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Am J Perinatol 2024; 41(S 01): e2151-e2158
DOI: 10.1055/s-0043-1770704
Original Article

The Contribution of Neighborhood Context to the Association of Race with Severe Maternal Morbidity

Francis M. Hacker
1   Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
,
Jaclyn M. Phillips
1   Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
,
Lara S. Lemon
1   Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
2   Department of Clinical Analytics, University of Pittsburgh Medical Center, Clinical Analytics, Pittsburgh, Pennsylvania
,
Hyagriv N. Simhan
1   Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania
› Author Affiliations Funding None.
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Abstract

Objective Severe maternal morbidity (SMM) has disproportionate frequencies among racial minorities and those of socioeconomic disadvantage, with people of Black race consistently having the highest proportion. Neighborhood level deprivation has been associated with maternal morbidity and mortality, including adverse pregnancy outcomes. We sought to explore the relationship between neighborhood socioeconomic disadvantage and SMM and describe how neighborhood context impacts the relationship between race and SMM.

Study Design We performed a retrospective cohort analysis of all delivery admissions in a single health care network from 2015 to 2019. Area deprivation index (ADI) was used to represent neighborhood socioeconomic disadvantage and is a composite index of neighborhood that spans income, education, household characteristics, and housing. The index ranges from 1 to 100 with higher values indicating higher disadvantage. Logistic regression assessed the relationship between ADI and SMM and estimated the effect that ADI has on the relationship between race and SMM.

Results Of the 63,208 birthing persons in our cohort, the unadjusted incidence of SMM was 2.2%. ADI was significantly associated with SMM, with higher values conferring higher risk for SMM (p < 0.001). The absolute risk of SMM increased roughly by 1.0% from the lowest to highest ADI value. Those of Black race had the highest unadjusted incidence of SMM compared with the referent group (3.4 vs. 2.0%) and highest median ADI (92; interquartile range [IQR]: 20). In the multivariable model, in which the primary exposure was race and ADI was adjusted for, Black race had a 1.7 times odds SMM when compared with White race (95% confidence interval [CI]: 1.5–1.9). This association was attenuated to 1.5 adjusted odds when controlling for ADI (95% CI: 1.3–1.7). Risk attenuation for SMM was not seen in other race categories.

Conclusion Neighborhood context contributes to SMM but does not explain the majority of racial disparities.

Key Points

  • Neighborhood context is associated with SMM, with higher disadvantage conferring higher risk.

  • Compared with White race, all other races had higher rates of SMM, with Black race having the highest.

  • Accounting for neighborhood modestly attenuates the magnitude of association of Black race with SMM.

  • Neighborhood context contributes to health outcomes but does not explain the majority of disparities.

Keywords

health disparities - maternal health - neighborhood context - race - severe maternal morbidity - socioeconomic drivers

Note

Presented as an oral plenary (no.: 47) at the 42nd Annual Meeting of the Society for Maternal-Fetal Medicine, virtual meeting, January 31–February 5, 2022. Recipient of the Disparities Award for Best Research on Diversity/Disparity in Health Outcomes.




Publication History

Received: 04 November 2022

Accepted: 22 May 2023

Article published online:
26 June 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
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  • References

