Neighborhood-level Measures of Structural Racism and Severe Maternal Morbidity Among Black Mothers in California

Drivers of persistent racial-ethnic inequities in severe maternal morbidity are poorly understood. This study examined how neighborhood-level structural racism measures shape risk of severe maternal morbidity among Black mothers.

Data are from live hospital births in California between 1997 and 2019 at ≥20 weeks' gestation (N = 555,511). We leveraged information from the U.S. Census Bureau and the American Community Survey to determine neighborhood (census tract) measures of structural racism across six domains (homeownership, unemployment, poverty, educational attainment, racialized economic deprivation, and racial residential segregation). We used (1) an additive composite index (quartile 1 [low]-quartile 4 [high]) and (2) latent class analysis to characterize four structural racism typologies. We examined associations across both measurement approaches using mixed-effects logistic regression models with neighborhood random intercepts, adjusting for maternal age, education, and hospital payer/insurance information.

Black mothers living in neighborhoods scoring high (quartile 4) on the additive composite index had 13% higher risk of severe maternal morbidity than those in neighborhoods scoring low (quartile 1) (95% confidence interval = 1.04, 1.24). Models evaluating latent class typologies also revealed that Black mothers living in neighborhoods characterized by consistently high racial inequity in unemployment, racialized economic deprivation, and racial residential segregation across the study period had a 12% higher risk of severe maternal morbidity compared with those in neighborhoods consistently scoring low in the domains examined (95% confidence interval = 1.03, 1.23).

Our findings support the hypothesis that neighborhood-level measures of structural racism influence the risk of severe maternal morbidity among Black mothers.