Multilevel Determinants of Racial and Ethnic Disparities in Maternal Morbidity and Mortality in the Context of COVID-19 Pandemic

摘要 每年在美国，近60，000名妇女经历了严重的孕产妇发病率和死亡率（SMMM）， 即使在COVID-19大流行之前，种族/民族之间的健康差异也很大。前所未有的 COVID-19大流行对有色人种社区的打击最大。非西班牙裔黑人和西班牙裔妇女， 怀孕妇女的SARS-CoV-2感染率和死亡率似乎不成比例。的相关问题 COVID-19大流行对SMMM种族差异的影响以及 多层次的决定因素，如更广泛的社会背景的SMMM仍然没有答案。总体目标 这项研究的目的是调查产妇发病率和死亡率（MMM）的种族/民族差异， 社会背景的贡献作用和中介途径（例如，居住隔离、种族隔离 贫困、教育、失业和住房所有权方面的歧视），以及他们长期的健康状况 产后的后果我们将通过研究COVID-19病例的分布来实现我们的目标， 南卡罗来纳州（SC）产妇健康的多层次决定因素， SMMM在历史系统的南方背景下，在美国，我们将建立在我们现有的全州范围内 SC COVID-19队列（S3 C）通过创建一个怀孕队列，将COVID-19检测数据，电子 健康记录（EHR）和2019-2020年SC所有出生的出生证明数据。为了确保普遍性， 我们将使用正在进行的国家COVID队列协作的EHR数据来证实我们的发现， （N3C）。全国范围的社会背景数据库和随时间变化的COVID-19严重程度和社交距离政策 将添加到S3 C和N3 C数据中。我们将使用社会生态框架， 三角测量，混合方法的研究设计，以实现三个具体目标：1）检查的影响， 2019冠状病毒病大流行对MMM种族/民族差异的影响; 2）研究和探索MMM的主要特征 社会背景导致MMM在流行期间种族/民族差异扩大 (Aim 2a）通过产妇护理和心理健康确定不同的调解途径（目标2b）; 研究社会背景因素的作用，并确定种族/民族差异的保护因素， 怀孕相关的长期发病率使用机器学习算法。对于目标2b， 将采用平行设计，其中包括对SC PRAMS数据的定量分析和定性分析。 产后妇女（20名黑人，20名西班牙裔）和10名产妇护理提供者的采访。我们经验丰富 团队有能力调查COVID-19期间MMM种族差异的复杂性 流行病，同时考虑到历史上的结构性种族主义在种族，社会经济和地理上， 不同的孕妇群体。严格审查社会背景下的种族/民族差异， 大流行期间的MMM和心理健康将为继续努力扭转 美国的SMMM。我们的提案涉及NOT-OD-21-071中的区域1、2和4。

Abstract Annually in the U.S., nearly 60,000 women experience severe maternal morbidity and mortality (SMMM) with substantial health disparities by race/ethnicity, even prior to the COVID-19 pandemic. The unprecedented COVID-19 pandemic has hit communities of color the hardest. Non-Hispanic Black and Hispanic women who are pregnant appear to have disproportionate SARS-CoV-2 infection and death rates. Questions regarding the impact of the COVID-19 pandemic on racial disparities in SMMM and the dynamics and interactions of multilevel determinants such as broader social contexts of SMMM remain unanswered. The overarching goal of this study is to investigate racial/ethnic disparities in maternal morbidity and mortality (MMM), the contributing roles and mediating pathways of social contexts (e.g., residential segregation, racial discrimination in poverty, education, unemployment, and home ownership), and their long-standing health consequences postpartum. We will achieve our goal by studying the distributions of COVID-19 cases and multilevel determinants of maternal health in South Carolina (SC), a state with persistent racial disparities in SMMM within historical systemic Southern contexts, and in the U.S. We will build upon our existing statewide SC COVID-19 Cohort (S3C) by creating a pregnancy cohort that will link COVID-19 testing data, electronic health records (EHR), and birth certificate data for all births in SC in 2019-2020. To ensure the generalizability of our findings, we will confirm them using EHR data from the ongoing National COVID Cohort Collaborative (N3C). Nationwide social context databases and time-varying COVID-19 severity and social distancing policies will be added to S3C and N3c data. We will use the socio-ecological framework and employ a concurrent triangulation, mixed methods study design to achieve three specific aims: 1) to examine the impacts of the COVID-19 pandemic on racial/ethnic disparities in MMM; 2) to examine and explore how the key features of social contexts have contributed to the widening of racial/ethnic disparities in MMM during the pandemic (Aim 2a) and identify distinct mediating pathways through maternity care and mental health (Aim 2b); and 3) to examine the role of social contextual factors and identify protective factors for racial/ethnic disparities in pregnancy-related, long-standing morbidities using machine learning algorithms. For Aim 2b, a convergent parallel design will be used, which includes a quantitative analysis of data from SC PRAMS and qualitative interviews of postpartum women (20 Black, 20 Hispanics) and 10 maternal care providers. Our experienced team is well positioned to investigate the complexity of racial disparities in MMM during the COVID-19 pandemic, while considering historical structural racism in a racially, socioeconomically, and geographically diverse population of pregnant women. A rigorous examination of social contexts on racial/ethnic disparities in MMM and mental health during the pandemic will inform continuing efforts to reverse the rising trends of SMMM in the U.S. Our proposal addresses Areas 1, 2, & 4 in the NOT-OD-21-071.