Assessing Social Determinants of Maternal and Infant Health: State Policy Strategies to Improve Population Health and Reduce Racial Disparities
Open AccessThe United States has high rates of maternal and infant mortality compared with similar countries and there are substantial, persistent racial disparities. In 2020, the maternal death rate was nearly three times higher for non-Hispanic Black women (55.3 deaths per 100,000 live births) than for non-Hispanic white women (19.1). In 2019, there were 5.58 infant deaths per 1,000 live births and the rate for infants born to non-Hispanic Black birthing people was more than double the rates for infants born to non-Hispanic white, non-Hispanic Asian, and Hispanic birthing people (10.62 compared to 4.49, 3.38, and 5.03, respectively). These trends are particularly troubling because maternal and infant mortality are sentinel indicators of population health and health care performance. The causes of maternal and infant mortality are complex and multifaceted. Most existing literature and interventions focus on individual-level and health care factors. However, these factors fail to fully explain observed disparities. By contrast, distal factors like sociopolitical and physical environments, discrimination, and socioeconomic position constrain downstream health care factors and individual lifestyle behaviors that may have consequences for maternal and infant health. Public policies provide a unique opportunity to intervene on social determinants of maternal mortality, because they are structural factors that shape both the distribution of maternal health risks and individual opportunities and behaviors. Moreover, policies are mutable. This dissertation investigates state-level policies that may drive the social patterning of maternal and infant mortality in the United States. The first chapter investigates Maternal Mortality Review Committees (MMRCs) as a strategy to reduce geographic and racial disparities. MMRCs are a key national strategy to reduce maternal mortality and are multidisciplinary committees that conduct maternal mortality surveillance and make recommendations to prevent future deaths. MMRCs traditionally focused on clinical quality improvement and safety to prevent maternal deaths but are broadening their scope of work in response to the newer aims to reduce social inequalities in maternal health. This broader scope requires enhanced capacities such as staffing and more comprehensive review activities. Using semi-structured interviews from purposely selected cases and a thematic content analysis approach, this study identifies certain structural features and actions of MMRCs as key conditions for them to reduce social inequalities in maternal mortality. Participants described the following key components and activities they believe MMRCs need to meet these new goals: (1) having a scope and mission to reduce social inequalities; (2) reliable sources, collection, and analysis of data on non-clinical factors; (3) broad and diverse committee membership with holistic expertise; and (4) resources to support enhanced reviews. They described three barriers to their work: (1) lack of evidence on social interventions to prevent maternal mortality; (2) lack of knowledge of the existing evidence base; and (3) lack knowledge of how to make structural recommendations from individual case reviews. Finally, respondents generally believe implementation to be beyond the scope of MMRCs and described relying on community partnerships to advocate for and to support dissemination and implementation of MMRC findings and recommendations. The second chapter builds on the first chapter to empirically assess the structures and activities of MMRCs theorized to be key conditions to reduce social inequalities in maternal mortality and to reduce maternal mortality overall. Drawing from legal documents, this study first describes the prevalence of these key components across all MMRCs in the U.S. and finds substantial variation. In addition, most of the components are present in only a fraction of MMRCs. Then, using vital statistics data on maternal deaths, the paper examines the relationships between these key components and maternal mortality overall, and by race and education. It finds significant correlations between the key MMRC components and overall maternal and late maternal mortality, but the magnitude and direction of these associations are not consistent. Similarly, certain key components related to committees’ scope and mission and to the breadth and diversity of their composition are also significantly correlated with social inequalities in maternal mortality. None of these relationships are consistent across both maternal mortality outcomes and both educational and racial disparities. Although no strong patterns emerged, these findings indicate that MMRC policy features theorized to reduce social inequalities in maternal mortality are also empirically correlated with both overall maternal mortality outcomes and with differences between social groups. Finally, Chapter 3 focuses on California’s paid parental leave policy, which allows new parents to bond with and care for a new child, as one state policy strategy that aims to improve maternal and infant health. I examine the causal effect of California’s paid parental leave policy on the postneonatal mortality rate (the death of an infant aged 28 days and older per 1,000 live births) and overall infant mortality rate (the death of a child aged 1 and under per 1,000 live births) using vital statistics data and the synthetic control method. I find reductions in postneonatal mortality of approximately 10% overall and by race; changes in overall infant mortality rates range from a decrease of 2.5% among all infants to a 10% increase among non-Hispanic Black infants. These effects are consistent in magnitude with prior literature, but none reach statistical significance.
- All rights reserved
Notice to Authors
If you are the author of this work and you have any questions about the information on this page, please use the Contact form to get in touch with us.