There is a critical need to identify reasons behind the entrenched and unacceptable racial inequity in mortality during pregnancy and postpartum in the US. Compared to White women Black women are 3-4 times more likely to die from both obstetric and non-obstetric causes. Previous efforts focused on individual-level and health care factors underlying differences in risk that have failed to explain the inequity, raising the concern that broader societal and structural conditions may at play. Moreover, despite evidence suggesting homicide is a leading cause of death during pregnancy and postpartum, it remains severely understudied. Failure to identify and address factors underlying pregnancy-associated homicide will perpetuate racial inequity in mortality during pregnancy and postpartum. Our overall objective in this application is to examine how key features of the social context in which women live ? income inequality, structural racism, community violence, and spatial social polarization ? increase their risk of death during pregnancy/postpartum and contribute to racial inequity in mortality. We will build upon and expand our existing vital records and social contexts databases to establish a system for public health monitoring of both distributions of health determinants and maternal population health across the country. This includes ongoing analyses of historical to the most recently available national death records and linkage of death, birth, and fetal death vital records from the state of Louisiana.
Our specific aims are (1) To identify which social contexts (income inequality, structural racism, violence, and spatial social polarization) increase risk for pregnancy-related mortality while developing a national geodatabase for monitoring trends in both social contexts and maternal deaths across the US, (2) To identify which social contexts (income inequality, structural racism, violence, and spatial social polarization) increase risk for pregnancy-associated homicide and to monitor trends in both over time, and (3) To identify distinct mediating pathways between social contexts and pregnancy-related mortality and pregnancy-associated homicide. The research includes two analytic designs: 1) national ecologic analysis of county-level pregnancy-related mortality and pregnancy-associated homicide, complemented by 2) local multi-level and mediation analysis to estimate individual- level mortality risk during pregnancy/postpartum. Findings from this work will include never before documented evidence of the social epidemiology of pregnancy-associated mortality and identification of targets for programmatic and policy intervention aimed at interrupting the pathway between adverse social contexts and death among pregnant and postpartum women.
This research represents a significant and innovative contribution to research on the entrenched and unacceptable racial inequity in mortality during pregnancy and postpartum. By focusing on social contextual factors ? exposures with broad scale and reach ? we seek to identify ways in which the largest number of women may be impacted by targeted programs and policies aiming to alter the context in which these deaths occur. Findings from this study will lay the foundation for continued monitoring of both obstetric and violent deaths among pregnant or postpartum women and provide the most accurate and complete picture of pregnancy-associated mortality in the country.