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Associations between neighborhood greenery and birth outcomes in a North Carolina cohort

Journal of Exposure Science & Environmental Epidemiology volume 35, pages 821–830 (2025)Cite this article

Abstract

Background

Higher levels of neighborhood greenery have been associated with improved birth outcomes. However, many studies use metrics relying on vegetation density and are not able to distinguish types of greenery or spatial context, which may result in variation in potential benefits.

Objective

We examined relationships between term low birth weight (TLBW) and preterm birth (PTB), and different types of neighborhood greenery (i.e., tree cover, herbaceous cover, and aggregate greenery) within various spatial contexts (i.e., Euclidean distance and network distance-based buffers, and busy roadways to represent overall, street, and near-road greenery).

Methods

North Carolina birth registry data from 2003 to 2015 were used to create a singleton live birth cohort and linked to greenery metrics from EnviroAtlas. Logistic regression models were used to estimate OR (95%CI) for associations between greenery metrics and TLBW (<2500 g) or PTB (<37 weeks gestational age) adjusting for potential confounders. Analyses were stratified by race/ethnicity, as many studies report potential differences in proximity to greenery across these groups.

Results

We observed modest associations between multiple measures of neighborhood greenery and TLBW and PTB. Most of our results indicated a decreased odds of adverse birth outcomes with increasing levels of neighborhood greenery, but some associations showed increased odds of adverse birth outcomes. We observed the strongest associations between overall aggregate greenery with TLBW (0.967 [0.939, 0.996]) and near-road tree cover with PTB (0.985 [0.971, 0.999]). We also observed unexpected associations between increased greenway density and TLBW among non-Hispanic Black mothers (1.181 [1.049, 1.326]). In contrast, we observed a decreased odds of PTB associated with increased greenway density for non-Hispanic white mothers (0.926 [0.871, 0.983]).

Impact statement

We examined relationships between adverse birth outcomes and different types of neighborhood greenery, generally finding decreased odds of adverse birth outcomes with increasing levels of neighborhood greenery, with the strongest associations between aggregate greenery based on the Euclidean distance and decreased odds of term low birth weight. However, we also observed unexpected associations with increased greenway density and increased term low birth weight among non-Hispanic Black mothers. These results highlight the importance of considering the ways greenspace may or may not benefit some communities and will be important in guiding future efforts to increase instorative value or restore neighborhood greenspaces.

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Fig. 1: Study area.
Fig. 2: Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) of having term low birth weight (TLBW) and preterm birth (PTB) for full population and stratification by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and Pacific Islander/Asian groups), given a 10% increase in neighborhood greenery, or 1-unit increase in greenway density.

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Data availability

Greenery data used are available through EPA’s Enviroatlas (EnviroAtlas | US EPA), North Carolina birth registry data contain PII and may be requested through the NCDHHS.

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Acknowledgements

The authors would like to thank Drs. Andrey Egorov and Caitlin Gould for their review and input, and Ms. Debora Andrews for QA review. The views expressed in this article are those of the author(s) and do not necessarily represent the views or policies of the US Environmental Protection Agency.

Funding

This work was performed as part of normal duties at the U.S. Environmental Protection Agency.

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Authors and Affiliations

  1. U.S. Environmental Protection Agency, Office of Research and Development, Center for Public Health and Environmental Assessment. Research Triangle Park, Chapel Hill, NC, USA

    Wei-Lun Tsai, Thomas J. Luben & Kristen M. Rappazzo

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  1. Wei-Lun Tsai
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  2. Thomas J. Luben
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  3. Kristen M. Rappazzo
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Contributions

All authors conceived study and designed analyses. TJL and WLT acquired data. WLT and KMR processed data. WLT performed analysis with guidance from TJL and KMR. WLT wrote initial manuscript draft. TJL and KMR revised manuscript.

Corresponding author

Correspondence to Kristen M. Rappazzo.

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Competing interests

The authors declare no competing interests.

Ethical approval

This study protocol was approved by the Institutional Review Boards of the University of North Carolina at Chapel Hill UNC (IRB Number: 09-0828) and the NC Division of Public Health. The EPA’s Human Subjects Research Officer also reviewed and approved this work (HSR-001254). This analysis was secondary data, and informed consent was not required. All methods were performed in accordance with the relevant guidelines and regulations.

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Tsai, WL., Luben, T.J. & Rappazzo, K.M. Associations between neighborhood greenery and birth outcomes in a North Carolina cohort. J Expo Sci Environ Epidemiol 35, 821–830 (2025). https://doi.org/10.1038/s41370-025-00780-4

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