Social Drivers of COVID-19 Disease Severity in Pregnant Patients

Abstract

Objective While coronavirus disease 2019 (COVID-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has had global impact in all populations, certain groups of patients have experienced disproportionate rates of morbidity and mortality. The purpose of this study was to assess the relationship between COVID-19 disease severity, demographic variables, race and ethnicity, and social determinants of health among pregnant patients in a diverse urban population.

Study Design A retrospective analysis was performed of all pregnant patients diagnosed with COVID-19 at two urban tertiary care centers in Houston, TX between March and August 2020. Maternal demographic, COVID-19 illness criteria, and delivery characteristics were collected. The Centers for Disease Control and Prevention Social Vulnerability Index (SVI) and COVID-19 Community Vulnerability Index (CCVI) were obtained based on a patients' census tract of residence. Analyses compared persons with asymptomatic, mild, or severe-critical disease at diagnosis.

Results A total of 317 persons tested positive for COVID-19 during this time period. Asymptomatic persons were more likely to be diagnosed at later gestational ages, but there were no other differences in baseline maternal characteristics. Persons with more severe disease had greater social vulnerability specifically for housing and transportation than those with mild disease (mean SVI [standard error]: 0.72 [0.06] vs. 0.58 [0.2], p = 0.03). Total SVI, total CCVI, and other themed SVI and CCVI indices were not significantly different between groups.

Conclusion In this cohort of pregnant persons infected with SARS-CoV-2, an association was shown between disease severity and increased vulnerability in living conditions and transportation. Drivers of the pandemic and COVID-19 outcomes are complex and multifactorial, and likely change over time. However, continued efforts to accurately identify and measure social determinants of health in medicine will likely help identify geographic areas and patient populations that are at risk of higher disease burden. This could facilitate preventative and mitigation measures in these areas in future disaster or pandemic situations.

Key Points

• SVI and CCVI estimate social determinants of health.

• COVID-19 is associated with housing and transportation vulnerability.

• Social determinants contribute to disease burden in pregnancy.

Keywords

COVID-19 - pregnancy - social determinants of health

Note

The study was previously presented as poster at SMFM 41st Annual Pregnancy Meeting on January 25–30, 2021.

