Date of Award

2021

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Graduate Group

Epidemiology & Biostatistics

First Advisor

Mary Regina Boland

Abstract

Globally, rates of maternal morbidity and mortality have declined; however, in the United States they continue to climb. In this dissertation we investigated individual-level and neighborhood-level exposures and their roles on adverse delivery outcomes, including severe maternal morbidity and cesarean delivery after labor induction. First, we developed a novel algorithm for large Electronic Health Record datasets to determine whether a patient has experienced residential mobility, (i.e., moved to another residence), during pregnancy, or any other time period of interest. The goal of this algorithm is to construct low-cost patient residential histories so as to more accurately assign geo-spatial exposures, such as poverty or violent crime, in epidemiologic studies. By taking residential mobility into consideration, the level of exposure misclassification is mitigated. Secondly, we investigated severe maternal morbidity in the University of Pennsylvania Health System, assessing the role of individual-level and neighborhood-level exposures in these life-changing outcomes. We demonstrated that the persistent racial disparities seen in national rates of severe maternal morbidity exist among our health system as well. Indeed, race at the individual-level, and proportion of people identifying as Black per census tract at the neighborhood-level, were associated with increased risk of severe maternal morbidity. Thirdly, we explored the effect of neighborhood deprivation on post-induction cesarean deliveries. Labor inductions are common, in fact 20% of pregnant people will experience a labor induction during delivery. Among those over one-third will have a post-induction cesarean delivery. Importantly, a disproportionately high number of people experiencing a post-induction cesarean delivery are people of color. Neighborhood deprivation has been shown to be associated with adverse health outcomes such as cancer, and adverse pregnancy outcomes such as preterm birth. We evaluated the link between neighborhood deprivation and cesarean delivery among women undergoing labor induction, an area of limited prior study. We found that neighborhood deprivation increases the risk of post-induction cesarean delivery, even after adjusting for important individual-level covariates, such as pregnancy-related hypertension. This dissertation study demonstrates the importance of individual-level and neighborhood-level context in understanding the increasing trends of adverse delivery outcomes, and for shedding light on underlying factors involved in racial health disparities.

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