ÌÇÐÄvlog

Separation at birth can be detrimental to both mother and infant.¹ Maintaining their union can have physiological and neurodevelopmental benefits for both.^2,3 However, if a mother is deemed unable to care for her newborn, then the child may be assigned to child protective services.¹

Limited research suggests that there is a disproportionate burden of newborn separation by child welfare services among mothers residing in lower-income or urban neighborhoods and those who frequently change their residence.^1,4 Longitudinal data are lacking about whether downward neighborhood income mobility between 2 births is associated with newborn custody by child protective services.

This population-based cohort study used multiple linked administrative databases from Ontario, Canada, within a universal health care system. Included were all female individuals with at least 2 consecutive singleton in-hospital births at 20 to 42 weeks’ gestation between April 1, 2002, and March 31, 2018, who were residing in a neighborhood with an income quintile (Q) of 2, 3, 4, or 5 (highest) at the time of the first birth (eTable 1 in Supplement 1).

Data use was authorized under section 45 of Ontario’s Personal Health Information Protection Act and exempt from a research ethics board review and informed consent. This study followed the reporting guidelines.

The study exposure, degree of downward neighborhood income mobility between the first and second births, was categorized as downward movement by: (1) 1 Q, (2) 2 Qs, (3) 3 Qs, or (4) 4 Qs, each relative to (5) no downward income mobility, defined as residing in the same income Q at both births or moving to a neighborhood with a higher income Q between births. The study outcome, newborn discharge to child protective services during the second birth hospitalization, up to the discharge date, was based on a discharge disposition variable in the newborn’s hospital record at the second birth. This approach was validated elsewhere.⁵ Study variables and databases are detailed in eTables 1 and 2 in Supplement 1.

We generated relative risks (RRs) and 95% CIs for newborn discharge to child protective services at the second birth by degree of maternal downward neighborhood income mobility. The eMethods in Supplement 1 details all analyses. Statistical analyses were conducted from March to August 2024 using SAS version 9.4 (SAS Institute). The magnitude of RRs and precision of corresponding 95% CIs indicated significant differences between exposure groups.

Within the cohort of 433 575 women, 104 663 (24.1%) experienced downward neighborhood income mobility between births (mean [SD] age, 31.0 [5.1] years), and 328 912 (75.9%) did not (mean [SD] age, 32.3 [4.5] years) (Table). Those with downward income mobility were younger and had a longer median time interval between births (Table). Relative to mothers with no downward neighborhood income mobility, the adjusted RRs for newborn discharge to child protective services at the second birth were 2.34 (95% CI, 1.92-2.85) for those with downward income mobility by 1 Q, 4.22 (95% CI, 3.22-5.53) by 2 Qs, 6.12 (95% CI, 4.23-8.83) by 3 Qs, and 7.02 (95% CI, 4.02-12.26) by 4 Qs (Figure).

In this study, a greater degree of maternal downward neighborhood income movement was associated with higher risk of newborn discharge to child protective services. As a limitation, some important maternal variables were unavailable, including individual-level income, race, and prior adverse life events. A woman may have had personal income loss or income gain without changing her neighborhood income Q between births. Likewise, a change in neighborhood income Q may not represent a change in personal income. Details about a newborn’s referral to child protective services or the duration of custody were also unavailable.

Identifying and mitigating modifiable factors coupled with maternal neighborhood income decline after a first birth may attenuate the need for future involvement of child protective services. Ongoing research should examine whether financial supplements can enhance neighborhood income stability and foster a stable maternal-newborn union.

Accepted for Publication: August 28, 2024.

Published: October 23, 2024. doi:10.1001/jamanetworkopen.2024.40604

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Jairam JA et al. ÌÇÐÄvlog Open.

Corresponding Author: Joel G. Ray, MD, MSc, Department of Medicine, St Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8, Canada (rayj@smh.ca).

Author Contributions: Dr Jairam had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jairam, Cohen, Diong, Guan, Ray.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Jairam.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Jairam, Diong, Guan, Ray.

Obtained funding: Jairam, Ray.

Administrative, technical, or material support: Butler.

Supervision: Berger, Ray.

Conflict of Interest Disclosures: Dr Cohen reported being a member of the Committee to Evaluate Drugs, which provides advice to Ontario’s Ministry of Health on public drug policy. No other disclosures were reported.

Funding/Support: This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). This study also received funding from a grant from the Ontario Academic Health Sciences Centre Alternative Funding Plan Innovation Fund. In support of this study, Dr Jairam received funding through a Keenan Postdoctoral Fellow Scholarship from the St Michael’s Hospital Foundation, and a Studentship Award from the Edwin S.H. Leong Centre for Healthy Children at University of Toronto and The Hospital for Sick Children.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This article used data adapted from the Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario MOH Postal Code Conversion File, which contains data copied under license from Canada Post Corporation and Statistics Canada. This does not constitute an endorsement by Statistics Canada of this product. Parts of this material are based on data and/or information compiled and provided by Canadian Institute for Health Information and the Ontario MOH. Parts or whole of this material are based on data and/or information compiled and provided by Immigration, Refugees and Citizenship Canada (IRCC) Permanent Resident data set current to September 30, 2020. However, the analyses, conclusions, opinions and statements expressed in the material are those of the authors, and not necessarily those of IRCC. The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.

Data Sharing Statement: See Supplement 2.