Individual-Level and Neighborhood-Level Risk Factors for Severe Maternal Morbidity
Jessica R Meeker1, Silvia P Canelón, Ray Bai
1Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, the Institute for Biomedical Informatics, the Center for Excellence in Environmental Toxicology, the Center for Public Health Initiatives, the Leonard Davis Institute for Health Economics, and the Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, and the Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and the Department of Statistics, University of South Carolina, Columbia, South Carolina.
Objective:
To investigate the association between individual-level and neighborhood-level risk factors and severe maternal morbidity.
Methods:
This was a retrospective cohort study of all pregnancies delivered between 2010 and 2017 in the University of Pennsylvania Health System. International Classification of Diseases codes classified severe maternal morbidity according to the Centers for Disease Control and Prevention guidelines. Logistic regression modeling evaluated individual-level risk factors for severe maternal morbidity, such as maternal age and preeclampsia diagnosis. Additionally, we used spatial autoregressive modeling to assess Census-tract, neighborhood-level risk factors for severe maternal morbidity such as violent crime and poverty.
Results:
Overall, 63,334 pregnancies were included, with a severe maternal morbidity rate of 2.73%, or 272 deliveries with severe maternal morbidity per 10,000 delivery hospitalizations. In our multivariable model assessing individual-level risk factors for severe maternal morbidity, the magnitude of risk was highest for patients with a cesarean delivery (adjusted odds ratio [aOR] 3.50, 95% CI 3.15-3.89), stillbirth (aOR 4.60, 95% CI 3.31-6.24), and preeclampsia diagnosis (aOR 2.71, 95% CI 2.41-3.03). Identifying as White was associated with lower odds of severe maternal morbidity at delivery (aOR 0.73, 95% CI 0.61-0.87). In our final multivariable model assessing neighborhood-level risk factors for severe maternal morbidity, the rate of severe maternal morbidity increased by 2.4% (95% CI 0.37-4.4%) with every 10% increase in the percentage of individuals in a Census tract who identified as Black or African American when accounting for the number of violent crimes and percentage of people identifying as White.
Conclusion:
Both individual-level and neighborhood-level risk factors were associated with severe maternal morbidity. These factors may contribute to rising severe maternal morbidity rates in the United States. Better characterization of risk factors for severe maternal morbidity is imperative for the design of clinical and public health interventions seeking to lower rates of severe maternal morbidity and maternal mortality.
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