Women’s Health
The Contribution of Contextual Factors to Geographic Variation in Pregnancy-Related Mortality: A Multilevel Analysis Chloe M. Barrera, PhD, MPH* Chloe Barrera David A. Goodman, PhD, MS Sarah Blake, PhD, MA Lauren Christiansen-Lindquist, PhD, MPH Alex Peahl, MD, MSc Michael R. Kramer, PhD, MMSc
Background Racial and geographic disparities in US pregnancy-related mortality are significant and persistent. This analysis assesses geographic variation in pregnancy-related deaths and the role of individual and county-level factors.
Methods Pregnancy Mortality Surveillance System data were linked with publicly available county-level indicator data. Three-level Poisson regression models (individuals, counties, regions) stratified by non-Hispanic Black/White race were used to estimate associations between county-level indicators and pregnancy-related mortality. We calculated median rate ratios (MRRs) from the estimated variance of the random effects for county and region to quantify the magnitude of the between geographic variance unexplained by the variables in each model. Model 1 was adjusted for individual characteristics and Models 2-6 were additionally adjusted for county-level indicators of economic stability, neighborhood environment, education and literacy, social context, and health.
Results Our analysis included 3,561 pregnancy-related deaths and 22,822,719 live births, representing 88% of all known pregnancy-related deaths and 99% of all known live births during 2014-2019. In Model 1, we found intercounty and interregional variation in pregnancy-related mortality among both Black and White populations. When county-level indicators were adjusted for, there was attenuation of the MRR that was generally greater among the White compared to Black population. For example, the introduction of county-level health indicators reduced the regional MRR from 1.35 to 1.09 among the White population and from 1.37 to 1.25 among the Black population.
Conclusion Geographic inequities in pregnancy-related deaths are experienced differently by non-Hispanic Black and non-Hispanic White women living in the same geographic units. Strategies are needed to address inequities in pregnancy-related deaths at different geographic levels.