stops contributed to racial inequities in preterm birth. Our model that interacted race and ethnicity with proactive stop rates suggested that its association with preterm birth did not vary significantly across race and ethnicity. However, when we considered the unequal prevalence of the exposure and outcome across race and ethnicity, we did find evidence of a meaningful racial disparity (Figure 2). Whereas 19.2% of Black birthing people lived in neighborhoods with the highest rates of proactive police stops, only 8.4% of White birthing people lived in these areas (Q5). Similarly, 29.1% of White and 16.0% of Black birthing people resided in neighborhoods with the lowest rates of proactive police stops (Q1). Marginal risk of preterm birth was approximately 3 times higher among Black compared with White birthing people at both the highest levels of exposure (Q5 Black = 0.15 [95% CI = 0.08, 0.28]; Q5 White = 0.05 [95% CI = 0.03, 0.11]), and elevated at the lowest levels of exposure (Q1 Black = 0.11 [95% CI = 0.06, 0.21]; Q1 White = 0.07 [95% CI = 0.04, 0.13]).
DISCUSSION
Our study documents elevated risk of preterm birth among Black birthing people who resided in neighborhoods with frequent proactive police stops in New Orleans. Given the overrepresentation of Black birthing people in neighborhoods that are subject to high rates of potentially harmful11,28 proactive policing, this exposure likely widens the Black‒White racial inequity in preterm birth. By contrast, we did not observe a positive association among White birthing people, further suggesting that neighborhood proactive policing serves as a racialized contextual stressor for Black people specifically. In addition to potential impacts on community health equity, proactive policing is an important source of racial inequities in the broader criminal legal system.29
Limited research has evaluated neighborhood policing as a determinant of adverse birth outcomes. A recent study in one US city (Minneapolis, MN) found a 100% increase in odds of preterm birth for US-born Black birthing people living in neighborhoods with a disproportionate number of police incident reports.11 In addition, previous research evaluating immigration enforcement, which may similarly operate as a racialized contextual stressor, found a rise in low birth weight infants born to Latina women after compared with before an immigration raid.15 Other studies on nearby exposure to fatal police violence have documented associations with preterm birth,28 pregnancy loss,30 and depressive symptoms among pregnant people.10 Future work must address the mechanisms linking aggressive policing practices with adverse birth outcomes. Mental health effects of police stops may be a critical component of these pathways, although limited extant research shows mixed results for women.7,13,31,32
Our study linked unique sources of administrative data on police stops and birth records to provide a comprehensive picture of the exposure and outcome in New Orleans. However, most cities do not make data on police stops publicly available, or only do so only after legal action or civil rights investigations. For research that evaluates these kinds of police actions to progress, municipalities need to collect and maintain comprehensive data on stop-and-search incidents and procedures and allow researchers to access these data.
Limitations
While they are uniquely available, the administrative data used in this analysis also impose a few limitations that should be noted. First, the police stop and birth certificate data were only able to be linked at the neighborhood level, so we were unable to individually identify birthing people who were stopped by police. Second, our cross-sectional analysis is only able to examine police stops that occurred in the year of birth, not prepregnancy exposure to police stops, and cumulative life-course exposure may be more relevant for adverse birth outcomes. Third, given that our data on police stops are collected by police, we do not have data on the nature of these stops from the perspective of residents, and more unjust, frequent, and aggressive police stops are likely to have a greater impact on community health.32,33 Lastly, the stop data used in this study only include encounters reported by New Orleans police and, therefore, underestimate total exposure that could also include unreported stops as well as stops by state or private police forces.
Public Health Implications
Our findings linking neighborhood proactive police stops with preterm births in New Orleans are consequential in a political moment when cities across the country are reevaluating the role and scale of policing in response to movements for racial justice, including Black Lives Matter, as well as ongoing scholarship documenting the harms of proactive policing.3,8,9 The federal consent decree aimed at addressing unconstitutional police conduct in New Orleans has been in place since 2013; however, it may not be having the intended impact if considered within the context of our study findings. Local policy officials in New Orleans and elsewhere must weigh potential negative health impacts and inequities of proactive policing with limited evidence that these strategies prevent criminalized behaviors1,34 and consider alternative strategies to reduce violence without police.35 In the midst of an ongoing Black perinatal health crisis,17 moreover, there is an urgent need to understand and address the ways that structural racism gives rise to racial inequities in reproductive health, including the potential role of proactive policing.
ACKNOWLEDGMENTS
This work was supported by the National Institutes of Health under award R01HD103684.
The authors gratefully recognize members of the Measuring and Operationalizing Racism to Achieve Health Equity Lab at the University of Minnesota School of Public Health for their feedback on an early draft of this article.
The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
HUMAN PARTICIPANT PROTECTION
The Tulane University institutional review board approved use of vital statistics data.
Footnotes
See also Testa, p. S10.
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