Building a causal pathway framework to identify interventions to eliminate racial/ethnic disparities in severe maternal morbidity

建立因果路径框架，以确定消除严重孕产妇发病率方面的种族/民族差异的干预措施

• 批准号: 10490296
• 负责人: SUZAN L CARMICHAEL
• 金额: $ 69.39万
• 依托单位: STANFORD UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-09-17 至 2026-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10490296
• 关键词: Address; Affect; Anemia; Attention; Birth; Black American; Caring; Censuses; Cesarean section; Clinical; Code; Communities; Complex; Country; County; Data; Data Set; Discipline of obstetrics; Health; Health Services; Health Services Accessibility; Hospitals; Hypertension; Improve Access; Income; Individual; Inequality; Institutional Racism; Intervention; Joints; Knowledge; Lead; Life; Maternal Health; Maternal Mortality; Maternal-fetal medicine; Methods; Native Americans; Neighborhoods; Outcome; Pathway Analysis; Pathway interactions; Perinatal; Perinatal Epidemiology; Physiological; Population; Predisposition; Pregnant Women; Prevention strategy; Quality of Care; Research; Resources; Risk; Sentinel; Social Environment; Solid; Time; Woman; base; comorbidity; design; disparities in morbidity; evidence base; health care availability; health care quality; health disparity; health equity; health inequalities; implicit bias; improved; large scale data; maternal morbidity; multidisciplinary; prevent; racial and ethnic disparities; severe maternal morbidity; social determinants; social epidemiology; sociodemographics; socioeconomic disadvantage; trend; women of color

ABSTRACT The US is in the midst of a maternal health crisis. The US has worse maternal mortality (MM) than any other high-income country and is the only one for which the rate is increasing. Severe maternal morbidity (SMM), which encompasses conditions that put pregnant women most at risk of dying, doubled in the last two decades. Women of color, especially Black and Native American women, are at 2-3-fold or greater increased risk of these outcomes. This proposal focuses on SMM, as a sentinel outcome leading to MM, yet 100 times more common. Most prior research on SMM has focused on proximal clinical factors (primarily related to co-morbidities and obstetric management); these factors alone are insufficient for explaining SMM or its racial/ethnic disparities. The objectives of this proposal are: 1) develop a causal pathway framework to understand how social determinants and more proximal health-related factors together contribute to SMM risk and disparities, and 2) use this framework to identify actionable strategies to reverse current trends and eliminate inequities. We will create a unique dataset that harmonizes 4 years of data from 6 states on 4.4 million births and 66,000 women with SMM. These states collectively include 1 in 4 US births and sufficiently diverse social environments to disentangle complex multi-level drivers of maternal health inequity. Our focus is on social determinants from 4 specific domains: socioeconomic disadvantage, structural inequality, community resources, and health care access, characterized at the county, neighborhood (census tract or ZIP code), and individual level. Health-related intermediaries include birth hospital quality of care, mode of birth, and maternal morbidities (eg, hypertension, anemia). These domains and intermediaries were selected for their relevance to racial/ethnic disparities in maternal health. In addition, we will evaluate impacts of 3 Quality Improvement (QI) collaboratives on SMM disparities, which were designed to improve specific aspects of hospital quality of care and implemented by state-wide perinatal quality collaboratives (PQCs) in 3 of the 6 states included in this proposal. Our Specific Aims are: 1) Assess the relative and joint contributions of multi-level social determinants to SMM and SMM disparities; 2) Identify potential health-related mechanisms by which multi-level social determinants affect SMM and SMM disparities by conducting causal pathway analyses; and 3) Evaluate the impact of 3 QI collaboratives designed to reduce SMM, on racial/ethnic disparities in SMM (3a), and apply the causal framework developed in Aims 1 and 2 to these state-specific contexts, to identify state-specific strategies for addressing SMM disparities (3b). We currently have very limited understanding of how social determinants contribute to SMM or its disparities. The proposed research will fill this important knowledge gap, which is an essential part of realizing sustainable improvement of maternal health and elimination of racial/ethnic disparities.

抽象的 美国正处于孕产妇健康危机之中。美国的孕产妇死亡率（MM）比任何人都要差 其他高收入国家，也是唯一提高利率的国家。严重的母亲发病率 （SMM）包括使孕妇最有可能死亡的危险的状况，在最后一倍 二十年。有色女性，尤其是黑人和美国原住民妇女，身高2-3倍或更高 这些结果的风险增加。该提案的重点是SMM，作为通往MM的前哨结果， 然而，普遍的100倍。关于SMM的大多数先前研究都集中在近端临床因素上 （主要与合并症和产科管理有关）；仅这些因素就不足 解释SMM或其种族/种族差异。该提案的目标是：1）发展因果关系 途径框架，以了解社会决定因素和更近端健康相关的因素如何 共同有助于SMM风险和差异，2）使用此框架来确定可行的策略 扭转当前趋势并消除不平等。我们将创建一个统一的独特数据集4 来自6个州的440万个出生和66,000名SMM女性的数据。这些国家集体 包括美国四分之一的出生和足够多样化的社会环境，以消除复杂的多级驱动程序 孕产妇健康不平等。我们的重点是来自四个特定领域的社会决定因素：社会经济 劣势，结构性不平等，社区资源和医疗保健获取，以此为特征 县，邻里（人口普查区或邮政编码）和个人级别。与健康有关的中介机构 包括出生医院的护理质量，出生方式和孕产妇病毒（例如，高血压，贫血）。 这些领域和中介被选为与种族/种族差异相关的 孕产妇健康。此外，我们将评估3种质量改进（QI）协作的影响 SMM差异旨在改善医院护理质量和 由全州范围的围产期质量合作组织（PQC）在此包含的6个州中的3个实施 提议。我们的具体目的是：1）评估多层次社会的相对和共同贡献 SMM和SMM差异的决定因素； 2）确定潜在的与健康相关的机制 多层社会决定因素通过进行因果途径分析来影响SMM和SMM差异。 3）评估旨在减少SMM的3个Qi合作申请对SMM种族/族裔差异的影响 （3a），并将目标1和2中开发的因果框架应用于这些特定国家的环境，以识别 解决SMM差异的国家特定策略（3B）。我们目前对 社会决定因素如何促进SMM或其差异。拟议的研究将填补这一重要的 知识差距，这是实现可持续改善孕产妇健康和 消除种族/种族差异。