  • 1 Robbins JM, Webb DA. Neighborhood poverty, mortality rates, and excess deaths among African Americans: Philadelphia 1999-2001. J Health Care Poor Underserved 2004; 15 (04) 530-537
    CrossrefPubMedGoogle Scholar
  • 2 Vos AA, Posthumus AG, Bonsel GJ, Steegers EA, Denktaş S. Deprived neighborhoods and adverse perinatal outcome: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2014; 93 (08) 727-740
    CrossrefPubMedGoogle Scholar
  • 3 Hesselman S, Wikström AK, Skalkidou A, Sundström-Poromaa I, Wikman A. Neighborhood deprivation and adverse perinatal outcomes in Sweden: a population-based register study. Acta Obstet Gynecol Scand 2019; 98 (08) 1004-1013
    CrossrefPubMedGoogle Scholar
  • 4 Janevic T, Stein CR, Savitz DA, Kaufman JS, Mason SM, Herring AH. Neighborhood deprivation and adverse birth outcomes among diverse ethnic groups. Ann Epidemiol 2010; 20 (06) 445-451
    CrossrefPubMedGoogle Scholar
  • 5 Ma X, Fleischer NL, Liu J, Hardin JW, Zhao G, Liese AD. Neighborhood deprivation and preterm birth: an application of propensity score matching. Ann Epidemiol 2015; 25 (02) 120-125
    CrossrefPubMedGoogle Scholar
  • 6 Elo IT, Culhane JF, Kohler IV. et al. Neighbourhood deprivation and small-for-gestational-age term births in the United States. Paediatr Perinat Epidemiol 2009; 23 (01) 87-96
    CrossrefPubMedGoogle Scholar
  • 7 Ncube CN, Enquobahrie DA, Albert SM, Herrick AL, Burke JG. Association of neighborhood context with offspring risk of preterm birth and low birthweight: a systematic review and meta-analysis of population-based studies. Soc Sci Med 2016; 153: 156-164
    CrossrefPubMedGoogle Scholar
  • 8 Adhikari Dahal K, Premji S, Patel AB, Williamson T, Peng M, Metcalfe A. Variation in maternal co-morbidities and obstetric interventions across area-level socio-economic status: a cross-sectional study. Paediatr Perinat Epidemiol 2017; 31 (04) 274-283
    CrossrefPubMedGoogle Scholar
  • 9 Ludwig J, Sanbonmatsu L, Gennetian L. et al. Neighborhoods, obesity, and diabetes: a randomized social experiment. N Engl J Med 2011; 365 (16) 1509-1519
    CrossrefPubMedGoogle Scholar
  • 10 Hu J, Kind AJH, Nerenz D. Area deprivation index predicts readmission risk at an urban teaching hospital. Am J Med Qual 2018; 33 (05) 493-501
    CrossrefPubMedGoogle Scholar
  • 11 Kind AJH, Buckingham WR. Making neighborhood-disadvantage metrics accessible: the neighborhood atlas. N Engl J Med 2018; 378 (26) 2456-2458
    CrossrefPubMedGoogle Scholar
  • 12 Messer LC, Laraia BA, Kaufman JS. et al. The development of a standardized neighborhood deprivation index. J Urban Health 2006; 83 (06) 1041-1062
    CrossrefPubMedGoogle Scholar
  • 13 Singh GK. Area deprivation and widening inequalities in US mortality, 1969-1998. Am J Public Health 2003; 93 (07) 1137-1143
    CrossrefPubMedGoogle Scholar
  • 14 Department of Medicine University of Wisconsin School of Medicine and Public Health. “Neighborhood Atlas.”. Accessed October 13, 2021 at: www.neighborhoodatlas.medicine.wisc.edu
    PubMedGoogle Scholar
  • 15 Kind AJ, Jencks S, Brock J. et al. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study. Ann Intern Med 2014; 161 (11) 765-774
    CrossrefPubMedGoogle Scholar
  • 16 Kilpatrick SK, Ecker JL. American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine. Severe maternal morbidity: screening and review. Am J Obstet Gynecol 2016; 215 (03) B17-B22
    CrossrefPubMedGoogle Scholar
  • 17 Centers for Disease Control and Prevention. “Severe maternal morbidity in the United States.”. Accessed October 13, 2021 at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html
    PubMedGoogle Scholar
  • 18 Holdt Somer SJ, Sinkey RG, Bryant AS. Epidemiology of racial/ethnic disparities in severe maternal morbidity and mortality. Semin Perinatol 2017; 41 (05) 258-265
    CrossrefPubMedGoogle Scholar
  • 19 Creanga AA, Bateman BT, Kuklina EV, Callaghan WM. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010. Am J Obstet Gynecol 2014; 210 (05) 435.e1-435.e8
    CrossrefPubMedGoogle Scholar
  • 20 Shen JJ, Tymkow C, MacMullen N. Disparities in maternal outcomes among four ethnic populations. Ethn Dis 2005; 15 (03) 492-497
    PubMedGoogle Scholar
  • 21 Grobman WA, Bailit JL, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Racial and ethnic disparities in maternal morbidity and obstetric care. Obstet Gynecol 2015; 125 (06) 1460-1467
