Mean and variance of greenness and pregnancy outcomes in Tel Aviv during 2000-14: Longitudinal and cross-sectional approaches

Keren Agay-Shay, Yaron Michael, Xavier Basagaña, Èrica Martínez-Solanas, David Broday, Itamar M. Lensky, Mary Rudolf, Lisa Rubin, Rafi Kent, Nadav Levy, Ziona Haklai, Itamar Grotto

Research output: Contribution to journalArticlepeer-review


Background: Natural environments may have beneficial impacts on pregnancy outcomes. However, longitudinal evidence is limited and the associations with variance in surrounding greenness is unknown. Our objective was to evaluate these associations among 73 221 live births in Tel Aviv, Israel. Methods: Longitudinal exposure to mean of greenness during pregnancy and trimesters were calculated using satellite-based Moderate Resolution Imaging Spectroradiometer (MODIS) Normalised Difference Vegetation Index (NDVI) data. In addition, exposure to mean and variation of NDVI from high-resolution satellite and percentage of tree cover [Vegetation Continuous Fields (VCF)] at 300-m buffer were evaluated in a cross-sectional approach. Generalized linear models were used to estimate the crude and adjusted associations. We explore the possible mediating role of ambient exposures and distance to 'outdoor gyms' located in parks. Results: Crude beneficial associations between exposure to higher mean NDVI during pregnancy and pregnancy outcomes were observed [for birthweight, 3rd/1st tertile exposure increased the mean by 25.5 g, 95% confidence intervals (CIs): 15.4, 35.5] and decreased the odds of low birthweight, small for gestational age, preterm deliveries (PTD) and very PTD. Adjustment for individual and neighbourhood-level markers of socio-economic status (SES) attenuated all the associations. Strongest associations were observed during the first and second trimesters. Cross-sectional associations for mean greenness were similar with narrower CIs, and associations with NDVI were stronger than with tree cover and stronger for mean compared with variance of greenness. Associations were consistent for term births, different buffer sizes and for further adjustment to maternal education. Stronger associations were observed for lowest SES. Distance to 'outdoor gyms' and variance of greenness had the largest estimates of mediation. Conclusion: This study adds to the limited information on when exposure to greenness is most beneficial, on the association with variance of greenness and the possible pathways. These observations require confirmation in other populations.

Original languageEnglish
Article numberdyy249
Pages (from-to)1054-1072
Number of pages19
JournalInternational Journal of Epidemiology
Issue number4
StatePublished - 1 Aug 2019

Bibliographical note

Funding Information:
This research was supported by the Planet Education and Research Program of Planet (Planet Team 2017); Planet Application Program Interface: In Space for Life on Earth, San Francisco, CA, (https://api. by providing RapidEye-scenes. All authors contributed to the study and all authors confirm that they have read the manuscript and accept responsibility for the manuscript’s contents. The paper is the summary of an original work. There has been no ghost writing by anyone not named on the author list. All of the authors have read and approved the paper and it has not been published previously nor is it being considered by any other peer-reviewed journal.

Publisher Copyright:
© 2018 The Author(s).


  • Normalised Difference Vegetation Index (NDVI)
  • Vegetation Continuous Fields (VCF)
  • birthweight
  • greenness
  • low birthweight (LBW)
  • mediation
  • pregnancy outcomes
  • preterm deliveries (PTD)
  • small for gestational age (SGA)
  • very PTD (VPTD)

ASJC Scopus subject areas

  • Epidemiology


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