Health Disparities
When Education Fails to Protect: Severe Maternal Morbidity at the Intersection of Race/Ethnicity and Maternal Education Rashida S. Smith-Webb* Rashida S. Smith-Webb Martha M. Werler Samantha E. Parker Kelleher Collette N. Ncube
Background: Health disparities in severe maternal morbidity (SMM) across various dimensions of social inequality are well documented; however, limited research has explored how multiple axes of marginalization intersect to shape these disparities. Guided by intersectionality theory, we examined differences in SMM rates at the intersection of race/ethnicity and education.
Methods: We used the Massachusetts Pregnancy to Early Life Longitudinal Data System to identify nulliparous birthing people, aged 12-55 years, from 1998-2021. SMM during delivery hospitalizations was determined using the Centers for Disease Control and Prevention criteria. We used binomial regression models to estimate SMM rates and RD (95% CI) per 10,000 deliveries for six intersectional groups, defined by race/ethnicity (Black, Hispanic, White) and maternal education (no college degree, college degree or higher), adjusted for age, nativity, marital status, and delivery year.
Results: Rates of SMM were highest for Black birthing people with a college degree or higher (314) and lowest for their White counterparts (213). For White and Hispanic birthing people, higher levels of education were associated with lower rates of SMM. However, among Black birthing people, rates of SMM were similar for those with (314) and without a college degree (310). Compared to White birthing people with a college degree or higher, Black birthing people, regardless of education, had an excess of about 100 SMM cases: no college degree RD=102 (75, 128); at least a college degree RD=98 (83, 113). For Hispanic birthing people, RDs of 25 (4, 45) and 58 (46, 70) were observed for those with and without a college degree, respectively. Similar patterns emerged, albeit attenuated when examining SMM without blood transfusions.
Conclusion: Higher levels of education offer little protection against SMM for Black birthing people. Addressing structural racism and other socioeconomic drivers is critical to mitigating disparities in SMM.