@article{ref1,
title="Mediation of firearm violence and preterm birth by pregnancy complications and health behaviors: addressing structural and post-exposure confounding",
journal="American journal of epidemiology",
year="2020",
author="Goin, Dana E. and Rudolph, Kara E. and Gomez, Anu Manchikanti and Ahern, Jennifer",
volume="ePub",
number="ePub",
pages="ePub-ePub",
abstract="Firearm violence may indirectly affect health among pregnant women living in neighborhoods where it is endemic. We used birth, death, emergency department, and hospitalization data from California from 2007-2011 to estimate the association between living in a neighborhood with high firearm violence and preterm delivery, and assessed whether there was mediation by diagnoses of pregnancy complications and health behaviors during pregnancy. We used an ensemble machine learning algorithm to predict the propensity for neighborhoods to be classified as high firearm violence. Risk differences (RD) for the total effect and stochastic direct and indirect effects were estimated using targeted maximum likelihood. Residence in high violence neighborhoods was associated with higher prevalence of preterm birth [RD = 0.46 (95% CI: 0.13, 0.80)], infections [RD = 1.34 (95% CI: -0.17, 2.86)], asthma [RD = 0.76 (95% CI: 0.03, 1.48)], and substance use [RD=0.74 (95% CI: 0.00, 1.47)]. The largest indirect effects between violence and preterm birth were observed for infection [0.04 (95% CI: 0.00, 0.08)] and substance use [0.04 (95% CI: 0.01, 0.06)]. Firearm violence was associated with risk of preterm delivery, and this association was partially mediated by infection and substance use.<br><br>© The Author(s) 2020. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<p /> <p>Language: en</p>",
language="en",
issn="0002-9262",
doi="10.1093/aje/kwaa046",
url="http://dx.doi.org/10.1093/aje/kwaa046"
}