    CrossrefPubMedGoogle Scholar
  • 22 Leonard SA, Main EK, Scott KA, Profit J, Carmichael SL. Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Ann Epidemiol 2019; 33: 30-36
    CrossrefPubMedGoogle Scholar
  • 23 Metcalfe A, Wick J, Ronksley P. Racial disparities in comorbidity and severe maternal morbidity/mortality in the United States: an analysis of temporal trends. Acta Obstet Gynecol Scand 2018; 97 (01) 89-96
    CrossrefPubMedGoogle Scholar
  • 24 Howland RE, Angley M, Won SH. et al. Determinants of severe maternal morbidity and its racial/ethnic disparities in New York City, 2008-2012. Matern Child Health J 2019; 23 (03) 346-355
    CrossrefPubMedGoogle Scholar
  • 25 Grobman WA, Bailit JL, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Frequency of and factors associated with severe maternal morbidity. Obstet Gynecol 2014; 123 (04) 804-810
    CrossrefPubMedGoogle Scholar
  • 26 Liese KL, Mogos M, Abboud S, Decocker K, Koch AR, Geller SE. Racial and ethnic disparities in severe maternal morbidity in the United States. J Racial Ethn Health Disparities 2019; 6 (04) 790-798
    CrossrefPubMedGoogle Scholar
  • 27 Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012-2015. Obstet Gynecol 2018; 132 (05) 1158-1166
    CrossrefPubMedGoogle Scholar
  • 28 Main EK, Abreo A, McNulty J. et al. Measuring severe maternal morbidity: validation of potential measures. Am J Obstet Gynecol 2016; 214 (05) 643.e1-643.e10
    CrossrefPubMedGoogle Scholar
  • 29 Callaghan WM, Mackay AP, Berg CJ. Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003. Am J Obstet Gynecol 2008; 199 (02) 133.e1-133.e8
    CrossrefPubMedGoogle Scholar
  • 30 Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol 2012; 120 (05) 1029-1036
    CrossrefPubMedGoogle Scholar
  • 31 Kuklina EV, Meikle SF, Jamieson DJ. et al. Severe obstetric morbidity in the United States: 1998-2005. Obstet Gynecol 2009; 113 (2, Pt 1): 293-299
    CrossrefPubMedGoogle Scholar
  • 32 Phillips JM, Hacker F, Lemon L, Simhan HN. Correlation between hemorrhage risk prediction score and severe maternal morbidity. Am J Obstet Gynecol MFM 2021; 3 (05) 100416
    CrossrefPubMedGoogle Scholar
  • 33 StataCorp. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC; 2019
    Google Scholar
  • 34 Snelgrove JW, Lam M, Watson T. et al. Neighbourhood material deprivation and severe maternal morbidity: a population-based cohort study in Ontario, Canada. BMJ Open 2021; 11 (10) e046174
    CrossrefPubMedGoogle Scholar
  • 35 Rossen LM. Neighbourhood economic deprivation explains racial/ethnic disparities in overweight and obesity among children and adolescents in the U.S.A. J Epidemiol Community Health 2014; 68 (02) 123-129
    CrossrefPubMedGoogle Scholar
  • 36 Laveist TA, Thorpe Jr RJ, Mance GA, Jackson J. Overcoming confounding of race with socio-economic status and segregation to explore race disparities in smoking. Addiction 2007; 102 (suppl 2): 65-70
    CrossrefPubMedGoogle Scholar
  • 37 Thorpe Jr RJ, Brandon DT, LaVeist TA. Social context as an explanation for race disparities in hypertension: findings from the Exploring Health Disparities in Integrated Communities (EHDIC) Study. Soc Sci Med 2008; 67 (10) 1604-1611
    CrossrefPubMedGoogle Scholar
  • 38 Do DP, Dubowitz T, Bird CE, Lurie N, Escarce JJ, Finch BK. Neighborhood context and ethnicity differences in body mass index: a multilevel analysis using the NHANES III survey (1988-1994). Econ Hum Biol 2007; 5 (02) 179-203
    CrossrefPubMedGoogle Scholar
  • 39 LaVeist TA, Thorpe Jr RJ, Galarraga JE, Bower KM, Gary-Webb TL. Environmental and socio-economic factors as contributors to racial disparities in diabetes prevalence. J Gen Intern Med 2009; 24 (10) 1144-1148
    CrossrefPubMedGoogle Scholar
  • 40 Howell EA, Brown H, Brumley J. et al. Reduction of peripartum racial and ethnic disparities: a conceptual framework and maternal safety consensus bundle. Obstet Gynecol 2018; 131 (05) 770-782
    CrossrefPubMedGoogle Scholar
  • 41 Culhane JF, Elo IT. Neighborhood context and reproductive health. Am J Obstet Gynecol 2005; 192 (5, suppl): S22-S29
    CrossrefPubMedGoogle Scholar
  • 42 Geller SE, Rosenberg D, Cox SM. et al. The continuum of maternal morbidity and mortality: factors associated with severity. Am J Obstet Gynecol 2004; 191 (03) 939-944
    CrossrefPubMedGoogle Scholar