A preconception cohort study of historical mortgage lending discrimination and present-day fecundability

We estimated the association between redlining, a historic racist practice of mortgage lending discrimination, and fecundability, the per-cycle probability of conception. We analyzed data from 1901 U.S. female participants aged 21-45 years in Pregnancy Study Online (PRESTO; 2013-2023), a prospective preconception cohort study. Participants completed self-administered questionnaires at baseline and every 2 months until conception or 12 months, whichever came first. Using participants' baseline residential addresses, we linked to neighborhoods graded by the U.S. Home Owners' Loan Corporation (HOLC) during the 1930s for perceived riskiness of mortgage lending: A + B (best or still desirable), C (definitely declining), and D (hazardous; ie, redlined). We used proportional probabilities regression models to estimate fecundability ratios (FRs) and 95% CIs, adjusting for age, calendar year of enrollment, and geographic region of residence. Most participants resided in neighborhoods with riskier grades: 47.1% grade C and 21.7% grade D. Compared with neighborhoods graded A + B, FRs were 0.91 (95% CI, 0.81-1.03) and 0.86 (95% CI, 0.74-1.00) for neighborhoods graded C and D, respectively. In this preconception cohort study, current residence in a historically redlined or declining neighborhood was associated with a moderate decrease in fecundability.