Publication History

Received: 08 November 2022

Accepted: 08 June 2023

Accepted Manuscript online:
13 June 2023

Article published online:
20 July 2023

• References

• 1 National Center for Immunization and Respiratory Diseases Division of Viral Diseases. COVID-19 People with Certain Medical Conditions. Centers for Disease Control and Prevention. Published 2021. Updated December 14, 2021. Accessed December 2021 at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html
• 2 Nordhues HC, Bhagra A, Stroud NN, Vencill JA, Kuhle CL. COVID-19 gender disparities and mitigation recommendations: a narrative review. Mayo Clin Proc 2021; 96 (07) 1907-1920
• 3 Gausman J, Langer A. Sex and gender disparities in the COVID-19 pandemic. J Womens Health (Larchmt) 2020; 29 (04) 465-466
• 4 D'Annibale DA, Purks JL, Huria J, Ramasamy A, Akhouri S, Mark S. Viewing the COVID-19 pandemic through a sex and gender lens. J Womens Health (Larchmt) 2021; 30 (04) 457-459
• 5 Pineles BL, Alamo IC, Farooq N. et al. Racial-ethnic disparities and pregnancy outcomes in SARS-CoV-2 infection in a universally-tested cohort in Houston, Texas. Eur J Obstet Gynecol Reprod Biol 2020; 254: 329-330
• 6 Gur RE, White LK, Waller R. et al. The disproportionate burden of the COVID-19 pandemic among pregnant black women. Psychiatry Res 2020; 293: 113475
• 7 Baradaran Motie G, Biolsi C. County-level determinants of social distancing (or lack thereof) during the Covid-19 pandemic. Contemp Econ Policy 2020; 39 (02) 264-279
• 8 Hu S, Xiong C, Younes H, Yang M, Darzi A, Jin ZC. Examining spatiotemporal evolution of racial/ethnic disparities in human mobility and COVID-19 health outcomes: evidence from the contiguous United States. Sustain Cities Soc 2022; 76: 103506
• 9 Yehia BR, Winegar A, Fogel R. et al. Association of race with mortality among patients hospitalized with coronavirus disease 2019 (COVID-19) at 92 US hospitals. JAMA Netw Open 2020; 3 (08) e2018039
• 10 Ames JL, Ferrara A, Avalos LA. et al. COVID-19 prevalence, symptoms, and sociodemographic disparities in infection among insured pregnant women in Northern California. PLoS One 2021; 16 (09) e0256891
• 11 Webb Hooper M, Nápoles AM, Pérez-Stable EJ. COVID-19 and racial/ethnic disparities. JAMA 2020; 323 (24) 2466-2467
• 12 Holtgrave DR, Barranco MA, Tesoriero JM, Blog DS, Rosenberg ES. Assessing racial and ethnic disparities using a COVID-19 outcomes continuum for New York State. Ann Epidemiol 2020; 48: 9-14
• 13 Raifman MA, Raifman JR. Disparities in the population at risk of severe illness from COVID-19 by race/ethnicity and income. Am J Prev Med 2020; 59 (01) 137-139
• 14 National Center for Health Statistics. Health Disparities: Provisional Death Counts for Coronavirus Disease 2019 (COVID-19). Published 2021. Updated December 8, 2021. Accessed December 2021 at: https://www.cdc.gov/nchs/nvss/vsrr/covid19/health_disparities.htm
• 15 Onwuzurike C, Diouf K, Meadows AR, Nour NM. Racial and ethnic disparities in severity of COVID-19 disease in pregnancy in the United States. Int J Gynaecol Obstet 2020; 151 (02) 293-295
• 16 Goldfarb IT, Clapp MA, Soffer MD. et al. Prevalence and severity of coronavirus disease 2019 (COVID-19) illness in symptomatic pregnant and postpartum women stratified by Hispanic ethnicity. Obstet Gynecol 2020; 136 (02) 300-302
• 17 Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and mortality among black patients and white patients with Covid-19. N Engl J Med 2020; 382 (26) 2534-2543
• 18 Millett GA, Jones AT, Benkeser D. et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol 2020; 47: 37-44
• 19 Peek ME, Simons RA, Parker WF, Ansell DA, Rogers SO, Edmonds BT. COVID-19 among African Americans: an action plan for mitigating disparities. Am J Public Health 2021; 111 (02) 286-292
• 20 Podewils LJ, Burket TL, Mettenbrink C. et al. Disproportionate incidence of COVID-19 infection, hospitalizations, and deaths among persons identifying as Hispanic or Latino - Denver, Colorado March-October 2020. MMWR Morb Mortal Wkly Rep 2020; 69 (48) 1812-1816
• 21 Arrazola J, Masiello MM, Joshi S. et al. COVID-19 mortality among American Indian and Alaska Native persons - 14 states, January-June 2020. MMWR Morb Mortal Wkly Rep 2020; 69 (49) 1853-1856
• 22 U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Healthy People 2030: Social Determinants of Health. Accessed January 2022 at: https://health.gov/healthypeople/objectives-and-data/social-determinants-health
• 23 Elias RR, Jutte DP, Moore A. Exploring consensus across sectors for measuring the social determinants of health. SSM Popul Health 2019; 7: 100395
• 24 Flanagin A, Frey T, Christiansen SL, Bauchner H. The reporting of race and ethnicity in medical and science journals: comments invited. JAMA 2021; 325 (11) 1049-1052
• 25 Centers for Disease Control Agency for Toxic Substances and Disease Registry. . CDC/ATSDR Social Vulnerability Index; 2020 Accessed January 2022 at: https://www.atsdr.cdc.gov/placeandhealth/svi/index.html
• 26 Flanagan BE, Gregory EW, Hallisey EJ, Heitgard JL, Lewis B. A social vulnerability index for disaster management. J Homel Secur Emerg Manag 2011;8(01):
• 27 Grabovschi C, Loignon C, Fortin M. Mapping the concept of vulnerability related to health care disparities: a scoping review. BMC Health Serv Res 2013; 13: 94
• 28 Yee CW, Cunningham SD, Ickovics JR. Application of the social vulnerability index for identifying teen pregnancy intervention need in the United States. Matern Child Health J 2019; 23 (11) 1516-1524
• 29 Surgo Ventures. Vulnerable Communities and COVID-19: The Damage Done, and the Way Forward: In-depth analysis and policy recommendations for mitigating impacts. Published 2021. Accessed November 2021 at: https://surgoventures.org/resource-library/report-vulnerable-communities-and-covid-19
• 30 Centers for Disease Control and Prevention/ Agency for Toxic Substances and Disease Registry/ Geospatial Research Analysis and Services Program. . CDC/ATSDR Social Vulnerability Index 2018 Database Texas. Accessed November 2021 at: https://www.atsdr.cdc.gov/placeandhealth/svi/data_documentation_download.html
• 31 Yancy CW. COVID-19 and African Americans. JAMA 2020; 323 (19) 1891-1892
• 32 Wadhera RK, Wadhera P, Gaba P. et al. Variation in COVID-19 hospitalizations and deaths across New York City boroughs. JAMA 2020; 323 (21) 2192-2195
• 33 Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health 2002; 92 (05) 758-768
• 34 Hernández D, Swope CB. Housing as a platform for health and equity: evidence and future directions. Am J Public Health 2019; 109 (10) 1363-1366
• 35 Pekmezaris R, Zhu X, Hentz R, Lesser ML, Wang JJ, Jelavic M. Sociodemographic predictors and transportation patterns of COVID-19 infection and mortality. J Public Health (Oxf) 2021; 43 (03) e438-e445
• 36 Zheng R, Xu Y, Wang W, Ning G, Bi Y. Spatial transmission of COVID-19 via public and private transportation in China. Travel Med Infect Dis 2020; 34: 101626
• 37 Zambrano LD, Ellington S, Strid P. et al; CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team. Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22-October 3, 2020. MMWR Morb Mortal Wkly Rep 2020; 69 (44) 1641-1647
• 38 Lokken EM, Huebner EM, Taylor GG. et al; Washington State COVID-19 in Pregnancy Collaborative. Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State. Am J Obstet Gynecol 2021; 225 (01) 77.e1-77.e14
• 39 Adhikari EH, Moreno W, Zofkie AC. et al. Pregnancy outcomes among women with and without severe acute respiratory syndrome coronavirus 2 infection. JAMA Netw Open 2020; 3 (11) e2029256
• 40 Adhikari EH, SoRelle JA, McIntire DD, Spong CY. Increasing severity of COVID-19 in pregnancy with Delta (B.1.617.2) variant surge. Am J Obstet Gynecol 2022; 226 (01) 149-151