在美国,严重孕产妇发病率(SMM)的持续种族和族裔差异仍然是公共卫生问题。结构性种族主义使有色人种妇女处于不利地位,特别是在COVID-19期间,导致种族和少数民族妇女遭受不成比例的大流行折磨。
研究COVID-19大流行之前和期间SMM比率的种族和族裔差异,以及这种差异是否随黑人居住隔离的程度而变化。
一项基于全州人群的回顾性队列研究使用了与南卡罗来纳州所有付款人分娩索赔数据相关的出生证明。参与者包括2018年1月至2021年6月分娩的妇女。数据从2021年12月到2022年2月进行了分析。
接触是(1)妇女分娩的时期,无论是在大流行之前(2018年1月至2020年2月)还是在大流行期间(2020年3月至2021年6月)和(2)黑白住宅隔离(隔离指数),将一个县的美国人口普查范围归类为低(<40%),中等(40%-59%),高(≥60%)。
SMM是使用国际疾病统计分类确定的,第十次修订,美国疾病控制和预防中心开发的临床修改(ICD-10-CM)代码。使用了带有中断方法的多级逻辑回归,调整产妇水平和设施水平的因素,居民县级随机效应的核算。
在166791名女性中,95098(57.0%)生活在低隔离县(平均[SD]年龄,28.1[5.7]年;5126[5.4%]西班牙裔;20523[21.6%]非西班牙裔黑人;62690[65.9%]白人),和23521名(14.1%)女性(平均[SD]年龄,28.1[5.8]年;782[3.3%]西班牙裔;12880[54.8%]非西班牙裔黑人;7988[34.0%]白人)生活在高隔离地区。大流行前SMM率正在下降,其次是2020年3月后的月度增长趋势。平均而言,生活在高隔离社区与SMM的几率更高(调整后的优势比[AOR],1.61;95%CI,1.06-2.34)。无论居住隔离如何,黑人女性患SMM的几率都高于白人女性(AOR,1.47;95%CI,低偏析1.11-1.96;2.12;95%CI,高偏析1.38-3.26)。生活在低隔离社区的西班牙裔妇女患SMM的几率较低(AOR,0.48;95%CI,0.25-0.90),但生活在高隔离社区的人患SMM的几率接近两倍(aOR,1.91;95%CI,1.07-4.17)与白人同行。
生活在南卡罗来纳州高度隔离的黑人社区与种族和族裔SMM差异有关。在COVID-19大流行期间,黑白差距持续存在,没有差距扩大的迹象,而西班牙裔与白人之间的差异加剧。有必要进行减少居住隔离或打击相应的结构性种族主义的政策改革,以帮助改善孕产妇健康。
Persistent racial and ethnic disparities in severe maternal morbidity (SMM) in the US remain a public health concern. Structural racism leaves women of color in a disadvantaged situation especially during COVID-19, leading to disproportionate pandemic afflictions among racial and ethnic minority women.
To examine racial and ethnic disparities in SMM rates before and during the COVID-19 pandemic and whether the disparities varied with level of Black residential segregation.
A statewide population-based retrospective cohort study used birth certificates linked to all-payer childbirth claims data in South Carolina. Participants included women who gave birth between January 2018 and June 2021. Data were analyzed from December 2021 to February 2022.
Exposures were (1) period when women gave birth, either before the pandemic (January 2018 to February 2020) or during the pandemic (March 2020 to June 2021) and (2) Black-White residential segregation (isolation index), categorizing US Census tracts in a county as low (<40%), medium (40%-59%), and high (≥60%).
SMM was identified using International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes developed by the US Centers for Disease Control and Prevention. Multilevel logistic regressions with an interrupted approach were used, adjusting for maternal-level and facility-level factors, accounting for residential county-level random effects.
Of 166 791 women, 95 098 (57.0%) lived in low-segregated counties (mean [SD] age, 28.1 [5.7] years; 5126 [5.4%] Hispanic; 20 523 [21.6%] non-Hispanic Black; 62 690 [65.9%] White), and 23 521 (14.1%) women (mean [SD] age, 28.1 [5.8] years; 782 [3.3%] Hispanic; 12 880 [54.8%] non-Hispanic Black; 7988 [34.0%] White) lived in high-segregated areas. Prepandemic SMM rates were decreasing, followed by monthly increasing trends after March 2020. On average, living in high-segregated communities was associated with higher odds of SMM (adjusted odds ratio [aOR], 1.61; 95% CI, 1.06-2.34). Black women regardless of residential segregation had higher odds of SMM than White women (aOR, 1.47; 95% CI, 1.11-1.96 for low-segregation; 2.12; 95% CI, 1.38-3.26 for high-segregation). Hispanic women living in low-segregated communities had lower odds of SMM (aOR, 0.48; 95% CI, 0.25-0.90) but those living in high-segregated communities had nearly twice the odds of SMM (aOR, 1.91; 95% CI, 1.07-4.17) as their White counterparts.
Living in high-segregated Black communities in South Carolina was associated with racial and ethnic SMM disparities. During the COVID-19 pandemic, Black vs White disparities persisted with no signs of widening gaps, whereas Hispanic vs White disparities were exacerbated. Policy reforms on reducing residential segregation or combating the corresponding structural racism are warranted to help improve maternal health.