Abstract

Drivers of persistent racial-ethnic inequities in severe maternal morbidity are poorly understood. This study examined how neighborhood-level structural racism measures shape risk of severe maternal morbidity among Black mothers.Data are from live hospital births in California between 1997-2019 at ≥20 weeks' gestation (N=555,511). We leveraged information from the U.S. Census Bureau and the American Community Survey to determine neighborhood (census-tract) measures of structural racism across six domains (homeownership, unemployment, poverty, educational attainment, racialized economic deprivation, and racial residential segregation). We used 1) an additive composite index (Quartile 1 (low)- Quartile 4 (high)) and 2) latent class analysis to characterize four structural racism typologies. We examined associations across both measurement approaches using mixed-effects logistic regression models with neighborhood random intercepts adjusting for maternal age, education, and hospital payer information.Black mothers living in neighborhoods scoring high (Quartile 4) on the additive composite index had 13% higher risk of severe maternal morbidity than those in neighborhoods scoring low (Quartile 1) (95% Confidence Interval (CI): 1.04-1.24). Models evaluating latent class typologies also revealed that Black mothers living in neighborhoods characterized by consistently high racial inequity in unemployment, racialized economic deprivation, and racial residential segregation across the study period had 12% higher risk of severe maternal morbidity compared to those in neighborhoods consistently scoring low in the domains examined (95% CI: 1.03-1.23).Our findings support the hypothesis that neighborhood-level measures of structural racism influence risk of severe maternal morbidity among Black mothers.

View details for DOI 10.1097/EDE.0000000000001941

View details for PubMedID 41397239

Abstract

We sought to assess the extent to which folic acid supplementation and dietary folate intake are associated with preterm delivery among infants with spina bifida.We conducted a retrospective population-based study using the National Birth Defects Prevention Study (NBDPS; 1999-2011) and the Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS; 2014-2019). We utilized robust Poisson regression to calculate the risk ratio (RR) and 95% confidence interval (CI) for the associations between preterm birth (< 37 weeks) and maternal use of folic acid-containing supplements, dietary folate intake quartile, and a combined variable accounting for supplementation and dietary folate status.Among 1199 infants with spina bifida (1011 in NBDPS, 188 in BD-STEPS), 217 (18.1%) were born preterm. There were no statistically significant associations between preterm birth and lack of supplementation (RR 1.24, 95% CI: 0.92-1.69) or maternal dietary folate intake quartile (RRs 1.12-1.39). The combination of lack of supplementation and low dietary folate intake had the strongest association with preterm birth (RR 1.73, 95% CI: 1.01-2.96), compared to women who took supplements and had higher dietary folate intake.Our findings suggest a modestly elevated risk of preterm birth among infants with spina bifida born to women with the combination of no supplementation and low dietary folate intake. Future work confirming these findings and further investigating the timing of supplementation could help elucidate whether low folate intake is a risk factor for preterm birth in spina bifida-affected pregnancies.

View details for DOI 10.1002/bdr2.70008

View details for PubMedID 41387300

Abstract

Severe maternal morbidity (SMM) and its racial and ethnic inequities are the result of a mixture of risk factors ranging from clinical comorbidities to socio-economic contexts. One under-explored dimension is neighbourhood contexts.In order to understand the impact of neighbourhood contexts on SMM, this study investigates the relationship between a 20-year history of neighbourhood poverty and SMM among 8.6 million births in California from 2000 to 2018 and assesses effect measure modification by race/ethnicity and nativity.Data include hospital live births in California from 2000 to 2018 from the California Department of Public Health. The final sample for this study consisted of 8,632,436 live births. Mixed-effects logistic regression models accounting for area-level clustering were used to compare the odds of SMM across neighbourhood poverty histories, adjusting for sociodemographic and pregnancy-related factors and comorbidities.The prevalence of SMM was 1.2%. In fully adjusted models, neighbourhoods with persistent high poverty had 32% higher odds of SMM (OR 1.32, 95% confidence interval [CI] 1.28, 1.37), and those with persistent moderate poverty had 9% higher odds (OR 1.09, 95% CI 1.06, 1.12), compared to neighbourhoods with a persistent low poverty history. The odds of SMM were also higher in neighbourhoods with increasing poverty; 23% higher for early increase (OR 1.23, 95% CI 1.19, 1.27) and 13% higher for late increase (OR 1.13, 95% CI 1.09, 1.16). In contrast, neighbourhoods with early decreasing poverty had 11% lower odds of SMM (OR 0.89, 95% CI 0.84, 0.94) compared to persistent lowpoverty neighbourhoods.The findings indicate that persistent high poverty in neighbourhoods is associated with higher odds of SMM, independent of individual sociodemographic and clinical factors. The strongest associations were found among Asian, Hispanic, Pacific Islander and white birthing people. These results underscore the significance of neighbourhood poverty histories and their impact on maternal health.

