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Social and Structural Determinants of Health Risk Factors for Maternal Morbidity and Mortality: An Evidence Map

Draft Comments Nov 1, 2022
Download PDF files for this report here.

Table of Contents

Mother cuddling baby

Main Points

  • Included study exposures broadly covered social-structural determinants of health for pregnant and birthing people; however, the identified determinants still represent only a subset of potential social-structural determinants of interest and did not address interdependence of risk factors, including biological/medical risk factors.
  • Limited depth and quality of available research within each social-structural determinant—including racism and other forms of discrimination—impeded our ability to understand mechanisms or pathways connecting social-structural determinants of health and maternal health outcomes.
  • We found an unexpectedly large volume of research on violence and trauma relative to other potential social determinants of health for pregnant people.
  • For outcome domains, depression/other mental health outcomes represented a large proportion of the health outcomes captured.
  • We found one study investigating patterns of intersecting social-structural determinants of health that is an exemplar of new approaches to risk factor research.
  • Rarely did studies report the excess risk attributable to a specific exposure. Of note, very recent studies, mostly limited geographically, reported:
    • Income inequality was associated with a 14 percent increase in excess risk of death for Black pregnant women relative to white women in Virginia; prolonged 5-year income inequality was associated with a 20 percent increase.
    • Hispanic birthing women were more likely to deliver at hospitals with higher risk-adjusted severe maternal morbidity, contributing up to 37 percent of ethnic disparity in severe maternal morbidity in New York City.
    • Combined race and income segregation was associated with increased severe maternal morbidity in birthing women in New York City; delivery hospitals accounted for 35 percent of the attributable risk, and 50 percent of comorbidities.
    • Nationally, if rural Indigenous birthing women experienced severe maternal morbidity and mortality at the same rate as urban white women, they would see a 9 percent reduction in cases.

Structured Abstract

Objective. To understand the risk factors associated with maternal morbidity and mortality in the United States during the prenatal and postpartum periods. The primary purpose was to inform the “National Institutes of Health Pathways to Prevention Workshop: Identifying Risks and Interventions to Optimize Postpartum Health,” to be held November 29 – December 1, 2022.

Data Sources. We searched the following databases: MEDLINE, CINAHL, and Social Sciences Citation Index through April 2022.

Review Methods. We searched for eligible observational studies examining exposures related to social and structural determinants of health and at least one health or healthcare-related outcome for pregnant and birthing people. Our focus was studies that attempted to examine the mechanisms underlying the risks. We extracted basic study information and grouped studies by social and structural determinants of health domains and maternal outcomes. We subjectively prioritized studies according to study design and rigor of analytic approaches to focus risk of bias assessment on the studies most likely to achieve moderate risk of bias. We summarize all included studies and provide additional descriptions of direction of association between potential risk exposures and outcomes.

Results. We identified 8,866 unique references, with 109 included studies reporting social and structural determinants of health associated with maternal health outcomes. Studies broadly covered risk factors, including: identity and discrimination, socioeconomic, violence, trauma, psychological stress, structural/institutional, rural/urban, environment, comorbidities, hospital, and healthcare use factors. However, these risk factors represent only a subset of potential social and structural determinants of interest. We found an unexpectedly large volume of research on violence and trauma relative to other potential exposures of interest for pregnant people. Outcome domains included maternal mortality, severe maternal morbidity, hypertensive disorders, gestational diabetes, cardiometabolic disorders, weathering (the physiological effect of premature aging caused by chronic stressful experiences), depression, other mental health or substance use disorders, and cost/healthcare use outcomes. Depression/other mental health outcomes represented a large proportion of medical outcomes captured. Risk of bias was high and rarely did studies report the excess risk attributable to a specific exposure.

Conclusions. Identifying risk factors pregnant and birthing people face is vitally important. However, limited depth and quality of available research within each social and structural determinant of health impeded our ability to understand underlying mechanisms, including risk factor interdependence. While the most recently published literature showed a definite trend toward improved rigor, future research can emphasize techniques that improve the ability to estimate causal impacts. Improved reporting in studies, along with organized and curated catalogues of maternal health exposures and their presumed mechanisms, could make it easier to examine exposures in the future. In the longer term, the field could be advanced by datasets designed to more fully capture the data required to robustly examine racism and other social and structural determinants of health and their intersections and feedback loops with other biologic/medical risk factors.

Project Timeline

Maternal Morbidity and Mortality

Dec 7, 2021
Topic Initiated
Dec 9, 2021
Nov 1, 2022
Draft Comments
Oct 27, 2022 - Dec 4, 2022
Page last reviewed November 2022
Page originally created October 2022

Internet Citation: Draft Comments: Social and Structural Determinants of Health Risk Factors for Maternal Morbidity and Mortality: An Evidence Map. Content last reviewed November 2022. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/maternal-morbidity-mortality/draft-comment

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