Was living in a highly segregated Black community associated with severe maternal morbidity (SMM) before and during the COVID-19 pandemic?
In this cohort study of 166 791 South Carolina women with childbirths from January 2018 to June 2021, Black and Hispanic women living in high-segregated Black communities had higher odds of SMM than their counterparts living in less segregated communities. During the pandemic, Black vs White disparities in SMM persisted, while the Hispanic vs White disparities were exacerbated.
These findings suggest that policy initiatives on improving maternal health should combat the corresponding structural racism associated with residential segregation.
Persistent racial and ethnic disparities in severe maternal morbidity (SMM) in the US remain a public health concern. Structural racism leaves women of color in a disadvantaged situation especially during COVID-19, leading to disproportionate pandemic afflictions among racial and ethnic minority women.
To examine racial and ethnic disparities in SMM rates before and during the COVID-19 pandemic and whether the disparities varied with level of Black residential segregation.
Design, Setting, and Participants
A statewide population-based retrospective cohort study used birth certificates linked to all-payer childbirth claims data in South Carolina. Participants included women who gave birth between January 2018 and June 2021. Data were analyzed from December 2021 to February 2022.
Exposures were (1) period when women gave birth, either before the pandemic (January 2018 to February 2020) or during the pandemic (March 2020 to June 2021) and (2) Black-White residential segregation (isolation index), categorizing US Census tracts in a county as low (<40%), medium (40%-59%), and high (≥60%).
Main Outcomes and Measures
SMM was identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes developed by the US Centers for Disease Control and Prevention. Multilevel logistic regressions with an interrupted approach were used, adjusting for maternal-level and facility-level factors, accounting for residential county-level random effects.
Of 166 791 women, 95 098 (57.0%) lived in low-segregated counties (mean [SD] age, 28.1 [5.7] years; 5126 [5.4%] Hispanic; 20 523 [21.6%] non-Hispanic Black; 62 690 [65.9%] White), and 23 521 (14.1%) women (mean [SD] age, 28.1 [5.8] years; 782 [3.3%] Hispanic; 12 880 [54.8%] non-Hispanic Black; 7988 [34.0%] White) lived in high-segregated areas. Prepandemic SMM rates were decreasing, followed by monthly increasing trends after March 2020. On average, living in high-segregated communities was associated with higher odds of SMM (adjusted odds ratio [aOR], 1.61; 95% CI, 1.06-2.34). Black women regardless of residential segregation had higher odds of SMM than White women (aOR, 1.47; 95% CI, 1.11-1.96 for low-segregation; 2.12; 95% CI, 1.38-3.26 for high-segregation). Hispanic women living in low-segregated communities had lower odds of SMM (aOR, 0.48; 95% CI, 0.25-0.90) but those living in high-segregated communities had nearly twice the odds of SMM (aOR, 1.91; 95% CI, 1.07-4.17) as their White counterparts.
Conclusions and Relevance
Living in high-segregated Black communities in South Carolina was associated with racial and ethnic SMM disparities. During the COVID-19 pandemic, Black vs White disparities persisted with no signs of widening gaps, whereas Hispanic vs White disparities were exacerbated. Policy reforms on reducing residential segregation or combating the corresponding structural racism are warranted to help improve maternal health.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: September 6, 2022.
Published: October 20, 2022. doi:10.1001/jamanetworkopen.2022.37711
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Hung P et al. JAMA Network Open.
Corresponding Author: Peiyin Hung, PhD, MSPH, Department of Health Services Policy and Management, University of South Carolina Arnold School of Public Health, 915 Greene St, Columbia, SC 29208 (email@example.com).
Author Contributions: Drs Hung and Liu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Hung, Liu, Liang, Li.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Hung, Norregaard, Shih, Zhang.
Critical revision of the manuscript for important intellectual content: Hung, Liu, Norregaard, Liang, Olatosi, Campbell, Li.
Statistical analysis: Hung, Shih, Liang, Zhang.
Obtained funding: Hung, Liu, Liang, Li.
Administrative, technical, or material support: Hung, Liu, Norregaard, Liang, Olatosi, Campbell, Li.
Supervision: Liu, Liang, Li.
Conflict of Interest Disclosures: Dr Hung reported receiving grants from the National Institutes of Health (NIH) and Health Resources and Services Administration during the conduct of the study. Dr Liu reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Shih reported receiving grants from University of South Carolina outside the submitted work. Dr Liang reported receiving grants from the NIH during the conduct of the study. Dr Zhang reported receiving grants from NIH during the conduct of the study. Dr Olatosi reported receiving grants from NIH outside the submitted work. Dr Li reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported.
Funding/Support: Research reported in this study was supported by National Institute of Allergy and Infectious Diseases of the NIH under award number R01AI127203-5S2.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Additional Information: Data for this study were provided by the South Carolina Department of Health and Environmental Control and the South Carolina Office of Revenue and Fiscal Affairs.
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