African-American women bear a disproportionate burden of maternal morbidity and mortality in the United States, regardless of socio-economic, educational, or marital status. Fortunately, maternal death rarely occurs without warning. Pregnancy complications, such as those that increase the risk of future cardiovascular disease (preterm birth, growth restriction, preeclampsia, and gestational diabetes), or severe maternal morbidity (SMM) can serve as sentinel events that herald the impending possibility of a mother's increased risk for maternal mortality (MM). Most health disparities studies to date have used a deficit-based model and have included white women as the reference group to identify detrimental factors. In this supplement, I propose to instead use a strength-based model that utilizes African-American women with healthy pregnancy outcomes as the reference group. I will compare them to African American women with pregnancy complications to identify protective factors because African American women with healthy pregnancies may provide key insight to inform future prevention strategies. The objective of this supplement is to identify environmental, systems, behavioral, medical, and biological constructs that predict a healthy, uncomplicated pregnancy in African- American women. The proposed supplemental study leverages a rich repository of clinical, survey and biospecimen data from a contemporary cohort of 852 African American women enrolled in an observational preterm birth study from 2017-2020, 549 (64%) of whom went on to have a healthy pregnancy, free from complications that predict future cardiovascular disease. I will use two complementary approaches, multi-level modeling and machine learning, to quantify the relative contributions of modifiable protective factors to a healthy pregnancy across multiple levels and domains of influence. Using an adaptation of the National Institute on Minority Health Disparities Research Framework, I will identify factors that protect African-American women from pregnancy complications that predict future cardiovascular disease (Aim 1.1), SMM (Aim 1.2), and a composite morbidity index combining the two (Aim 1.3). Finally, the work of interpreting the empirical findings from Aim 1, to develop potential interventions and policy changes, will begin in Aim 2.
This aim i s aspirational in nature, but included in this brief supplement to stress the importance of identifying actionable items from study findings of protective factors that are most amenable to targeting through interventions and/or health policy. A team of diverse stakeholders, including a Maternal Advisory Panel of African American Mothers, Clinicians, and Perinatal Researchers will use intervention mapping (a rigorous method that has been used to create behavioral health interventions) to review study findings, methodically think through ways to translate study findings into action, and make recommendations for future directions that are most likely to promote health equity for African American mothers. 1
Most health disparities studies that have attempted to identify factors that explain the higher rates of severe maternal morbidity and mortality among African-American women have used a deficit-based model and included white women as the reference group to identify detrimental factors. In this supplement, I propose to instead use a strength-based model that utilizes African American women with healthy pregnancies as the reference group to identify protective factors that can be targeted through the design of future interventions to promote health equity. 1