Objective: To synthesize the literature on associations between social determinants of health and pregnancy-related mortality and morbidity in the US and to highlight opportunities for intervention and future research.
Data Sources: We performed a systematic search using Medline Ovid, CINAHL, Popline, Scopus and ClinicalTrials.gov (1990–2018) using MeSH terms related to maternal mortality, morbidity, and social determinants of health, and limited to the United States.
Methods of Study Selection: Selection criteria included studies examining associations between social determinants and adverse maternal outcomes including pregnancy-related death, severe maternal morbidity, and emergency hospitalizations or readmissions. Using Covidence, three authors screened abstracts and two screened full articles for inclusion.
Tabulation, Integration, and Results: Two authors extracted data from each article and the data were analyzed using a descriptive approach. A total of 83 studies met inclusion criteria and were analyzed. Seventy eight out of 83 studies examined socioeconomic position or individual factors as predictors, demonstrating evidence of associations between minority race and ethnicity (58/67 studies with positive findings), public or no insurance coverage (21/30), and lower education levels (8/12) and increased incidence of maternal death and severe maternal morbidity. Only 2/83 studies investigated associations between these outcomes and socioeconomic, political and cultural context (e.g. public policy); and 20/83 studies investigated material and physical circumstances (e.g. neighborhood environment, segregation), limiting the diversity of social determinants of health studied as well as evaluation of such evidence.
Conclusion: Empirical studies provide evidence for the role of race and ethnicity, insurance, and education in pregnancy-related mortality and severe maternal morbidity risk, although many other important social determinants, including mechanisms of effect, remain to be studied in greater depth. (author abstract)
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