Neighborhood disinvestment and severe maternal morbidity in the state of California

Abstract

Background: Social determinants of health, including neighborhood context, may be a key driver of severe maternal morbidity and its related racial and ethnic inequities; however, investigations remain limited.

Objective: This study aimed to examine the associations between neighborhood socioeconomic characteristics and severe maternal morbidity, as well as whether the associations between neighborhood socioeconomic characteristics and severe maternal morbidity were modified by race and ethnicity.

Study design: This study leveraged a California statewide data resource on all hospital births at ≥20 weeks of gestation (1997-2018). Severe maternal morbidity was defined as having at least 1 of 21 diagnoses and procedures (eg, blood transfusion or hysterectomy) as outlined by the Centers for Disease Control and Prevention. Neighborhoods were defined as residential census tracts (n=8022; an average of 1295 births per neighborhood), and the neighborhood deprivation index was a summary measure of 8 census indicators (eg, percentage of poverty, unemployment, and public assistance). Mixed-effects logistic regression models (individuals nested within neighborhoods) were used to compare odds of severe maternal morbidity across quartiles (quartile 1 [the least deprived] to quartile 4 [the most deprived]) of the neighborhood deprivation index before and after adjustments for maternal sociodemographic and pregnancy-related factors and comorbidities. Moreover, cross-product terms were created to determine whether associations were modified by race and ethnicity.

Results: Of 10,384,976 births, the prevalence of severe maternal morbidity was 1.2% (N=120,487). In fully adjusted mixed-effects models, the odds of severe maternal morbidity increased with increasing neighborhood deprivation index (odds ratios: quartile 1, reference; quartile 4, 1.23 [95% confidence interval, 1.20-1.26]; quartile 3, 1.13 [95% confidence interval, 1.10-1.16]; quartile 2, 1.06 [95% confidence interval, 1.03-1.08]). The associations were modified by race and ethnicity such that associations (quartile 4 vs quartile 1) were the strongest among individuals in the "other" racial and ethnic category (1.39; 95% confidence interval, 1.03-1.86) and the weakest among Black individuals (1.07; 95% confidence interval, 0.98-1.16).

Conclusion: Study findings suggest that neighborhood deprivation contributes to an increased risk of severe maternal morbidity. Future research should examine which aspects of neighborhood environments matter most across racial and ethnic groups.

Keywords: Health equity; Neighborhood deprivation index; Neighborhood health effects; Racial and ethnic disparities; Social determinants of health.