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: 10280836
• 负责人: SUZAN L CARMICHAEL
• 金额: $ 74.85万
• 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/10280836
• 关键词: Address; Affect; African American; Anemia; Attention; Birth; Caring; Censuses; Cesarean section; Clinical; Code; Color; 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; Structure; 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

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）比任何国家都严重 是其他高收入国家中唯一一个这一比率正在上升的国家。严重的孕产妇发病率 （SMM），其中包括使孕妇面临最高死亡风险的疾病，在过去的一年中翻了一番 二十年。有色人种女性，尤其是黑人和美洲原住民女性，这一比例是 2-3 倍或更高 这些结果的风险增加。该提案重点关注 SMM，作为通向 MM 的哨兵结果， 但常见程度却高出 100 倍。大多数 SMM 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）；仅凭这些因素还不足以 解释 SMM 或其种族/民族差异。该提案的目标是：1）制定因果关系 路径框架，以了解社会决定因素和更近的健康相关因素如何 共同造成 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。我们将创建一个独特的数据集，协调 4 来自 6 个州的 440 万名新生儿和 66,000 名患有 SMM 的妇女的多年数据。这些州统称为 包括四分之一的美国出生人口和足够多样化的社会环境来理清复杂的多层次驱动因素 孕产妇健康不平等。我们的重点是来自 4 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的获取，其特点是 县、社区（人口普查区或邮政编码）和个人级别。健康相关中介机构 包括分娩医院的护理质量、分娩方式和孕产妇疾病（例如高血压、贫血）。 选择这些领域和中介是因为它们与种族/民族差异的相关性 孕产妇健康。此外，我们将评估 3 个质量改进 (QI) 合作对 SMM 差异，旨在改善医院护理质量的特定方面和 由全州围产期质量协作机构 (PQC) 在本报告所包括的 6 个州中的 3 个州实施 提议。我们的具体目标是： 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) 确定潜在的健康相关机制 通过进行因果路径分析，多层次社会决定因素影响SMM和SMM差异； 3) 评估 3 个旨在减少 SMM 的 QI 合作对 SMM 中种族/民族差异的影响 (3a)，并将目标 1 和 2 中制定的因果框架应用于这些特定于州的情况，以确定 解决 SMM 差异的州特定策略 (3b)。我们目前的了解非常有限 社会决定因素如何影响 SMM 或其差异。拟议的研究将填补这一重要空白 知识差距是实现孕产妇健康可持续改善的重要组成部分 消除种族/民族差异。