BMC Public Health Research article The joint influence of area income, income inequality, and immigrant density on adverse birth outcomes: a population-based study Nathalie Auger*1,2,3, Julie Giraud4 and Mark Daniel2,3,5 BioMed Central Open Access Address: 1Unité Études et analyses de l'état de santé de la population, Institut national de santé publique du Québec, Montréal, Québec, Canada, 2Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada, 3Département de médecine sociale et préventive, Université de Montréal, Montréal, Québec, Canada, 4Institut de Santé Publique d'Épidémiologie et de Développement, Bordeaux School of Public Health, Bordeaux, France and 5School of Health Sciences, University of South Australia, Adelaide, Australia Email: Nathalie Auger* - nathalie.auger@inspq.qc.ca; Julie Giraud - juliegiro@hotmail.com; Mark Daniel - mark.daniel@unisa.edu.au * Corresponding author Published: 14 July 2009 BMC Public Health 2009, 9:237 doi:10.1186/1471-2458-9-237 This article is available from: http://www.biomedcentral.com/1471-2458/9/237 Received: 16 January 2009 Accepted: 14 July 2009 © 2009 Auger et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: The association between area characteristics and birth outcomes is modified by race. Whether such associations vary according to social class indicators beyond race has not been assessed. Methods: This study evaluated effect modification by maternal birthplace and education of the relationship between neighbourhood characteristics and birth outcomes of newborns from 1999– 2003 in the province of Québec, Canada (N = 353,120 births). Areas (N = 143) were defined as administrative local health service delivery districts. Multi-level logistic regression was used to model the association between three area characteristics (median household income, immigrant density and income inequality) and the two outcomes preterm birth (PTB) and small-for-gestational age (SGA) birth. Effect modification by social class indicators was evaluated in analyses stratified according to maternal birthplace and education. Results: Relative to the lowest tertile, high median household income was associated with SGA birth among Canadian-born mothers (odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06, 1.20) and mothers with high school education or less (OR 1.13, 95% CI 1.02, 1.24). Associations between median household income and PTB were weaker. Relative to the highest tertile, low immigrant density was associated with a lower odds of PTB among foreign-born mothers (OR 0.79, 95% CI 0.63, 1.00) but a higher odds of PTB among Canadian-born mothers (OR 1.14, 95% CI 1.07, 1.21). Associations with income inequality were weak or absent. Conclusion: The association between area factors and birth outcomes is modified by maternal birthplace and education. Studies have found that race interacts in a similar manner. Public health policies focussed on perinatal health must consider the interaction between individual and area characteristics. Page 1 of 11 (page number not for citation purposes)