Topic: How neighborhood racial and economic spatial polarization, an extreme form of residential segregation, influences maternal health.
What: The objective was to examine whether racial and economic spatial polarization is associated with severe maternal morbidity rates, and whether the delivery hospital partially explains the association.
When: We analyzed New York City birth and hospitalization data from 2012-2014 along with U.S. Census data.
Who: The study included 316,600 women living in New York City who gave birth in a New York City hospital.
Results: Our examination of racial and economic social polarization in association with severe maternal morbidity in New York City found stark differences in risk of severe maternal morbidity across neighborhoods. Women living in zip codes with the highest concentration of poor blacks relative to wealthy whites experienced 4.0 cases of severe maternal morbidity per 100 deliveries, compared with 1.7 cases per 100 deliveries among women in the neighborhoods with the lowest concentration (risk difference=2.4 cases per 100). Thirty-five percent of this difference was attributable to the delivery hospital. The associations between racial and economic spatial polarization and severe maternal morbidity were of the largest magnitude among black and Latina women.
Why the Research Is Interesting: Our examination of racial and economic social polarization in association with severe maternal morbidity in New York City found stark differences in risk of severe maternal morbidity across neighborhoods. These differences were due in part to the hospital of delivery. Neighborhoods with extreme racial polarization experienced the greatest excess risk of severe maternal morbidity. Furthermore, the associations between racial and economic spatial polarization and severe maternal morbidity were of the largest magnitude among black and Latina women.
The study also suggests that neighborhood polarization plays a role in the disparate care received by black and Latina women and must be considered in any strategy to reduce severe maternal morbidity disparities. Improving women's health in neighborhoods with a high relative concentration of black residents or low-income households could reduce comorbidities, in particular for women of color. At the same time, part of the excess burden of severe maternal morbidity in those neighborhoods is due to the hospital of delivery, which indicates that women in these neighborhoods could benefit by accessing the same quality of obstetric care as do women in neighborhoods with a high relative concentration of white residents or high-income households.
Background: In the United States, compared to white women, black women are three times more likely to experience a pregnancy-related death. In New York City, Asian and Latina women are also at increased risk. In the city, black and Latina women are also three and two times, respectively, more likely than white women to experience severe maternal morbidity, defined as having a life-threatening condition or life-saving procedure during childbirth. Alarmingly, both severe maternal morbidity and mortality are increasing in the United States. Legislation has been enacted at the federal and state levels in response to the crisis of rising maternal death rates, which creates the opportunity to develop strategies for reducing the risk of maternal mortality and decreasing disparities. To create effective intervention strategies, it is important to learn the underlying macro-level determinants that drive increased risk for women of color. One important determinant of severe maternal morbidity may be the geography of racial and economic privilege and disadvantage, which is patterned by structural racism. Structural racism is the manifestation of historical and current oppression that shapes neighborhoods and institutions, which results in differential access to opportunities and resources. Public health policy makers acknowledge that historical discriminatory housing practices (called redlining) in New York City have had a lasting effect on neighborhood racial segregation and institutions serving those neighborhoods. At the same time, growing economic inequality globally has brought increasing attention to social inequality and polarization, and a concern exists that this growing polarization is reflected in urban neighborhoods. Racial and economic spatial polarization, defined as extreme concentrations of residents from certain racial/ethnic or economic groups in a given neighborhood, may have a profound impact on health, including severe maternal morbidity. A growing body of literature suggests that racial and economic spatial polarization is associated with adverse health outcomes, including birth outcomes. This literature builds on decades of evidence regarding the ill effects of racial segregation on infant outcomes, particularly among infants of black women. However, racial segregation--including racial spatial polarization--has not been studied in association with maternal health outcomes, including severe maternal morbidity.
Said Mount Sinai's Dr. Teresa Janevic about the research:
"Previous research has documented that a sizable portion of racial and ethnic disparities in severe maternal morbidity rates were explained by between-hospital differences--i.e., black and Latina mothers receiving care at hospitals with worse outcomes. This study digs deeper to study if structural racism, manifested as the geography of racial and economic privilege and disadvantage in New York City, lays the foundation for the hospital-level disparities in care. Women in poor black neighborhoods were four times more likely to experience a life-threatening event in childbirth than women in wealthy white neighborhoods, and this was partially due to their delivery hospital. These findings suggest that policies addressing racial and economic segregation, health promotion in highly polarized neighborhoods, and quality improvement in hospitals that serve these neighborhoods are needed."
Funding: This study was funded by the National Institute on Minority Health and Health Disparities (R01MD007651)
Corresponding Author: Teresa Janevic, PhD, Assistant Professor of Obstetrics, Gynecology, and Reproductive Science, and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
*This research is supported by The Blavatnik Family Women's Health Research Institute