View details for DOI 10.1111/ppe.70088

View details for PubMedID 41230617

Abstract

To examine the recurrence risk of SMM and SMM subtypes among specific subgroups, such as age, race/ethnicity, educational status, and insurance status.We used vital records (live birth and fetal death certificates) from 1997 to 2020 that were linked to maternal hospital discharge records to identify 1,989,104 first and second birth pairs. The outcomes, SMM and non-transfusion SMM (nt-SMM), were identified using ICD-9/10 codes for 21 indicators and further categorized into 8 subtypes based on the organ systems impacted (cardiac SMM, renal SMM, respiratory SMM, hemorrhage SMM, sepsis SMM, other obstetric SMM, other medical SMM, and transfusion SMM). We used sequentially adjusted modified Poisson regression model with bootstrapped errors to estimate the recurrences of composite SMM,SMM subtypes, and SMM indicators between first and second birth. Risk ratios were stratified by the following: age, education, insurance, interpregnancy interval, nativity, plurality, race/ethnicity, and the Expanded Obstetric Comorbidity Index.The recurrence risk ratio of overall SMM and nt-SMM between first and second births were 3.4 (95% CI: 2.9-4.1) and 3.7 (95% CI: 2.6-5.3), respectively, adjusted for sociodemographic and clinical factors. Among the SMM subtypes, the adjusted risk of recurrence was particularly elevated among individuals who experienced other medical SMM (RR: 119, 95% CI: 30-267) and cardiac SMM (RR: 32.6, 95% CI: 6.6-88.4). In stratified analyses, recurrence risk ratios were highest among individuals with higher education, private insurance, singleton pregnancies, and lower co-morbidity scores (all groups with lower absolute prevalence of SMM). Hispanic populations had a notably lower recurrence risk ratios for SMM compared with White, Black and Asian subgroups. For nt-SMM, Black individuals were the only group that had both higher absolute prevalence and higher recurrence risk ratios for nt-SMM (relative to other racial and ethnic subgroups).The recurrence risk of SMM and nt-SMM varies by SMM subtypes as well as among sociodemographic subgroups. This recurrence risk remains elevated after adjustment for sociodemographic and clinical factors. We identify subgroups among whom additional counseling and monitoring may be warranted after an initial SMM occurrence, if additional pregnancies are desired. Some groups that typically have a lower absolute prevalence of SMM had higher recurrence risk ratios relative to their counterparts, which suggests the importance of close monitoring for the potential recurrence of SMM, regardless of baseline prevalence based on known risk factors.

