Available online 3 May 2023

Author links open overlay panel, , , , , , AbstractPurpose

To measure associations of area-level racial and economic residential segregation with severe maternal morbidity (SMM).

Methods

We conducted a retrospective cohort study of births at two Philadelphia hospitals between 2018-2020 to analyze associations of segregation, quantified using the Index of Concentration at the Extremes (ICE), with SMM. We used stratified multivariable, multilevel, logistic regression models to determine whether associations of ICE with SMM varied by self-identified race or hospital catchment.

Results

Of the 25,979 patients (44.1% Black, 35.8% White), 1,381 (5.3%) had SMM (Black [6.1%], White [4.4%]). SMM was higher among patients residing outside (6.3%), then inside, (5.0%) Philadelphia (P<0.001). Overall, ICE was not associated with SMM. However, ICErace (higher proportion of White vs. Black households) was associated with lower odds of SMM among patients residing inside Philadelphia (aOR 0.87, 95% CI: 0.80–0.94) and higher odds outside Philadelphia (aOR 1.12, 95% CI: 0.95–1.31). Moran’s I indicated spatial autocorrelation of SMM overall (P<0.001); when stratified, autocorrelation was only evident outside Philadelphia.

Conclusions

Overall, ICE was not associated with SMM. However, higher ICErace was associated with lower odds of SMM among Philadelphia residents. Findings highlight the importance of hospital catchment area and referral patterns in spatial analyses of hospital datasets.

Section snippetsINTRODUCTION

Severe maternal morbidity (SMM) in the United States increased by nearly 200% between 1993 and 2014, and is continuing to rise [1]. SMM is defined by the Centers for Disease Control and Prevention (CDC) as “unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health.” [1], [2] The CDC tracks SMM using administrative hospital-discharge data and International Classifications of Diseases (ICD) diagnostic and procedural codes [1].

MATERIALS AND METHODS

We conducted a retrospective cohort study that included patients with singleton, live births from January 1, 2018, through December 31, 2020, in two hospitals within the University of Pennsylvania’s Health System, the Hospital of the University of Pennsylvania and Pennsylvania Hospital. The study cohort was generated through a query of patients’ electronic medical records (EMRs) including demographic and obstetric data as well as International Classification of Diseases, Tenth Revision (ICD-10)

RESULTS

Our initial dataset included 27,198 patients. After applying exclusion criteria, 25,979 patients were included in analyses (Figure A1). Overall, 5.32% of patients experienced SMM, or 532 per 10,000 live births from January 1, 2018, through December 31, 2020. The most common SMM indicator was blood product transfusion, occurring in 3.34% of all patients and in 62.9% of patients with SMM (Table 1). Excluding blood transfusions, 2.57% of patients experienced SMM, or 257 per 10,000 live births.

DISCUSSION

In a hospital system-based birth cohort, we found that associations of racial residential segregation (ICErace) with SMM differed between Philadelphia residents and patients living outside Philadelphia. Overall, we observed higher odds of SMM among White patients from higher income areas (ICEincome). Since this finding was counter to our hypothesis, additional analyses, including stratification by Philadelphia residential status, revealing the expected findings of lower odds of SMM among

Limitations

Limitations of this study include the reliance on EMR data coding, specifically ICD-10 codes during patient encounters, which can cause possible misclassification biases and under-ascertainment. Data on prior cesarean births was not available for this study. This study was not population-based, and thus may reduce generalizability. However, as these hospitals account for 51% of all Philadelphia births, stratifying by Philadelphia residential status allowed us to get closer to a

CONCLUSIONS

In conclusion, we found that Philadelphia residential status modified associations of census-tract level indices of the concentrations of the extremes with SMM among patients at two Philadelphia Hospitals. Therefore, this study makes important methodological strides with respect to use of area-level variables with hospital datasets and highlights the importance of considering hospital catchment area and referral patterns when analyzing the effects of neighborhood factors on outcomes using

CRediT authorship contribution statement

Katey E. Mari: Conceptualization, Methodology, Formal Analysis, Investigation, Software, Writing-Original Draft and Review and Editing, Visualization. Nancy Yang: Methodology, Formal Analysis, Software, Data Curation, Validation, Writing- Review and Editing. Mary Regina Boland: Writing- Review and Editing. Jessica R Meeker: Writing- Review and Editing. Rachel Ledyard: Data Curation, Software, Validation. Elizabeth A Howell: Writing- Review and Editing. Heather H. Burris: Conceptualization,

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Heather H. Burris reports financial support was provided by National Institutes of Health

Acknowledgements/Funding

Funding to develop the cohort used for this analysis came from The Penn March of Dimes Prematurity Research Center (PI Driscoll) and NIH/NHLBI (R01 HL157160, PIs Burris and South). The funding sources were not involved in the design, analysis, or preparation of this manuscript.

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