Severe Maternal Morbidity: An Investigation of Racial-Ethnic Disparities, Social Disadvantage & Maternal Weight

摘要 重度孕产妇死亡（SMM）包括在分娩或产后发生的对孕产妇健康和生存的严重威胁。 根据CDC开发的SMM指数，该指数侧重于最危及生命的病症和并发症，SMM的患病率从1998年至2011年翻了一番，目前每年影响美国> 65，000名妇女。 产妇保健对妇女照顾子女的能力和一生的健康至关重要，但我们对SMM的原因了解有限。 该提案涉及SMM研究的三个关键和未充分研究的领域：种族/民族差异，产妇体重和社会劣势。 SMM的种族/民族差异及其促成条件是众所周知的-相对于非西班牙裔白人，非西班牙裔黑人的SMM风险往往高出2.5倍，西班牙裔和亚洲人的风险往往高出1.5倍。 对这些差异的解释尚不清楚，但初步 有证据表明，母亲的体重和社会不利地位可能是原因之一。 在美国，25%的女性在怀孕时肥胖，一半在怀孕期间体重增加过多，25%保留>10磅。产后，但这因种族而异。 一些研究表明肥胖与SMM相关，但很少有人研究肥胖的严重程度，体重不足状态或体重变化。 社会劣势在非白人中比白人更常见，并与无数围产期结局相关，但几乎没有研究探讨其对SMM的贡献。 异常高和低的产妇体重和体重增加最有可能发生在社会弱势妇女中，但尚未研究其对SMM的相互影响。 我们的目标是通过分析2007年至2014年加州发生的400万例新生儿，增加对SMM及其种族/民族差异的生物和社会决定因素的理解。 这些数据包括生命记录和母亲和婴儿从怀孕到产后的出院数据。 结果将包括导致SMM的最常见疾病-产后出血，子痫/重度先兆子痫，选择心血管疾病和败血症-以及CDC开发的SMM指数。 具体目的是：1）检查孕妇体重状况的关联之前，期间，和之间 SMM妊娠及其是否因种族/民族而改变; 2）检查多水平的SMM总体和按种族/族裔分列的SMM社会不利（个人、家庭、邻里）指标（目标2a），以及这些关系受母亲体重状况影响的程度（目标2b）;（3）调查产妇体重状况和社会弱势对SMM人口负担的贡献及其种族/民族差异。拟议的研究将通过研究母亲体重，社会劣势，种族/民族差异和SMM之间的复杂关系来开辟新天地。这些知识对于制定有效的公共卫生和临床干预措施以减少SMM及其差异，包括产妇体重指南至关重要。

ABSTRACT  Severe Maternal Morbidity (SMM) includes serious threats to maternal health and survival that occur at delivery or postpartum. Based on the SMM index developed by CDC that focuses on the most life-­threatening conditions and complications, the prevalence of SMM doubled from 1998-­2011 and currently affects >65,000 women in the U.S. each year. Maternal health is essential to a woman’s ability to care for her children and to her health over her life course, yet our understanding of causes of SMM is limited. This proposal addresses three key and understudied areas of research for SMM: racial/ethnic disparities, maternal weight, and social disadvantage. Racial/ethnic disparities in SMM and its contributing conditions are well known – risk of SMM tends to be up to 2-­fold higher among non-­Hispanic blacks and 1.5-­fold higher among Hispanics and Asians, relative to non-­Hispanic whites. The explanation for these disparities is unknown, but preliminary evidence suggests that maternal weight and social disadvantage may contribute. In the U.S., 25% of women are obese at conception, half gain excessive weight during pregnancy, and 25% retain >10 lb. postpartum, but this varies by race-­ethnicity. Some studies suggest an association of obesity with SMM, but few have examined severity of obesity, underweight status, or weight change. Social disadvantage is much more common among non-­whites than whites and associated with myriad perinatal outcomes, but almost no studies have examined its contribution to SMM. Unusually high and low maternal weight and weight gain are most likely among socially disadvantaged women, but their inter-­related impacts on SMM have not been studied. Our goal is to increase understanding of biologic and social determinants of SMM and its racial/ethnic disparities, by analyzing 4 million births that occurred in California from 2007-­2014. The data include vital records and mother and infant hospital discharge data from pregnancy through postpartum. Outcomes will include the most common conditions that contribute to SMM – postpartum hemorrhage, eclampsia/severe preeclampsia, select cardiovascular conditions, and sepsis – as well as the SMM index developed by CDC. The Specific Aims are: 1) Examine associations of maternal weight status before, during, and between pregnancies with SMM and whether they are modified by race/ethnicity; 2) Examine associations of multi-­level (individual, household, neighborhood) indicators of social disadvantage with SMM, overall and by race/ethnicity (Aim 2a), and the extent to which these relationships are mediated by maternal weight status (Aim 2b); and 3) Investigate the contribution of maternal weight status and social disadvantage to the population burden of SMM and its racial/ethnic disparities. The proposed research will break new ground by studying the complex relationships among maternal weight, social disadvantage, racial/ethnic disparities, and SMM. This knowledge is essential to the development of effective public health and clinical interventions to reduce SMM and its disparities, including guidelines for maternal weight.