View details for DOI 10.1016/j.ajog.2025.11.005

View details for PubMedID 41223958

View details for DOI 10.1007/s40471-025-00373-7

View details for Web of Science ID 001610764100001

Abstract

Ethnic enclaves are neighborhoods formed through discriminatory policies that concentrate disadvantage in marginalized communities. Living in these neighborhoods has important implications for maternal health; however, few studies have assessed this concerning severe maternal morbidity (SMM). We examined the relationship between residence in an ethnic enclave, comparing three methods of classification and SMM among 7 million births to Asian, Black, and Hispanic people in California from 1997 to 2018. SMM was constructed using the CDC's SMM index. We considered three methods of measuring ethnic enclaves (racial composition, location quotient, and the Gi* statistic) at the census tract level. Race-stratified mixed-effects logistic regression models accounting for area-level clustering were used to compare the odds of SMM in ethnic enclaves compared to average neighborhoods, adjusting for sociodemographic and pregnancy-related clinical factors and comorbidities. Among Hispanic birthing people, mixed results were found for ethnic enclave measures. Adjusted models showed lower odds of SMM for those in ethnic enclaves defined by Gi* (aOR 0.96, 95%CI 0.94, 0.98) and location quotient (aOR 0.90, 95%CI 0.88, 0.92) but higher odds using racial composition (aOR 1.03, 95%CI 1.01, 1.06). Black birthing people had higher odds of SMM in ethnic enclaves across all measures. Effect modification by nativity showed that US-born Black birthing people in enclaves had higher odds of SMM, while immigrant Black birthing people had lower odds. Overall, residence in ethnic enclaves is associated with SMM among Asian, Hispanic, and Black birthing people, with variations by ethnic enclave measure and nativity.

View details for DOI 10.1007/s11524-025-01010-w

View details for PubMedID 41165955

View details for PubMedCentralID 6112984

Abstract

To address the maternal health crisis in the United States, it is important to closely examine the epidemiologic trends of and racial and ethnic disparities in maternal cardiovascular health.We used statewide birth hospitalization and vital statistics records from California (2007-2019; N=6 117 886) to examine the prevalence, trends, and racial and ethnic disparities of hypertensive disorders of pregnancy overall (ie, chronic hypertension, gestational hypertension/preeclampsia, or eclampsia), and chronic hypertension and gestational hypertension/preeclampsia separately. We also examined a construct indicating ideal cardiovascular health before and during pregnancy using the subset of data with information available on clinical cardiovascular health indicators (ie, hypertension, diabetes, smoking, body mass index [kg/m2], and gestational weight gain adjusted for gestational age; N=5 636 185). To quantify racial and ethnic disparities, we used modified Poisson regression models (with robust standard errors), controlling for sociodemographic characteristics, pregnancy-related factors, and year fixed effects.The age-standardized prevalence of adverse outcomes worsened over time for all racial and ethnic groups. Compared with non-Hispanic White (White) individuals, non-Hispanic Black mothers had higher risk of hypertensive disorders of pregnancy (risk ratio [RR], 1.60 [95% CI, 1.59-1.62]), including chronic hypertension (RR, 2.34 [95% CI, 2.29-2.38]) and gestational hypertension/preeclampsia (RR, 1.50 [95% CI, 1.49-1.52]). American Indian/Alaska Native mothers were less likely to have ideal cardiovascular health both before (RR, 0.66 [95% CI, 0.65-0.67]) and during pregnancy (RR, 0.80 [95% CI, 0.78-0.81]) compared with White mothers. These differences persisted throughout the study period.Our findings reveal stark racial and ethnic disparities in maternal cardiovascular health, highlighting the urgent need to investigate and address their structural determinants.

View details for DOI 10.1161/JAHA.124.039295

View details for PubMedID 40996078

Abstract

To evaluate prevalence of and characteristics associated with prenatal and late critical congenital heart defect (CCHD) detection among infants.Infants with CCHD born during 2014-2021 with interviewed mothers were included from the Birth Defects Study To Evaluate Pregnancy exposureS (BD-STEPS), a multi-site, population-based case-control study. Timing of detection was based on date of earliest fetal or postnatal echocardiogram: prenatal, timely postnatal (0-3 days after birth), and late (>3 days after birth). Unadjusted log-linear models evaluated trends in timing of CCHD detection by birth year. Multivariable log-binomial models calculated adjusted prevalence ratios (aPRs) for prenatal and late CCHD detection by demographic and clinical characteristics.There were 996 liveborn infants with CCHD included in this analysis. Prenatal detection increased from 2014 (25.0%) to 2021 (39.1%; P for trend=0.01). The prevalence of late detection was 22.7% in 2014 and 16.4% in 2021; P=0.06. Almost half (48.6%) of infants had timely postnatal detection. Prenatal detection was 1.2 times (95% CI 1.1-1.5) more likely among infants with extracardiac compared with isolated defects. Late CCHD detection was 2.0 times (95% CI 1.2-3.4) more common among infants whose mothers lacked prenatal insurance compared with those with prenatal insurance.Disparities in timing of CCHD detection exist by defect characteristics and insurance. Implementation of improved prenatal detection methods to detect more defect types and interventions to increase access to prenatal care may further improve earlier CCHD detection.

