Racial/ethnic disparities in severe maternal morbidity: An intersectional lifecourse approach

Abstract

Despite long‐existing calls to address alarming racial/ethnic gaps in severe maternal morbidity (SMM), research that considers the impact of intersecting social inequities on SMM risk remains scarce. Invoking intersectionality theory, we sought to assess SMM risk at the nexus of racial/ethnic marginalization, weathering, and neighborhood/individual socioeconomic disadvantage. We used birth hospitalization records from California across 20 years (1997–2017, N = 9,806,406) on all live births ≥20 weeks gestation. We estimated adjusted average predicted probabilities of SMM at the combination of levels of race/ethnicity, age, and neighborhood deprivation or individual socioeconomic status (SES). The highest risk of SMM was observed among Black birthing people aged ≥35 years who either resided in the most deprived neighborhoods or had the lowest SES. Black birthing people conceptualized to be better off due to their social standing (aged 20–34 years and living in the least deprived neighborhoods or college graduates) had comparable and at times worse risk than White birthing people conceptualized to be worse off (aged ≥35 years and living in the most deprived neighborhoods or had a high‐school degree or less). Our findings highlight the need to explicitly address structural racism as the driver of racial/ethnic health inequities and the imperative to incorporate intersectional approaches.

Trends and Disparities in Severe Maternal Morbidity Indicator Categories during Childbirth Hospitalization in California from 1997 to 2017

“…[54][55][56] This combination of findings and their precursors supports the important and complex role of other factors such as structural racism and economic inequalities in structuring risk of SMM through multiple and intersecting pathways. 41 Substantial prior research delineates the lower maternal health care quality received by racially and ethnically minorized individuals, [57][58][59] and targeted quality improvement initiatives have decreased racial and ethnic disparities in SMM. 60,61 Advocacy groups have called for comprehensive and sustained efforts to improve obstetrical care quality and patient centeredness, reorienting care models to address both clinical and social needs and respecting patient autonomy and informed decision-making.…”

“…8,10 Identifying salient intervention points for reversing increasing SMM prevalence and persistent disparities is critically important for maternal health and well-being, and our findings contribute to the literature supporting the imperative of looking beyond individual characteristics of individuals as explanatory factors for increasing SMM trends and disparities, including close attention to health care accessibility and quality of obstetric services, 20,21,47 and structural influences on maternal health. 41,48 The evidence base on risk factors for disaggregated SMM indicators is largely limited to individual biological factors, which suggest important clinical interventions for optimizing obstetric care quality of, but which may be inadequate for disparity resolution as evidenced by persisting disparities after risk adjustment using expanded obstetric comorbidity scores. 49 For example, some increased SMM among non-Hispanic Black versus White individuals may be attributable to antenatal anemia, which has been linked to multiple SMM indicators.…”

“…The increasing trends observed for hemorrhage, renal, respiratory, and sepsis SMM suggest key drivers of overall and nontransfusion SMM trends and priority focal points for research and intervention, both for California 9 18 and nationally. 4 41 42 Studies focused on major obstetric complications have identified differing time trends 19 43 and variation in SMM disparity by complication type, 8 suggesting the need to understand SMM overall and its underlying conditions to identify changing clinical contributors. For example, National Inpatient Sample 2012 to 2019 data demonstrated statistically significant increases in acute renal failure, sepsis, shock, adult respiratory distress syndrome, hysterectomy, embolism, and multiple cardiac complications during childbirth.…”

“…Identifying salient intervention points for reversing increasing SMM prevalence and persistent disparities is critically important for maternal health and well-being, and our findings contribute to the literature supporting the imperative of looking beyond individual characteristics of individuals as explanatory factors for increasing SMM trends and disparities, including close attention to health care accessibility and quality of obstetric services, 20 21 47 and structural influences on maternal health. 41 48…”

“…The increasing trends observed for hemorrhage, renal, respiratory, and sepsis SMM suggest key drivers of overall and non-transfusion SMM trends and priority focal points for research and intervention, both for California 9,18 and nationally. 4,41,42 Studies focused on major obstetric This article is protected by copyright. All rights reserved.…”