View details for DOI 10.1016/j.jpeds.2025.114825

View details for PubMedID 40972708

Abstract

To examine the prevalence of severe maternal morbidity (SMM) and the indicators (i.e., morbidities and procedures) that comprise the SMM composite among adolescents and to compare risks between adolescents and adults.This was a population-based study in California to individuals aged 10-55. We included prenatal, postpartum, and birth hospital discharge records linked to vital records from 2001 to 2020. SMM was defined using the Centers for Disease Control and Prevention index. We estimated adjusted risk ratios (RRs) using modified Poisson regression models.This study included 702,481 adolescent births among 9,529,689 total births. There were 19 cases of SMM per 1,000 adolescent births; prevalence was highest among those aged 10-14 (27.5). Compared to adults aged 25-29, adolescents had higher rates of blood transfusion (11.4 vs. 9.0) and eclampsia (2.3 vs. 0.8). Crude RRs for SMM were 1.18 (95% confidence interval [CI]: 1.15-1.21), 1.22 (95% CI: 1.18-1.26), and 1.74 (95% CI: 1.53-1.99) in ages 18-19, 15-17, and 10-14, respectively. Adjustments for payer, race/ethnicity, parity, and anemia explained excess risk among ages 15-19, but not the youngest adolescents (10-14 years; RR: 1.31; 95% CI: 1.15-1.49). Patterns of SMM risk were similar but less pronounced when excluding blood transfusions. Risks were also elevated among ages 30-34, 35-39, and 40-55.Adolescents are at increased risk for SMM compared to adults, largely explained by social disadvantage, parity, and anemia, but not prepregnancy comorbidities. These findings highlight the need for resources to prevent SMM in adolescents and should be considered during care and public health planning.

View details for DOI 10.1016/j.jadohealth.2025.03.018

View details for PubMedID 40576605

Abstract

OBJECTIVES: Race-ethnicity and place-based variables such as rurality, ZIP code-level poverty, and county maternity care desert status have been associated with severe maternal morbidity and maternal mortality rates in the US. We examined these associations in Louisiana, which has one of the highest maternal mortality rates in the US.STUDY DESIGN: This was a birth cohort study.METHODS: We used state-wide inpatient birth hospitalization discharge data in Louisiana between 2016 and 2021. Mixed-effects logistic regression models with individuals nested within ZIP codes were used to estimate adjusted odds ratios (aOR) for non-transfusion severe maternal morbidity (nt-SMM, defined using the CDC index) according to race-ethnicity and place-based variables (overall and stratified by race-ethnicity).RESULTS: Among 326,597 birth hospitalizations, 2486 (0.77%) involved nt-SMM. Non-Hispanic Black and Hispanic individuals had increased risk of nt-SMM compared to Non-Hispanic White individuals, after adjustment for sociodemographic factors, a comorbidity index, and place-placed variables (aORs 1.36, 95%CI 1.23-1.51 and 1.39, 95%CI 1.21-1.59, respectively). Residence in a maternity care desert county or rural ZIP code did not increase risk; however, residence in a ZIP code in the highest quartile of poverty was associated with increased risk (aOR 1.26, 95%CI 1.04-1.51). When stratified by race and ethnicity, an increased risk remained for Non-Hispanic Black and Hispanic individuals residing in the highest-poverty ZIP codes (aORs 1.33, 95% CI 1.00-1.78 and 1.32, 95% CI 1.05-1.65, respectively), and a potential increased risk associated with living in a maternity care desert emerged for Black individuals (aOR 1.33, 95% CI 1.00-1.76), but confidence intervals included 1.00.CONCLUSIONS: In Louisiana, to reduce the rate of nt-SMM, social factors must be addressed, especially for non-Hispanic Black individuals living in areas with the highest levels of poverty and in maternity care deserts, as they had the highest risks in this population.

View details for DOI 10.1016/j.puhe.2025.105824

View details for PubMedID 40543228